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I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
#51
RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
A colleague of mine underwent Transvenous phrenic nerve stimulation last year and he is very happy with the results. His oxygen levels are in the normal range in the morning and he says he has never slept better since he had the operation. It cost his insurance about $35k however it may have come down somewhat by now.
I'd say if your insurance covers it, then go for it however it is strictly designed for the permanent treatment of CAS in "Male" patients (91% of study subjects were male and their FDA approval is based on that 3 year study). I  therefore assume that your clinic would want a full assessment of your overall health before making an approval decision on TPNS, including a full cardiology checkup because apparently it is not suitable for patients with certain underlying cardiac conditions.
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#52
RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
Thank you very much again for the detailed explanations Sleeprider and Dave.  Thank you S. Huxley for the info on the TPNS.  Thanks S. Manz and QAL for comments.  

I found the DME order that the sleep specialist Doc gave me along with the sleep study I uploaded.  He recommended: 
DME device:  VIPAP/BI-LEVEL/VPAP (E0470).  
Device settings:  Min pressure below cm/H2O   Max pressure below cm/H2O 
Other settings:  max IPAP 25, min EPAP 6, PS 4 cm H2O.  

Diagnosis:  Obstructive sleep apnea (G47.3)
                 Central sleep apnea       (G47.31)
                 Cheyne Stokes/ Periodic Breathing (R06.3)
                 Hypersomnia, unspecified (G47.10)

Anything unusual here?  Something jumps out at me.  He has the Max IPAP at 25.  Min EPAP 6.  I remember the settings on the ST-A were:  15 Max IPAP, Min EPAP 8, and 4.5 (cm H2O?).  Would this pressure on the ST-A have been high enough to keep my airway open while I am trying to fall asleep, or could simply raising the pressure higher be the solution?  Astral settings are about as low as she can possibly set them according to her words.  
The last 2 nights I have woke up 2 times (as opposed to the usual 5 or so).  
My AHI was 42.7 on the sleep study per hour.  *But after looking more closely at the body position chart is shows me at 45.4 AHI on my back; it drops to 20.4 on my right side; Left side didn't have enough time on it to analyze.  Probably close to the 20.4 on my right side.  I drop from the Severe sleep apnea classification to the Moderate class sleeping on my side. 
I have had more energy the past 2 mornings.  
I tried sleeping on my left and right side the past 2 nights.  (I dislocated the left shoulder about 5 years ago or so and then I started sleeping exclusively on my back).  My left shoulder did not hurt sleeping on it - it has healed in the last 5 years.  
It feels easier to breathe on my side.  
The buzzing is about 50% less in my opinion also (in both frequency and intensity).  
I used the ST-A trying to fall asleep with naps laying on my back.  The Sleep study overnight was all on my back too - I was afraid to roll over with all the wires and electrodes on me.  So when the RT doing the overnight said I stop breathing, it was on my back.  The RT last week who came to my house twice last week and observed my breathing getting shallower as I was relaxing and about to fall asleep was on my back.  I have yet to try the Astral on my side.  I have gotten into the habit of falling asleep at night on my back in the past few years.  
Is this the scenario that is occuring:  as I relax more and more to fall asleep, my airway obstructs more and more (shallower and shallower breathing).  Just as I am about to fall asleep, my airway completely obstructs and I stop breathing (due to laying on my back).  Both the ST-A and AStral sense this and gently try to get me to breathe again.  Doesn't work.  So they pop me and I start breathing again (but I wake up).  Would higher pressure settings keep my airway open while I am falling asleep and fix everything (on my back)?  
I plan on trying to fall asleep on my side with the AStral.  It may work and it may not even try to pop me.  Maybe tonight if I have enough energy, but I will attempt it this week for sure.  I am going to try to get a copy of my overnight from the hospital and post it here also.  Of course another chance to mention the ASV to Dr.'s Rn.'s etc. when I go also.  Thanks again.
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#53
RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
The prescription you describe is a respiratory assist device (RAD) bilevel pressure device without a backup rate. The HCPS code is E0470, so I have no idea how you have been provided machines like the ST-A and Trilogy (E0471). ASV also falls into the E0471 category. The Trilogy can also be a EO472 when used with an invasive ventilation interface. Basically, none of the devices you have been issues are consistent with the prescription you recite above, and I suspect there are additional doctor's orders you don't have because there is no way a DME can issue these without a prescription.

The All of these devices have some operating principles in common. To control obstructive sleep apnea, the EPAP pressure must be high enough to prevent obstruction. IPAP is achieve by using pressure support. In adaptive servo ventilators and volume assured respirators, a minimum level of pressure support, usually 0 to 3 cm, is used for patient comfort, then the machine applies additional pressure support above the minimum PS to ensure the target ventilation rate is achieved. With the ASV and ST-A, if an apnea (no or low respiratory flow) occurs in spite of elevated pressure support, EPAP is raised to open the obstructed airway if settings allow.

If your initial apnea upon sleep transition are obstructive, then the machine needs to be adjusted for increased EPAP. If it is in Auto mode, that increase in pressure is built into the algorithm, however if you immediately quit therapy upon sensing the pressure support, then you never got that far. We have NO IDEA what your settings have been, especially minimum EPAP, so it is very hard to advise, but these machines must be properly titrated or used in auto mode long enough for EPAP min to be determined. Your test shows you have complex sleep apnea, and it is common for individuals to have central apnea upon sleep transition. This should result in air being delivered to the lungs, however if the airway is obstructed, it may be dumped to your stomach or otherwise arouse you. The answer is higher EPAP pressure to prevent that obstruction; however you have not provided any data or titration results that lets us even guess at your need for EPAP min.

Your medical supply is extraordinarily generous, but seem to be operating on very little actual information to set you up with these machines. Considering how hard these machines are to obtain for most people, I don't even know how this happens. I have probably helped dozens if not hundreds of complex apnea members to achieve very good therapy results and comfort over the years, and you are unique in having the best equipment, and no machine or titration data to even get started. To help you, we need to know what settings are in use. We can even use trial and error to see if higher EPAP pressure would avoid the problem you have at sleep transition, but where do we begin when nothing about your therapy settings is known.
Sleeprider
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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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#54
RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
Someone is mismanaging or bungling this badly. Your HCPCS code E0470 nets a BPAP like VAuto or less. Just not a BPAP with backup rate like ST-A or ASV, these have HCPCS code E0471. They issued you outside the doctor's script and I'd be of a mind to tell them on the phone ASAP.

Here's my guesstimate of something here. You were to get plain BPAP without backup rate, as in on the path to ASV. They somehow skipped that, maybe that is. You didn't get regular BPAP I don't think. So ok, they skipped over standard BPAP into BPAP with backup ST-A and not ASV. As ST-A wasn't warranted due to your Central based events, it didn't work and they somehow bungled it even more with an Astral which is ventilator class, likely HCPCS E0466 which equals "VENTILATOR, ANY TYPE, USED WITH NON-INVASIVE INTERFACE, (E.G., MASK, CHEST SHELL)".

Quack and/or DME and RT bungled bungled bungled.
Dave

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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#55
RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
Thank you both of you Sleeprider and Dave for explaining my situation.  I will try to describe the sequence of events of how this could have happened. 
April - pay out of pocket to get this home sleep study.  Results and DME order uploaded here.  *(sleep specialist Doc told me personally, "most insurance companies accept my home sleep study, but some do not.  With your level of involvement, I advise you to get a polysomogram so in the future you will have no problems with insurance.  I took his advice and asked my PCP for it and got it.  I have never used this particular DME script.  
June - Had polysomnogram.  *Here is the kicker though I think.  One RT did the study.  She also works for a DME.  6 weeks later after study no machine yet so I call local hospital here to check if something is wrong.  Local hosptal RT says, this DME can't get the machine you need, I will call 3 other DME's and the 1st one that calls me back, I will go with them.  1st one called (the one I currently have that got me both the ST-A and AStral).  Different RT than the one that did the study and different DME.  Surely she got a copy of the polysomnograph?  I have showed her the 1st home sleep study I uploaded here also.
July 29th or so - This RT with this DME gives me the ST-A.  Multiple unsucessful attempts.  
Last week of October - I have failed compliance with the ST-A, so RT with DME gives me another home sleep study (I guess to get me recertified for another 3 months?) 
Novemeber - I see ENT. (PCP gave me the consult to check is something was structurally wrong - and this ENT specializes in sleep apnea treatment). I think I scared the you know what out of him.  ("buzzing, 79 o2 Sats, etc.).   He tells me to get a Cardiologist ASAP (to get that A-fib checked out).  He seems very knowledgeable about sleep apnea though from talking to him.  (I am watching him and he pulls up data on me that I have never seen - looks as sophisticated as OSCAR.  Definintey nothing I have seen. I think he may have issued Astral to cover himself, etc. with all of my scary symptoms.  That is the vibe I got.  I get AStral in less than one week.  DME said they got the order for the AStral that night!  
I forgot - back in October - I saw my PCP also - supposed to do the 21 days out of 30 and 4 hours a night plus give Dr. a good report on it for insurance - "I feel much better becauase of therapy."  But I told my PCP the truth.  I said I don't think this machine is working for me.  She is great.  Has done just about anything I have asked of her.  RT at DME then gave me that 2nd home sleep study that week.  
I think I could actually ask her when I see her in 2 weeks for the Cardiologist consult to write a script for the ASV.  I guess I will try to use the ASTral in the mean time to get some data for us and for the RT to look at.  I guess with my plan for the ASV, I need to fail compliance with the Astral right?  I actually think if I contacted ENT I could possibly get a script for the ASV.  I want to try to give the RT at the DME some data though. She has been great too with all of the machines.  When she sees I am sleeping with it and still have high apneas, she will probably try to adjust things and this won't work.  Then maybe time to press for the Astral?   Or what should my plan be from today forward to get the ASV (and covered by insurance).  And also keep good relations with my PCT, RT, and ENT since they have bent over backwards so much trying to help me.  Just trying to explain how I think I ended up in this unique situation.  
*I will try to produce some analyzable data for everyone in the mean time.  I wll try not to pull off the mask and get some sleep and get some numbers to crunch.  I started in April, but no problem.  We will get it right eventually.  I believe this.
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#56
RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
I don't know that you need to fail compliance with the Astral because you are actually going back in therapy levels significantly to a point not previously attempted. You probably have no idea what the Astral machine costs to rent or buy. DMEs can get $1400/month rental on those ventilators. ASV costs under $3K complete. Your therapy progression has never made any sense to me, and once you get back on-track, costs will be lower and you will be better. Win-win.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
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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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#57
RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
As I mentioned a few posts upthread here (and as others have started noticing), your therapy sounds pretty strange. Like I mentioned before, you got diagnosed with a home study and within a short span of time you were given a $25,000 full-tilt clinical mobile ventilator which even licenced nurses and MDs usually spend at least a couple of weeks learning how to properly set and operate it...needless to say that none of it which makes much sense to me (unless there are other medical issues involved which according to yourself, there are none). 
So I am puzzled and now highly intrigued to find out what will come out of all this and whether you will finally start receiving some suitable therapy....Your latest study suggests that you have complex apnea with OSA preceding CSA in my opinion. This would be a 
"...E0471 RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITH BACK-UP RATE FEATURE, USED WITH NONINVASIVE INTERFACE, E.G., NASAL OR FACIAL MASK (INTERMITTENT ASSIST DEVICE WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE)..."  under HPCS, which would be (and I know some here may not like it) but a Philips Respironic BIPAP Auto SV, similar to my machine or even a IVAPS device (intelligent Volume Assured Pressure Support) that aims at maintaining a constant minute volume with auto or timed backup rate, like Philips Respironics BIPAP iVAPS machine, however my thinking is (and I am only thinking aloud here) that because neither machines are available due to the so called "Philips recall" ( DMEs don't want to part with them for obvious reasons of liability), they have been scrambling to find alternatives in Resmed line of machines that have these capabilities, except that with Resmed they have gone way  up to something like the Astral to find these capabilities at monumentally higher costs....You must have a VERY GENEROUS coverage. I wish mine were like yours:-)


Note that Resmed Aircurve 10 ASV does not have a "Backup Rate" in compliance to E0471 but a Resmed Aircurve 10 ST/A has both a backup rate and iVAPS capability. Both machines can also be set to act like regular run-off-the-mill CPAPS)

At any rate, I will definitely follow this thread to see where this rather bizarre course of therapy will end and wish you all the best.
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#58
RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
Just my opinion regarding failing Astral... There's no need to wait, it's failing you. It's the wrong therapy. Seriously, different machines with my history, but when the therapy is some sort of trainwreck, I don't care about time limits, there is a failure you can point to. Throw the fail flag.

PS
The ResMed AirCurve 10 ASV does meet HCPCS E0471 requirements with respiratory backup rate. The backup rate is algorithm controlled, so there's no manual, user controlled settings, but it does have backup rate. That's part of the ability for the ASV to nudge a breath if needed.
Dave

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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#59
RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
A correction to the statement by S. Manz, "Note that Resmed Aircurve 10 ASV does not have a "Backup Rate" in compliance to E0471". In fact while there is not manually set rate, the default backup rate is 15 BPM and software uses the patient's normal respiratory pace from the previous 90 seconds to set a backup rate that is natural and comfortable for most patients. Thousands of these machines have been issued in compliance with HCPCS code E0471.
Sleeprider
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www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
Organize your OSCAR Charts
Attaching Files
Mask Primer
How To Deal With Equipment Supplier


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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#60
RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
Thank you very much Sleeprider and Dave and S. Manz.  

I want to make an amendment to the previous post.  I believe the ENT Dr. acted out of compassion.  I have a suffering sleep apnea patient here.  How can I best help him:  1.  Acts as quickly as possible.   2.  Give him the top of the line equipment I can to try to help him.  

When I called my local RT here and she said the RT who did the sleep study could not get my machine because it was back ordered in June and early July of this year.  Was there a bipap machine that was on back order during this time?  This could well be the model machine I was supposed to get from my polysomnogram.  Multiple bipaps could have been on back order during this time though.  

I have not made every decsion perfectly with my sleep apnea diagnosis and treatment.  But in hindsight, one of the best decisions I made was getting the polysomnogram.  Also getting multiple sleep studies was probably even better.   I did not want to do them at the time, but I sure am glad now that I got them done.  Also another super decision was joining apneaboard.com AND POSTING my situation.  I joined in August out of frustration, sensing the Dr.'s and RT's could not figure out the problem.  I could not either.  I just looked at some posts though.  In December here I was desparate for anwers and solutions, so I posted my situation.  I am very glad that I did that.  I now have both clear direction and support to finally solve these mulit-month (and hopefully not mulit-year) problems.  

*I went by the hospital this morning and got a copy of my polysomnogram.  Very easy.  Took 10 mintues.  Just went to medical records window.  I will try to attach it here now.  Thank you so much.
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