BiPap Vs Cpap

[kasiahbug]

My son's Dr said he will likely need a BiPap and eventually a trach based on the condition he has - (ROHHAD) -- last night he had a split sleep study and the technician said she was on strict orders to have him sleep for 3 hours and then put onto Cpap or biPap - she sent us home with a loaner cpap and said that she set the settings and those will likely not change with his "real" machine... He had no destats and PCO2 was fine as well. The Dr knows that it isn't always, and is very unstable. I'm wondering what if there are things that happen on why a Cpap is recommended over a bipap? 

I am so new to all the sleep stuff and apologize for ignorance.

[Mosquitobait]

Insurance won't pay for it until you 'fail' a cpap. My bro's doctor also told him that he would end up with a bipap, but they had to go through the insurance hoops to get him that (he has restricted lung capacity, not apnea).

The reason why insurance won't pay is due to the cost of the bilevel being more than double the cost of a cpap. If you can afford to buy the bipap out of pocket, then there is no reason why the doc can't write you a script for it right off. You might find a local DME provider that will match online stores, but not likely. In that case, buy the machine from an online retailer and get masks locally since fitting may be a bigger problem.

Another option is to buy a used or out of box bilevel machine. Stick with current models of Resmed or Respironics. Your doctor's office can do the settings. You need to spend some time reading the stickies before going the used route, but many of us do. I have seen current model bilevel machines on Craigslist for between $400 and $700, which is a huge, huge bargain. The problem is that when you already have another major illness, there isn't a lot of money to go out and buy something so expensive, so you are stuck with playing the insurance game.

[kasiahbug]

Thank you for all the information -- had not heard of having to fail CPAP - I asked a respiratory therapist her opinion as she's been following my son. My thought was that the CPAP did what it needed last night so BiPAP isn't needed just yet? (I hope anyway.) We have an insurance caseworker for my son and she's been great at advocating for getting this approved based on his new diagnosis.

[Sleeprider]

Okay, not so true. Your son has co morbidity issues that qualify for bilevel therapy, and even bilevel with a backup rate. I don't think insurance coverage will be an issue. The fact he is establishing both efficacy and compliance (use of the machine at least 4-hours per night in 21 of 30 days) will satisfy any insurance requirements. Don't let that concern you. A bilevel machine can perform a significant portion of the work of respiration, so individuals with obesity hypoventilation and other respiratory insufficiency can achieve a healthy tidal volume and minute vent. If there are issues with central apnea, other machines can also provide a backup rate with non-invasive ventilation. Bilevel works by splinting the airway in the exhale cycle (EPAP) ensuring obstruction does not occur and the airway stays open. When it triggers to inhale pressure (IPAP) it assists in the work of inhaling, so if the diaphram is unable to expand normally or excess weight interferes with respiration, the positive pressure does some or all of the work. It sounds to me like your son is in good hands.

Something to watch is airway alignment is very important. You probably know that in artificial respiration, we tilt the chin back to help open the airway. When an individual is sleeping, and particularly with your son's condition, the airway can be closed by their sleep position when the chin tucks to the chest. An easy way to avoid this problem is by using a soft cervical collar to keep the head and neck aligned. This is not an injury hard cervical collar, but just an aid to keep the chin elevated a bit and prevent occlusion of the airway in various sleep positions that occur naturally. Watch for clusters of obstructive apnea and that will show you the airway is closing in spite of the splinting of the PAP pressure.

Please stay with the forum and let us help you to understand how this works, and how you can continue to monitor your son's therapy and advocate on his behalf.

[kasiahbug]

Thank you for such a detailed response Sleeprider - 
My son was sleeping in a CTO jacket for many months because his neck dislocates and hehad stroke like symptoms and was hospitalized. They did EEG and found nothing but then admitted for monitoring a couple weeks later where the neurologist had him bend his neck for 10 seconds and it showed slowing, but said they don't know why. It's been frustrating, but we did notice a big improvement when he wears it 24/7. 

He has a bed that he sleeps with his head raised and that also helps. 

I took a video of him the other day showing what a respiratory therapist said looks to be central hypoventilation. I asked her if the O2 drop (he's wearing an oximter that alarms) came from the 5 seconds of not breathing that you can see in the video and yet haven't seen any of the events at sleep studies, but he has so many good and bad days and it's never consistent. I showed the sleep Dr his sleep strips to show that some nights he has 0 O2 drops and other nights 24 - Wish there was a pattern. 

This is a very new diagnosis, so we are still learning, but I've been doing a lot of research - I just know zero about the hypoventilation part. His O2 drops even during the day, randomly and he has severe amnesia events as if he has Alzheimer's, which we now believe are desaturation events. I really appreciate any guidance as I want to learn - his loaner machine is an Escape II - but no idea when or what the new machine will be, the tech only said the Dr was adamant that he leave with something, but that was prior to the test.

[Sleeprider]

Kashiahbug, the Escape II is an antique CPAP (Resmed S8 Series). Ridiculous for your son's condition. Try to get a current Resmed Aircurve 10 ST-A with iVPAPS. This machine has bilevel algorithms with an "intelligent Volume-Assured Pressure Support". This machine is specifically designed for obesity hypoventilation, has the capability to provide the bilevel support your son needs, and can provide an assured aveolar volume of air with each breath. It also provides full data. This modern machine is the best in class for your son's problems, and also has alarms when programmed volume is not achieved. This machine can target a respiratory rate and volume, and when it is not delivered, it adjusts the pressure support and triggers inspiratory pressure on a timed basis, to provide the assured volume prescribed. https://www.resmed.com/us/en/commercial-...ivaps.html

The S8 is 3 generations old and is not capable of bilevel support or data. It certainly does not target volume support or have backup support. Learn about this machine and if you agree it is where you need to be, then "be the mom". Get it, or find out why it is not the perfect choice.

[kasiahbug]

Thank you -- that's exactly the info I'm wanting to research. This one is just a loaner so not sure how it works when we get the real deal, if they call prior or just show up. But I will be sure to ask for the right machine.
Do you think it's practical to message the Dr and let her know my thoughts on this prior to getting the authorization going? Or wait for the supplier to call?

[Sleeprider]

Part of the purpose of a trial on the Escape II may be to rule out the use of that device as effective. The problem is, the Escape records no data, so it seems more like a band-aid to give CPAP support until something better can be obtained. I kind of see this as a loaner machine, and you should focus on what comes next. In my non-professional opinion the Resmed Aircurve 10 VPAP ST-A iVAPS is the answer, but you may have to first trial a regular bilevel like the Resmed Aircurve 10 Vauto to get there. The Vauto is the machine I use, and it provides full bilevel therapy and data, but no backup rate or volume targeting. It's a great machine, but we are dealing with a case that seems to need a volume assured pressure support function (AVAPS, iVAPS).