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[Diagnosis] Long Time to Get Prescription for Machine
#11
RE: Long Time to Get Prescription for Machine
As per Vesimir's request:
[Image: 75bHRln.jpg]
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#12
RE: Long Time to Get Prescription for Machine
In my opinion...

looks like they ran out of time during the titration and only got to 15 cmH2O. that is quite common during these studies. report shows you are only dealing with obstructive based apneas so more pressure is the answer. A lot of times the higher pressures are hard to tolerate and easier to tolerate in the bipap mode. It does not appear you'll need an s/t or asv machine.

I know you think you did better at the lower pressures but that was just a short glimpse during one night of what is happening. stage of sleep will also affect the amount of apneas that occur. plus you never went into REM.

I think your on the right coarse of action, interpretation of report is correct. just going to take time to get the proper machine.
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#13
RE: Long Time to Get Prescription for Machine
Thanks dmeRT.  I didn't notice until you mentioned it that there were no central/mixed apneas.  That's something positive at least - I wonder if the initial home sleep study results could have been wrong about those?  I thought a CPAP machine doesn't prevent central apneas, so not sure why there wouldn't be any shown during the in-center study.

I just learned that the insurance company rejected a second polysomnography, but it seems like they might just need some additional information from the sleep center to approve -- not exactly sure what they need, but nothing else is going to happen today.

I think my options at this point are 
  1. continue to try to have the second PSG approved, spend another night at the sleep center, and retain the possibility of getting a bipap prescribed, or 
  2. just agree to get an APAP and monitor data carefully.  


So far I'm continuing down path #1 to ensure I end up with the right treatment.  Make sense?
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#14
RE: Long Time to Get Prescription for Machine
All events were obstructive, so higher CPAP pressure or bilevel pressure, which may make the higher pressures more tolerable. If money is an issue, you could ask the doctor to simply prescribe auto CPAP (Resmed Airsense 10 Autoset with EPR) or BiPAP (Resmed Aircurve 10 Vauto or Philips Dreamstation BiPAP Auto), and you should be able to self-titrate with either option with your doctor's assistance. If your insurance coverage is good and the additional study is affordable, it would be good to complete it. Based on what we are seeing, a bilevel therapy would be advantageous and justified based on the high titration pressures indicated. Auto bilevel would allow the machine to self-adjust you your needs up to 25 cm. I think you will end up on bilevel, preferably with auto settings rather than fixed pressure. Typically we would look at a minimum EPAP of 10 with pressure support of +4 and maximum IPAP of 25. If this could be prescribed and dispensed, then there would be no need for further study, and the machine data would adequately report efficacy of the treatment.
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#15
RE: Long Time to Get Prescription for Machine
(07-06-2017, 02:29 PM)Sleeprider Wrote: Based on what we are seeing, a bilevel therapy would be advantageous and justified based on the high titration pressures indicated.

Can you please explain what you're looking at to make this determination?  Is it because I was still experiencing numerous apneas at all pressures (including 9, 11, 13, and 15)?
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#16
RE: Long Time to Get Prescription for Machine
Yes. It is not uncommon for insurance to authorize bilevel for individuals with pressure requirements greater than 15 cm, especially if they have tried CPAP and not tolerated the pressure.  A bilvel machine can deliver up to 25 cm pressure compared to a CPAP with a maximum limit of 20 cm. The use of bilevel pressures to provide higher inhale (IPAP) and lower exhale (EPAP) pressure is a great way to increase comfort.  More importantly, the EPAP pressure will need to be high enough to treat your obstructive apnea (OA).  That pressure is very likely going to be in excess of 15 cm.  In addition to OA, you have hypopnea (H), flow limitations (FL) and snores (S), all of which can be treated with a higher IPAP.  With CPAP you would have to have very high fixed pressure to treat the H, FL and S events in addition to OA.  If we assume your OA is adequately treated at 17 cm EPAP, it may still take 21-24 cm pressure IPAP to resolve the secondary obstructive events.  This pressure is beyond the capability of CPAP, and I'm sure that is in the mind of the test doctor.  These are commonly accepted pressure titration fundamentals, and with the failure to successfully titrate you at up to 15 cm, it's almost a given that they will need to consider bilevel.
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#17
RE: Long Time to Get Prescription for Machine
(07-06-2017, 02:07 PM)Vesimir Wrote: ... - I wonder if the initial home sleep study results could have been wrong about those?  I thought a CPAP machine doesn't prevent central apneas, so not sure why there wouldn't be any shown during the in-center study.


I don't think your home sleep test was wrong.  Oddly enough, I've seen centrals go away with the introduction of cpap.  I know some sleep labs will titrate to a minimum of 10 cmH2O cpap before switching to bipap in the presence of central episodes because sometimes they just go away.

I agree with sleeprider, he is much more eloquent/informative in his responses than I am...

If you get too much resistance in getting the bipap approved then I'd start the auto cpap.  complain about not tolerating the high pressures to your dme company and they should be able to switch you to bipap then no problem.
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#18
RE: Long Time to Get Prescription for Machine
from ResMed pg 33 of CPAP and AutoSet Therapy Titration Protocol

Quote:Consider trial of bilevel if obstructive
events persist at a pressure of 15 cm H2O
Certainly doesn't make it mandatory.
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

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#19
RE: Long Time to Get Prescription for Machine
Vesimer, I don't know what all these studies and the equipment is costing you, but I want to point out a complete, new Dreamstation BiPAP Auto DSX700T11 with heated hose and humidifier is available on Amazon for $777.00. Just sayin' if you are getting beat up financially, there is an alternative.
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#20
RE: Long Time to Get Prescription for Machine
Thanks.  My insurance plan has been pretty good.  So far, it's only been a reasonable copay for each doctor visit or study.  Durable Medical Equipment, however, will only be 50% covered (in-network DME providers).  

That Dreamstation does look like a pretty sweet deal compared to the price of the Resmed Aircurve 10 Vauto (though I'd presumably be buying the Dreamstation w/out any insurance contribution).  I'll start worrying about this after my doctor issues a prescription.  I'm aware that what's specified on the prescription is important.
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