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Machine Recommendation
#1
Machine Recommendation
I have an upcoming appointment with a pulmonologist.  I have an 8 year old System One Bipap machine and the doctor office told me that they are going to try to get me a new machine that my insurance will cover.  I am considering the Resmed Aircurve 10 but I am looking for other options in case insurance will not cover that model.  

What other BIPAP machines should I ask the doctor to try to get?  Thank you.
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#2
RE: Machine Recommendation
The Resmed Aircurve 10 Vauto is a great auto bilevel, and I'm sure you already know I regard it much higher than the Philips. You are currently on a Auto SV model, so what mode, and settings are you actually using. If on SV fixed mode, the EPAP is fixed at 8.0 and PS can vary up to your maximum pressure. If in SV auto mode, you should have a minimum and maximum EPAP pressures, min and max PS. What was your last diagnosis? If you have central apnea or complex apnea, then you are still going to need an adaptive servo ventilator, and I would not recommend anything but the Resmed Aircurve 10 ASV.

How about posting a chart or two of your current therapy. We can help you identify where the machine is treating events (or not) and it might help with your discussions with the doctor. Insurance will cover what is medically necessary, and unless there is some change in your diagnosis, I see no reason to worry about approval to replace your ASV with another ASV.
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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#3
RE: Machine Recommendation
(01-21-2021, 03:39 PM)Sleeprider Wrote: The Resmed Aircurve 10 Vauto is a great auto bilevel, and I'm sure you already know I regard it much higher than the Philips. You are currently on a Auto SV model, so what mode, and settings are you actually using.  If on SV fixed mode, the EPAP is fixed at 8.0 and PS can vary up to your maximum pressure. If in SV auto mode, you should have a minimum and maximum EPAP pressures, min and max PS.  What was your last diagnosis? If you have central apnea or complex apnea, then you are still going to need an adaptive servo ventilator, and I would not recommend anything but the Resmed Aircurve 10 ASV.  

How about posting a chart or two of your current therapy. We can help you identify where the machine is treating events (or not) and it might help with your discussions with the doctor.  Insurance will cover what is medically necessary, and unless there is some change in your diagnosis, I see no reason to worry about approval to replace your ASV with another ASV.

Thank you for the reply.  I'll gather together a few days of Oscar charts and stats and post them later tonight or tomorrow.

I am using SV mode.  I made some small EPAP and PS adjustments but my AHI is regularly over 5 and some nights is in the low teens with a large amount of hypopnea events.  So I made the pulmonologist appointment to see if I can do something to get my AHI under 5.

I was diagnosed in 2010.  Initially prescribed a fixed Cpap.  Then I had a study done in 2012 (my last one) and I was diagnosed with complex apnea so I have both obstructive and central apnea.  I had stopped using my machine for a long time, just couldn't get used to it and hated it.  I decided this past September to give it another go.  I got a Dreamwear mask and using the under nose nasal pillows.   I've been tolerating the therapy much better so my past issues could have been the mask I had.

Since I have complex apnea it seems like the Aircurve 10 ASV is what I should try to get so I'll see what the doctor says. 



Thank you for the reply.  I'll gather together a few days of Oscar charts and post them later tonight or tomorrow.
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#4
RE: Machine Recommendation
(01-21-2021, 03:39 PM)Sleeprider Wrote: How about posting a chart or two of your current therapy. We can help you identify where the machine is treating events (or not) and it might help with your discussions with the doctor.  Insurance will cover what is medically necessary, and unless there is some change in your diagnosis, I see no reason to worry about approval to replace your ASV with another ASV.

Hello.  Here are 3 charts that I have selected from this month.  These represent my best and worst AHI nights and one night where I was around the magic AHI of 5 or under.

Machine Settings:
Mode ASV
Min EPAP 7.50
Max EPAP 12.00
Min IPAP 13.00 
Max IPAP 25.00
PS Min 5.50 
PS Max 14.00 
Auto On
Breath Rate Auto
Flex Level 2 
Flex Mode Bi-Flex
Hose Diam. 22mm
Humid. Lvl 4 
Humid. Mode Fixed (Classic)
Humidifier Connected
Mask Res. Lock Off
Mask Resist. 1 
Ramp Pressure 4.00 cmH2O
Ramp Time 30.00 Minutes


   

Clear Airway Events - 3
Obstructive Events - 9
Hypopneas - 12

   

Clear Airway Events - 4
Obstructive Events - 9
Hypopneas - 22

   

Clear Airway Events - 5
Obstructive Events - 15
Hypopneas - 47
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#5
RE: Machine Recommendation
First of all, insist that the replacement machine is the Resmed Aircurve 10 ASV. The response speed and way that pressure support is applied will be much more comfortable, and if you want to get into some zoomed views, I'll prove it.

We can see this System One DS960 is working overtime to keep you breathing. All the black hash marks are triggered breaths. The job of an ASV is to maintain your tidal volume and respiration rate (minute vent) and the AutoSV gets extremely variable results for you. My concern throughout all your charts is how unbalanced the flow rate looks. This is usually a sign of significant flow limitation.

Do you see a mask pressure chart option? If so, I would like to see some random close-up zooms of the flow rate and mask pressure at a 2-3 minute resolution where the flow wave shape can be clearly seen. Include either pressure or mask pressure if available.
Sleeprider
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____________________________________________
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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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#6
RE: Machine Recommendation
(01-25-2021, 04:00 PM)Sleeprider Wrote: First of all, insist that the replacement machine is the Resmed Aircurve 10 ASV. The response speed and way that pressure support is applied will be much more comfortable, and if you want to get into some zoomed views, I'll prove it.  

We can see this System One DS960 is working overtime to keep you breathing. All the black hash marks are triggered breaths.  The job of an ASV is to maintain your tidal volume and respiration rate (minute vent) and the AutoSV gets extremely variable results for you.  My concern throughout all your charts is how unbalanced the flow rate looks. This is usually a sign of significant flow limitation.  

Do you see a mask pressure chart option?  If so, I would like to see some random close-up zooms of the flow rate and mask pressure at a 2-3 minute resolution where the flow wave shape can be clearly seen.  Include either pressure or mask pressure if available.

Can you explain what a triggered breath is?

Here are my 2-3 minute snap shots from last night I hope this is what you are looking for.  If you need the snap shots from the nights that I previously posted instead then I'll provide that.

           
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#7
RE: Machine Recommendation
Let's use this graph to explain a "triggered breath".   First the basics. When a machine transitions from expiratory positive pressure (EPAP) to the higher inspiratory positive pressure (IPAP) we call that "trigger", and similarly, when the machine changes from IPAP to EPAP, that is "cycling or cycle".  So the machine triggers to support inspiration and cycles to make exhale easier. 

In the graph below, we can see about 7 vertical hash marks above the flow rate. These are "triggered breaths" where more time has passed since the last breath than the timed or auto breath function allows. The machine triggers IPAP to cause a breath. The first triggered breath is still below your usual tidal volume, and we can see the pressure support behind that breath is not greater than the pressure of the breath before it at 4:46:50. The second, third and fourth triggered breaths are progressively greater pressure support, but fails to cause a normal breath, and the machine flags a CA event because respiratory flow meets the definition of an apnea, but the airway was open enough to cause some respiratory response.  At 4:47:20 you take a "spontaneous" breath.  Spontaneous is when you make a voluntary effort to breathe, and the machine responds by reducing the pressure support. There are 4-spontaneous breaths, then a pause in spontaneous effort causes the machine to trigger another 4-breaths, again with inadequate respiratory response in spite if increasing pressure support.   Let's continue this discussion below the graph.

[Image: attachment.php?aid=29580]

The reason I suggested the Resmed Aircurve 10 ASV is that it is much faster to provide pressure support, and it will provide that support on the first breath, not after 4-breaths.  In other words, this machine is NOT doing its job, but a Resmed would absolutely restore your tidal volume.  When we look at your chart above we see that pressure support on the first triggered breath is only about 5.0 cm (estimating EPAP at 9 and IPAP at 15, and even after 4-triggered breaths, I don't see IPAP much above 18 cm (PS 8.0). That's pathetic! The settings would allow PS of up to 15 and this dumb, slow machine is not giving it to you when you need it.  THAT is why we try to get people on Resmed ASVs.  Now, for some reason on your third chart, we finally see a respectable pressure support response at 08:17:55.  It should have gone all the way to 25 because it didn't actually achieve a respiratory response, but at least it got over 20.   It's not your fault, but this is why your Philips BiPAP AutoSV sucks.

[Image: attachment.php?aid=29581]
Sleeprider
Apnea Board Moderator
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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#8
RE: Machine Recommendation
To help you visualize the difference in response rate and pressure support, here are some other ASV charts I found.  The individuals posting are not apnea-free, but the machine is doing a great job responding when needed.  In this example, we can see the pressure support stays near 4.0 until needed, but when needed, it can hit the problem with everything allowed in the settings, in this case up to 14 cm PS.

[Image: f1JmAoN.png]

Here we can see the normal quiet response of a Resmed ASV. It maintains low pressure through the night, but when higher pressure support is needed, it doesn't take 4 breaths to get halfway there. It delivers on time, every time.

[Image: 1M8SW4y.png]

Here is an example of just how quickly the Resmed S9 ASV responds to oscillating respiratory flow as it tries to maintain a steady minute vent rate.   Without the PS, those respiratory reductions would likely be CA or H events.  Notice also how natural the breathing rate is for the Resmed ASV.  You don't see triggered breaths, because the machine does not wait for an event before responding, it learns when to expect a breath and is already increasing pressure when one is missed or has inadequate volume. Notice also the shape of the mask pressure. Rather than an on/off pressure like the Philips, it is more of a wave that follows the respiratory wave more naturally.

[Image: ?u=http%3A%2F%2Fwww.apneaboard.com%2Ffor...f=1&nofb=1]
Sleeprider
Apnea Board Moderator
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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