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Bipap st not resolving problems
#1
I had two initial sleep studies but slept very little with either one, so the doctor was reluctant to give a clear diagnosis.  In the first one I had mostly central apneas and the AHI was in the 30's. On the second one I had very few centrals and the AHI was 14.  I tried APAP for two months but always had clusters of central events. My average AHI was around 10, but based on sleepyhead data, it looked like in some hours I was getting closer to 30 events.  

My doctor switched me to BiPap ST (Resmed AirCurve 10 st), and last night was my first night.  I am attaching my sleepyhead results.  It looks like I had an AHI of 9.37, and about half were UAs and half were hypopneas.  I think the total AHI is probably worse than this data says because I was actually awake quite a bit of the time that the chart appears to be free of apneas.  I thought that the point of the backup rate was that the machine would force me to breathe if I stopped on my own.  Why am I still getting apneas?  Also, why does the sleepyhead data not list centrals?  Is it likely that the unknown apneas are central or could they be something else?  

I would appreciate any help interpreting these results!


Attached Files
.pdf   sleep data.pdf (Size: 884.58 KB / Downloads: 25)
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#2
The big problem is your doctor should have switched you to a Resmed Aircurve 10 ASV, not the ST. The ST only provides a fixed pressure support , in your case at 13.0/9.0 it is PS of 4.0. That is not enough pressure support to resolve central apnea. The ST machines are intended for people with hypoventilation, respiratory insufficiency and similar problems. The ASV is needed for people with central and complex sleep apnea. The ASV provides a variable exhale pressure (EPAP) that responds to changing needs to stabilize the airway and prevent obstructive apnea. It provides variable pressure support on a breath by breath basis to maintain your breathing rate and volume, so it can provide anywhere from zero to 15 or more cm additional pressure as needed, when needed. You are on the wrong machine according to the manufacturer and I suggest you ask your doctor why he did not prescribe the right machine, ASV.

Read the titration guidelines linked here and pay attention to the intended use for ST and ASV machines on pages 28 and 34 (Note IVAPS and ST are similar machines, but the iVAPS is more sophisticated and can vary pressure to target aveolar volume). These guidelines suggest protocols for titrating individuals. In your case on your current machine you are having a lot of hypopnea and unclassified apnea which may be central. The appropriate response to this is to increase IPAP pressure leaving EPAP pressure lower. Did you have a titration study?

Link to titration guidelines: https://www.resmed.com/us/dam/documents/...er_eng.pdf
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#3
I can understand sleep docs not understanding for whatever reason and making the wrong call. what I don't understand is why the 'system' requires bilevel failure in cases of central mixed apnea when it appears to be well known that bilevel won't resolve this affliction? does anyone with central or mixed apnea ever not fail bilevel? why not go immediately to asv? wouldn't insurer's save $ by doing so?
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#4
(08-09-2018, 12:54 PM)sheepless Wrote: I can understand sleep docs not understanding for whatever reason and making the wrong call.  what I don't understand is why the 'system' requires bilevel failure in cases of central mixed apnea when it appears to be well known that bilevel won't resolve this affliction?  does anyone with central or mixed apnea ever not fail bilevel? why not go immediately to asv?  wouldn't insurer's save $ by doing so?

At first glance I'd agree with you. But than I thought about. I'm sure it saves the Insurance companies money in the long run the way they do it now. For them it's all about profits and they wouldn't have this policy if it didn't benefit them. You can be sure they ran this through their collected data in their computers to figure out how to squeeze the most money out of us. Wink
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#5
The ST does have the capability for both bilevel pressure and a backup rate, and it has the same HCPCS code as ASV and both machines have comparable costs. This machine has all the same prerequisites of ASV, it's just the wrong machine for this application. In order to treat central apnea, the ST has to be set with anywhere from 8 to 12 cm of pressure support, and it provides that on every breath. This will cause central apnea to be much worse so the machine ends up being a ventilator on every breath. The ASV is normally setup for a low EPAP pressure and a minimum PS of 2-3 cm and maximum PS of 12-15. It is a dynamic ventilator that only provides pressure support when needed, rather than every breath. The SERVE-HF study identified risks for ASV with a population of heart failure patients with a left ventricular ejection fraction less than 45%. Some doctors have simply stopped prescribing ASV out of mis-placed caution, even when the patient is not in that risk group, even when ASV is clearly the superior choice for efficacy. That may or may not be the situation here.
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#6
good info from you both walla walla and sleeprider. it's just not apparent to me how the bilevel step can save insurer's money when central or mixed apnea is known to be present, particularly after a sleep study but with cpap/apap data as well (assuming pressure induced centrals are resolved or ruled out). maybe it's small potatoes and the actuaries gotten around to catching up with the science?
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#7
The mysterious reasoning for insurance providers making patients take the required steps to qualify for machines like an ASV are more likely than not going to be based on money issues. If a more basic machine can "treat" the average Joe, it seems insurance would rather you prove you're not average Joe. This process may cost insurance some money, but most patients pay as well through co-pay. IMO the insurance bean counters have calculated that if they can weed out those that can obtain the AHI of 5.0, and be labeled treated by the doc, then their accounting books stay within proper acceptable limits.

I believe we have seen a few that can be "treated" with a standard CPAP or APAP that would be better off on BPAP. And there are some that would be better treated via ASV or similar that haven't made it there yet in providing proof due to various reasons. The doc needs to take the action in requesting the proper PSG and writing the script.

Patients seem to be required to be strong self advocates of their needs as well, and not every patient has the knowledge of what their needs are. I believe if it weren't for being on AB and learning what I needed, I'd still be struggling on a BPAP today. If I had not gone in for that urgent care visit, where the nurse and I asked each other why I was NOT on ASV, I'd not have one today.

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Dave

I'm not a doctor in real or fictional life. My posts include opinions based upon user experience regarding CPAP therapy and should not be considered medically professional direction or advice. Even a 1,000 mile trip requires a good first step. My recommended first steps include getting good walking shoes, 1 great cup of coffee, and a good GPS.

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#8
I don’t think insurance is the problem here. The OP has a bilevel with backup, just the wrong one.
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#9
right you are, sleeprider. my fault for diverting attention from the OP to the general question as to why insurance requires people with known central or mixed apnea to fail bilevel before allowing us to try asv. sorry about that.
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#10
That is correct, Sleeprider. I went on a tangent that didn't fit the OP's situation. My apology for disrupting the flow of the conversation.

I agree that the ASV will be best suited instead of the dispensed ST. IMO I think that LVEF issue is causing docs to shy away from scripting the ASV. That may or may not be the case here, but I'm thinking it happens frequently.
Dave

I'm not a doctor in real or fictional life. My posts include opinions based upon user experience regarding CPAP therapy and should not be considered medically professional direction or advice. Even a 1,000 mile trip requires a good first step. My recommended first steps include getting good walking shoes, 1 great cup of coffee, and a good GPS.

Wiki Info for Beginners
Sleepyhead Chart Organization
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