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[CPAP] Pressure mandating very tight mask & worsening AHI
(02-20-2017, 11:11 PM)justMongo Wrote: What are they doing about the Cushing's Disease?  Is the source an adrenal tumor?

Pituitary benign neoplasm. Surgery did not cure it. Gamma knife radiation also did not. Currently on a waiting list with the Medicaid MCO for approval for a very expensive medicine called Korlym to treat it.
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WRZ, the most recent chart at 18.5 showed pretty nice improvement of the hypopnea. At this pressure, you qualify for a BiPAP machine, which would REALLY help with the hypopnea through pressure support during inspiration. If you have Cushings changes in the neck region, then this may explain some of the obstruction, particularly if you are stomach sleeping with your head turned acutely to the side. You can test this by laying in a typical sleep position and just turning your head and seeing if you are aware of increased respiratory effort with different head and neck positions. This experiment may give you some idea of the postures that are a problem.

More on bilevel or BiPAP. Your results so far show that that it may be medically necessary to obtain bilevel therapy in order to obtain the treatment efficacy expected from PAP therapy. Bilevel would provide much more pressure relief during exhale, and pressure support during inhale. This is precisely what is needed to overcome hypopnea. Bilevel is also used for patients with pressure consistently higher than 15 cm that cannot tolerate the high CPAP pressure. You would accomplish this by discussing these issues with your doctor.
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If you are interested in pursuing BiPAP under Medicare, which is HCPCS code E0470, read the information in this link, at least the summary in Tables 1 and 2. https://www.cms.gov/Outreach-and-Educati...905064.pdf The criteria for approving an upgrade to bilevel is in Table 1 D on page 4.

The fact you have followed up with your physician, and he recommended an increase of pressure to 17, all suggest you may be qualified for the bilevel device, but you will have to push the doctor to move that direction. If you do get this, an Auto bilevel will be the best bet because it can let you self titrate your EPAP, IPAP and pressure support needs. For example, based on your current experience, a logical bilevel prescription could be BiPAP Auto with EPAP minimum of 12, IPAP maximum 20 with PS 3 to 5. This would produce an automated therapy with comfortable pressures in the range you are showing greatest success.

If you plan to go this route, I'd be careful about demonstrating success, even though it is coming at 18.5 pressure, and I would start a discussion with the doctor as soon as possible.
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Thank you I will inquire about BiPAP therapy with the doctor next I see him

Upon your suggestion about hypopneas I enabled A-Flex with a value of '3' (known as C-Flex+ when A-Trial is disabled on CPAP Pro) to see if it gave any improvement on that front - since it gives both inhale and exhale relief of 3 cmH2O. At A-Trial mode 17-20 cmH2O it did indeed give a much better AHI and less hypopneas were logged than with A-Flex disabled.

My intention is to continually use A-Trial going forward until if/when I can get a BiPAP as it mostly mimics APAP mode from what I've read (though it still does not log 'Flow Limitation' metadata like APAP mode does). Some sources indicate that once hitting the 30 day limitation of A-trial it can be set to another 30 days four more times. I intend to work around that by re-entering therapy settings and changing the day setting for A-trial before the 30 days are up. It is my belief that it resets the A-trial counter if you do this BEFORE you accrue 30 days. Failing that, I will use it 4 more times and then simply use the factory reset function (after performing a 1:1 sector by sector backup of the SD card first) to purge the A-Trial usage limit counter.

My pulmonologist has a hostility toward automatic type devices for some reason. But I will push harder for one next time. He at least respects my level of knowledge and hasn't expressed an issue with me "cheating" my non-APAP machine into behaving (mostly) like an APAP.

The DreamStation series seems to me to be the exact same on the hardware level (including ICs) the difference seems to be the firmware. Philips intentionally disables features on certain models. As someone who tinkers with software and hardware on an advanced level it really bugs me when companies do that. They should just sell ONE DreamStation that has all the modes available in the therapy settings: BiPAP, APAP, CPAP, C Check, etc. If that were the case then I could simply suggest to my doctor switching the machine to BiPAP mode.
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Just wanted to update: I now have a copy of my titration study now that my provider gives easy online access to my entire chart via MyChart as a PDF file.

Here it is (with certain info redacted of course) just in case it yields any further insight (scroll down to see additional pages, ordered from top to bottom) 
Note: I was on 10mg of Zolpidem / Ambien for this; which likely explains the lack of REM since GABAergic drugs such as Z-drugs interfere with REM (though to a far lesser extent than benzodiazepines).

I have had continued success with A-Trial 17-20 with A-Flex 3 (Having A-Flex disabled results in higher AHI). I have had no further issue with the mask after reorienting it to position the rear strap higher and not over neck.

The use of high pressures does cause a relatively minor issue though: my humidifier tank is sometimes depleted before a single session ends resulting in a nasty smell that tends to wake me up (even if the reservoir and mask were cleaned the night before). Resolved by turning down the humidifier setting. Results in some drymouth but not too bad.

I will still inquire about BiPAP next appointment though since the evidence of A-Flex improving my AHI indicates I likely would get better treatment longterm from it.

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