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[CPAP] New and need some help lowering AHI
#51
(12-05-2016, 08:16 PM)richb Wrote: I like the idea you have. "I'm quite optimistic with these results so far and I'm thinking that tonight I'll raise the EPAP and keep the IPAP making it 7-8CM range. I'm going to leave the EPR setting at 1 for tonight and depending on results I'm thinking of EPR off with the same 7-8CM range for the following night. If the pattern continues I'd expect to see lower CAs and higher Hypopnea/Obstructive events." My hope is that at slightly higher pressures you will see a very minimum number of Obstructive events and as you tighten up the pressure range you will see less in the way of Central events. If I had to characterize your condition right now I would suggest that you have mild Obstructive Apnea complicated by mild Central Hypopnea. This would be classified as mild Mixed apnea. Your machine can pretty well handle the Obstructive events at somewhat higher pressures but those same higher pressures can turn the Hypopnea to Central Apnea. Pressure differentials may be responsible for some of the increase in Central events especially at higher pressures. You now know that at low pressures your Centrals revert to Central Hypopneas and Periodic Breathing. Thus you had that condition all along. It was not caused by the machine it was only changed by the machine. You also know that at lower pressures you have more Obstructive events because the pressures are too low. You are essentially doing a self titration to find the sweet spot. If you can find that sweet spot where Obstructive and Central events are controlled an an AHI under 5 with few if any desaturations your present machine will probably be satisfactory. If your AHI cannot be brought consistently under 5 you should be a candidate for an ASV machine. Most insurance requires that you fail at CPAP/BiPAP before they will authorize an ASV machine.

Rich

Rich,

So the change I made had some interesting results. The CAs actually went back up to 44, but very evenly spread out this time. Everything else was almost non-existent. These results make me think I need to go to a 6-7CM range while leaving EPR 1 on another night, but let me know what you think. The screenshots are below. Also I'm assuming that once I get the pulse oximeter that will help determine what EPR needs to be set on.

Whole Night - http://imgur.com/krgeWgk
5 min - http://imgur.com/zoeKJ8E
5 min - http://imgur.com/EM6GSyJ
5 min - http://imgur.com/RlPEPcf
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#52
I think you are closing in on better settings, but you need to use the settings more than one night to establish whether you need to make further changes. Give this current setting a couple nights to settle in before jumping to the next change. Your thought process is otherwise solid, but you could pass up the best setting by not giving it enough time, especially when dealing with mostly CA events.
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#53
(12-06-2016, 11:05 AM)Sleeprider Wrote: I think you are closing in on better settings, but you need to use the settings more than one night to establish whether you need to make further changes. Give this current setting a couple nights to settle in before jumping to the next change. Your thought process is otherwise solid, but you could pass up the best setting by not giving it enough time, especially when dealing with mostly CA events.

Gotchya. trying to gather as much data as possible via self-titration so when I see my doctor on the 14th I can build a really good case to move forward with a clinical sleep study and/or a new machine. I'm on a time crunch with my insurance and trying to get as much as possible done before the end of the year. Have a very bad plan next year Sad

~Casey
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#54
SR makes a good point about trying settings for more than 1 night. Try your new settingafter another day or so then try a straight setting with no differential between EPAP and IPAP. As you can see you don't need much pressure to control the Obstructive events. It will also be interesting to see what your Pulse Oximeter tells you.


Rich
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#55
Side Questions:

I've been using the AmaraView and I really like it compared to the DreamWear. The only issue I've come across is mild irritation. I get itches around my nose or just under my bottom lip that cause me to have to lift the mask and scratch those areas. Is there any solution someone can recommend for that?
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#56
Casey, you have classic CPAP induced complex sleep apnea. Your doctor does not seem very open to that suggestion, or aware of its prevalence. Here is a link to an article that you can print and provide to your doctor, hopefully in advance of your appointment http://www.aasmnet.org/jcsm/Articles/040501.pdf I think this might be more helpful than going over your forum discussions. While Apneaboard is an invaluable resource, referring to a forum discussion with any doctor is guaranteed to cause his eyes to roll. Avoid that.

By optimizing your results now, you are undermining the chances that you will be covered by insurance for an upgraded machine. Insurance guidelines for ASV will require that you "fail" CPAP and Bilevel PAP. This means that it must be demonstrated that you cannot be titrated to clinically acceptable levels of sleep disorder on either of those two classes of machine, before you are given a trial on ASV. In most cases I have seen, this ends up requiring a demonstration that CPAP is failed, followed by a clinical titration that will attempt to titrate for bilevel, and if that fails, may either continue the trial to ASV, or the best bilevel will be issued and must be failed before an ASV titration is given.

This "reality" means you are already past the time when a change of machines could be accomplished in the current year under your better insurance. Just scheduling a bilevel - ASV sleep study could be weeks, if not months out, let alone the prescribing, and dispensing of a machine. It would be nice if the sleep study could be accomplished, as that alone is going to be expensive.

Another way to look at this is, if your insurance is really going to suck, you may have to look at alternative approaches. First, you are actually getting borderline on good treatment with your auto CPAP. I think you are making progress and may actually push that AHI and hopefully comfort to tolerable levels. That may be the best end result due to financial considerations. If you want to pursue ASV treatment options, you need to balance the costs of ASV sleep titration, which could exceed $3K, and the Aircurve 10 ASV machine which is just over $4K using the lowest online provider.

The point is, your results are getting very close to acceptable, and you are unlikely to be insured for the "ideal" machine, especially given your current level of success. So strategically, you need to either go all-in on optimizing your CPAP, or back-off in hopes of getting ASV approved. If you choose to go all-in on CPAP, then the conversation with your doctor changes. You want him to at least acknowledge your real problem and and be an ally in your challenging fight to optimize treatment. My personal opinion is that this is the more constructive path at this point.
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#57
(12-06-2016, 12:38 PM)Sleeprider Wrote: Casey, you have classic CPAP induced complex sleep apnea. Your doctor does not seem very open to that suggestion, or aware of its prevalence. Here is a link to an article that you can print and provide to your doctor, hopefully in advance of your appointment http://www.aasmnet.org/jcsm/Articles/040501.pdf I think this might be more helpful than going over your forum discussions. While Apneaboard is an invaluable resource, referring to a forum discussion with any doctor is guaranteed to cause his eyes to roll. Avoid that.

By optimizing your results now, you are undermining the chances that you will be covered by insurance for an upgraded machine. Insurance guidelines for ASV will require that you "fail" CPAP and Bilevel PAP. This means that it must be demonstrated that you cannot be titrated to clinically acceptable levels of sleep disorder on either of those two classes of machine, before you are given a trial on ASV. In most cases I have seen, this ends up requiring a demonstration that CPAP is failed, followed by a clinical titration that will attempt to titrate for bilevel, and if that fails, may either continue the trial to ASV, or the best bilevel will be issued and must be failed before an ASV titration is given.

This "reality" means you are already past the time when a change of machines could be accomplished in the current year under your better insurance. Just scheduling a bilevel - ASV sleep study could be weeks, if not months out, let alone the prescribing, and dispensing of a machine. It would be nice if the sleep study could be accomplished, as that alone is going to be expensive.

Another way to look at this is, if your insurance is really going to suck, you may have to look at alternative approaches. First, you are actually getting borderline on good treatment with your auto CPAP. I think you are making progress and may actually push that AHI and hopefully comfort to tolerable levels. That may be the best end result due to financial considerations. If you want to pursue ASV treatment options, you need to balance the costs of ASV sleep titration, which could exceed $3K, and the Aircurve 10 ASV machine which is just over $4K using the lowest online provider.

The point is, your results are getting very close to acceptable, and you are unlikely to be insured for the "ideal" machine, especially given your current level of success. So strategically, you need to either go all-in on optimizing your CPAP, or back-off in hopes of getting ASV approved. If you choose to go all-in on CPAP, then the conversation with your doctor changes. You want him to at least acknowledge your real problem and and be an ally in your challenging fight to optimize treatment. My personal opinion is that this is the more constructive path at this point.

Yeah I was thinking about that myself. It seems like such a narrow gap you need to squeeze in to get maximum insurance help. I'm just thinking longterm that I know dozens of people who go all night with 0.00 AHI when properly treated. So that is ultimately my goal regardless of cost. When I say my insurance is going to be bad I'm just comparing to what I currently have. Since I've met my deductible (only $600) for the year, I'm covered at 100% right now hoping that I can at the every least get the sleep study I need. Next year I'll have a high deductible (3K) and then it only covers 90%. While this is much better than some alternatives, I selected this more affordable plan prior to being "diagnosed" with Sleep Apnea and I apparently can't change it or I would.

I like the idea of a lower AHI and being comfortable in general. I'm learning a tremendous amount about my condition and I'm pretty anxious to get the pulse oximeter and see what it says.

If my Blood Oxygen levels are quite low is an ASV the only way to fix that or is there hope for that a Bilevel PAP could resolve much of the issues. With CAs persisting at such a low IPAP setting I'm not so sure a Bilevel is going to do the trick. Especially since my machine truly being an APAP it comes very close to the function of a Bilevel PAP especially when EPR is in use.

I guess what I'm asking is do we expect my Blood Oxygen levels to be low or high given the number of CA events I'm having? Additionally if they're normal levels doesn't that entirely rule out the need for an ASV? Is there a possibility that BiPAP treatment could remedy poor blood oxygen levels?

I feel like I have a pretty solid understanding of various types of sleep apnea (now anyways), but I'm still very new to all of this. I sincerely appreciate the thorough details.

~Casey
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#58
Hi again Casey. SR points the significant problems getting an ASV machine paid for. It has been my assumption that you were going to get your AHI into the "considered treated" area since it has already been there. My concern is that you might have occasional levels of desaturation that could be detrimental to your sleep quality and health. Your Central Apnea breathing patterns could be causing your O2 saturation to drop to unhealthy levels. Oxigen Desaturation Index Definition: ODI is the hourly average number of desaturation episodes, which are defined as at least 4% decrease in saturation from the average saturation in the preceding 120 seconds, and lasting >10 seconds. 1. Many people with "machine induced Central Apnea show no signs of Central Apnea during a sleep study. a. In your case we already have seen that you were diagnosed with a significant number of Hypopneas during your sleep study. b. We also saw that as your pressure was lowered the machine induced Centrals reverted to hypopneas. and c. we saw that your Obstructive events disappeared at fairly low pressure. We still do not know if your O2 levels are remaining at levels that are considered normal. Having unhealthy desaturations would seem to be a reason to qualify for an ASV machine. As SR says you are going to need ammunition that does not reference this or any other internet site. There are numerous scholarly papers that you can use instead of saying you heard "it" from The Apnea Board. In my case I never mentioned The Apnea Board when dealing with my old and new Doctors even though this site is where i got my education.
1. source: https://www.researchgate.net/profile/Fra...735bdc.pdf
Apnea Board Member RobySue has posted a Beginners Guide to Sleepyhead Software here:  http://www.apneaboard.com/wiki/index.php...SleepyHead

Download Sleepyhead
Organize your Sleepyhead Charts
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#59
(12-06-2016, 04:02 PM)richb Wrote: Hi again Casey. SR points the significant problems getting an ASV machine paid for. It has been my assumption that you were going to get your AHI into the "considered treated" area since it has already been there. My concern is that you might have occasional levels of desaturation that could be detrimental to your sleep quality and health. Your Central Apnea breathing patterns could be causing your O2 saturation to drop to unhealthy levels. Oxigen Desaturation Index Definition: ODI is the hourly average number of desaturation episodes, which are defined as at least 4% decrease in saturation from the average saturation in the preceding 120 seconds, and lasting >10 seconds. 1. Many people with "machine induced Central Apnea show no signs of Central Apnea during a sleep study. a. In your case we already have seen that you were diagnosed with a significant number of Hypopneas during your sleep study. b. We also saw that as your pressure was lowered the machine induced Centrals reverted to hypopneas. and c. we saw that your Obstructive events disappeared at fairly low pressure. We still do not know if your O2 levels are remaining at levels that are considered normal. Having unhealthy desaturations would seem to be a reason to qualify for an ASV machine. As SR says you are going to need ammunition that does not reference this or any other internet site. There are numerous scholarly papers that you can use instead of saying you heard "it" from The Apnea Board. In my case I never mentioned The Apnea Board when dealing with my old and new Doctors even though this site is where i got my education.
1. source: https://www.researchgate.net/profile/Fra...735bdc.pdf

Rich/SR,

First and foremost I appreciate everyone's feedback about how to address the doctor. Unfortunately this is not my first rodeo where I've had to do a lot of my own research/advocating. I really need them on my side so I'm going to approach him carefully, but firmly. I'm really hoping he'll understand my position and be willing to help.

Here is the second night of identical settings. While the overall AHI is just a smidgen lower, there appear to be larger clusters closer together. I'm not sure if that means anything special just an observation.

My Pulse Oximeter arrives today so I'll hopefully have that data for y'all tomorrow. Are we thinking same settings in addition to pulse oximeter tonight or shall I lower down to 6-7? or possibly keep it a straight 7 or 8? I'm assuming EPR should be left at 1 unless that's the only change we're making. Screenshots below.

Whole Night - http://imgur.com/a5pGZUX
5 min - http://imgur.com/IjfjxNr
5 min - http://imgur.com/EL3vB0B
5 min - http://imgur.com/cnkALmj

~Casey
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#60
In my case I was able to see immediate changes in frequency of CAs with pressure changes. I would look at a setting of straight 7 CM H2O to see if you can get a drop in
CAs. I also hope you can hook up that Pulse Oximeter soon.

Rich
Apnea Board Member RobySue has posted a Beginners Guide to Sleepyhead Software here:  http://www.apneaboard.com/wiki/index.php...SleepyHead

Download Sleepyhead
Organize your Sleepyhead Charts
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