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Help with Bipap settings
#11
The prescribed machine is a bilevel ASV (Aircurve 10 ASV / BiPAP Auto SV Advanced). Insurance and medicare requires that a patient must demonstrate medical necessity for a higher level machine by progressively failing at CPAP, and BPAP before being approved for an adaptive servo ventilator. In some cases, CPAP and BPAP does work. Usually it is a sub-optimal outcome but good enough to be considered medically "treated". It is a near certainty that a person diagnosed with central apnea or mixed apnea will ultimately require ASV; however many of these people quit before getting the right machine. It takes a lot of knowledge and perseverance to use ineffective machines long enough to demonstrate that the therapy failed in spite of compliance. Insurers are counting on you quitting before getting ASV approval, especially if you have high deductibles or co-pays. It is not unusual for 3-4 sleep studies to be completed before ASV is approved, and that you will cycle between numerous machines and masks.
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#12
Bipap is NOT prescribed for people with CA. We get ASVs - auto servo ventilators which are similar to bipaps but do more than bipaps. A bipap changes pressure in response to the user's breathing - one pressure when the user inhales, which changes to the other pressure when the user begins to exhale. An ASV switches pressures on a timed basis to trigger the patient to inhale as the pressure increases - it does not respond to the user, but attempts to get the user to respond to a prescribed rate breaths per minute. It also tries to get the user to maintain the breathing pattern that has been used in the last several breaths.

Unlike Sleeprider's experience, I went from Cpap to Bipap to ASV in three months.
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#13
Thanks for all the info here. Very helpful.

I didn't realize I had centrals until it was pointed out here. Is that amount normal or do my results warrant pushing for an asv?
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#14
Hi SupraSeth94,
WELCOME! to the forum.!

I wish you good luck as you start CPAP therapy, hang in there for more responses to your post.
trish6hundred
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#15
Quote: An ASV switches pressures on a timed basis to trigger the patient to inhale as the pressure increases - it does not respond to the user, but attempts to get the user to respond to a prescribed rate breaths per minute.

Just for clarification, the Resmed ASV does not work quite like this. It does respond to the user, but will adjust pressure support if the user's breathing strays outside parameters determined by his own minute ventilation for the previous few minutes. It only forces breaths if the user's breathing stops or slows too much, and then the rate is determined by the user's own breathing rate. It is for this reason that I found the Respironics unusable, but the Resmed is a perfect partner.
DeepBreathing
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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#16
Quote:I didn't realize I had centrals until it was pointed out here. Is that amount normal or do my results warrant pushing for an asv?

Everybody gets a few centrals and our machines tend to show a few false positives. In your case it looks like you didn't have any centrals until pressure was applied, and then you had quite a lot. Some people are susceptible to pressure induced central apnea, which occurs when the CO2 levels in your blood are temporarily reduced because of the extra air you're getting. In simple terms, the brain scans your blood for CO2 and when the level reaches a certain threshold it sends a "breathe now" message to your lungs. Under PAP therapy it's possible for the CO2 level to remain artificially low, so the brain doesn't see any need to breathe. This is a central apnea.

Pressure induced central apneas often go away of their own accord once you get used to the therapy - sometimes they don't. But you need a machine which is capable of recording and detecting centrals, and a lot of older (and a few newer) ones don't. From what SleepRider wrote above your M series may be one that doesn't. I'm not sure about your F&P.

Two things which can exacerbate centrals are increased pressure and the use of EPR. For reasons I don't understand, a lot of people have success controlling their centrals by turning EPR down or off, which tends to contra-indicate use of bipap or a machine with EPR. Having said that, I think SleepRider's suggestion of a Resmed Airsense Auto is probably a good one. With judicious adjustments of your pressures and EPR there's every chance those pressure induced centrals will go away. If they don't, then you will need to look towards getting an ASV in future.

For these reasons, you need to understand exactly what the insurance rules are - ask your insurance company, not the DME. Then you need to go back to the sleep clinic and have that deep and meaningful conversation mentioned above. They need to explain to you how your centrals came about, are you still experiencing them (which the Airsense Auto can tell you), and what the progression is from this point to getting them eliminated. It might be that you need to "fail" on regular CPAP and bipap before perhaps eventually going on to an ASV. You should work with your clinic and the insurance company to make sure that all the options and scenarios are covered at minimal cost to yourself.
DeepBreathing
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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#17
Excellent post by DB above. For more information, do a Google search for respiratory drive You will find terms like hypoxic and hypercapnic drive.

Also see Insurance Guidelines for bilevel and ASV. This summary from Resmed is pretty good.

Getting ASV approval is a difficult process, as a medical necessity must be established for the equipment. The patient must try CPAP and it must be proven ineffective in order to progress to bi-level. Then bi-level must also be failed and a medical justification written that non-invasive ventilation is necessary and in the doctor's opinion will be beneficial.

Medicare will cover a bi-level respiratory assist device without backup (this is what they call a bi-level or BiPAP) for patients with obstructive sleep apnea if the patient meets the criteria for PAP therapy (outlined above) and:

CPAP is tried and proven ineffective based on therpeutic trial conducted in either a facility (sleep center) or home setting.
A face-to-face clinical re-evaluation is completed during the 3-month trial period. The physician must document that the following issues were addressed prior to changing from CPAP:
Mask fit and comfort (read more about different types of mask and how they fit here)
CPAP pressure setting prevent tolerating therapy and lower settings were tried, but failed to:
Control symptoms of OSA; or
Improve sleep; or
Reduce AHI/RDI to acceptable levels

If the patient switches to a bi-level device within the 3-month trial, the length of the trial is not changed as long as there are at least 30 days remaining. If less than 30 days remain of the trial period, re-evaluation must occur before the 120th day (following the same criteria as CPAP adherence).
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#18
Thanks for all the replies.

Sounds like even if the Bipap makes me tolerate the therapy more, it may actually cause more centrals. I guess I'll give it a whirl and hope for the best until my appointment in late January.

Now at least I feel like I will know what to ask them.
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#19
We're getting way ahead of ourselves. Use the machine, record some data. If there is a problem it will be pretty easy to spot.
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