My Experience So Far (and thoughts on changes to therapy)

[Esq.]

I've started a few threads, but in the interest of keeping things consolidated will just keep it all in one thread moving forward.

Prior threads:
http://www.apneaboard.com/forums/Thread-New-to-Apnea-Therapy
http://www.apneaboard.com/forums/Thread-One-Week-Check-In
http://www.apneaboard.com/forums/Thread-Nasal-Pillows--19075

Here is where I am now. I'm committed to the P10 nasal pillows, which seem to be working okay. My AHI is staying below 3 for the most part, and I seem to have gotten the aerophagia mostly under control, though I have the occasional bad night here and there. I'm using a soft cervical collar now. So, I'm settling into therapy, but SleepyHead continues to show both OA and CA, with CA dominant. I had my first meeting with my doctor since beginning therapy earlier this week, and because of the CA issue and the fact that I'm not feeling any better whatsoever, he has referred me to an in-lab sleep study (my initial diagnosis was based on a home study). He thinks I may need to transition to an ASV because of the mixed apnea. I'm just curious on about what the knowledgeable folks here think based on my data. Below are the last 3 nights of SleepyHead data. As always, thanks to all for being so helpful.

9/19:
 

9/20:


9/21:

[Walla Walla]

Well after a month your Doctor may be right. The problem maybe getting the insurance to pay for it. The numbers are under 5 and insurance will say that's good enough.

[Esq.]

Well after a month your Doctor may be right.  The problem maybe getting the insurance to pay for it. The numbers are under 5 and insurance will say that's good enough.

I assume the insurance issue is one of the reasons for the referral to an in-lab study, to confirm untreated AHI and the mixed nature of the apneas?

[Sleeprider]

If you are approved for ASV with an AHI under 5, you will be the first case I'm aware of. Please keep us informed. CA can be stubborn and in cases where it has a relatively low frequency, it can be as much from sleep disturbance and movement as a respiratory problem. It helps to look a bit closer at the event duration and even the flow chart detail to see if respiration tails off and back on which is more characteristic of CA, or if the transitions are more abrupt. The machines are less than perfect in their interpretation of apnea as compared to more sophisticated PSG. In your case the CA seems to correlate with some flow limits and leaks, so this might point to some lighter sleep, movement and other causes than a central respiratory failure. We can look at a closeup of the flow rate wave form if you want. For the most part your respiratory and pressure statistics look pretty good.

Your pressure is nearly optimized and varies a reasonably small amount at night, so the only thing I can think of to try is turn off EPR. It sometimes works, sometimes not. The CA events tend to go away in time although even after 10 years I have a few, generally less than 1 AHI, but if I do something like increase pressure support or have disrupted sleep that will increase events quite a bit.

[SarcasticDave94]

Hello, Esq.

FWIW: The spring 2017's PSG for me going to BiPAP had 345.0 sleep minutes with 124 CA 24 OA & 3 H. This helped trigger a new PSG for my ASV. It slipped my memory just now in what that ASV PSG recorded, but I had the numbers for an ASV. I'm not sure, but you're sounding to be below borderline IMO. But I could be wrong. Let me look what I posted in my Newbie thread and/or you can look it up as well. The PSG ought to be there. Nonetheless, wishing whatever is best for ya. BTW IF you do go ASV, my personal opinion is think on ResMed. I had the DreamStation BiPAP and whatever the older CPAP model was. They weren't comfortable for me, yeah it could be that incompatibility thing with the as-yet revealed mixed status, but I'm not so sure. IMO and YMMV and all that.

Dave

[Hojo]

If you are approved for ASV with an AHI under 5, you will be the first case I'm aware of.  Please keep us informed.  CA can be stubborn and in cases where it has a relatively low frequency, it can be as much from sleep disturbance and movement as a respiratory problem.  It helps to look a bit closer at the event duration and even the flow chart detail to see if respiration tails off and back on which is more characteristic of CA, or if the transitions are more abrupt.  The machines are less than perfect in their interpretation of apnea as compared to more sophisticated PSG.  In your case the CA seems to correlate with some flow limits and leaks, so this might point to some lighter sleep, movement and other causes than a central respiratory failure. We can look at a closeup of the flow rate wave form if you want.  For the most part your respiratory and pressure statistics look pretty good.

Your pressure is nearly optimized and varies a reasonably small amount at night, so the only thing I can think of to try is turn off EPR.  It sometimes works, sometimes not. The CA events tend to go away in time although even after 10 years I have a few, generally less than 1 AHI, but if I do something like increase pressure support or have disrupted sleep that will increase events quite a bit.

Sleeprider:  Your comment about probably not getting an ASV with an AHI less than 5 got me thinking.  AHI is based on the number of events per hour, correct?  But what about time with apnea, is that ever used as a sole (or compounding factor) for CPAP (or ASV), since you in theory, have a low number of events, but a high number of minutes per event.

For example:  I had 2 nights with an AHI of 3.76, which is very low for me, but on one night the number minutes spent in apnea was 5.5 minutes and 9.75 minutes on another night, almost double the amount of time not breathing.  I suspect one could argue for therapy based on that???

[Sleeprider]

Hojo, I think that it gets into oxygen desaturation and PSG determination of a central breathing problem. Medicare and insurance is only recently even recognizing complex sleep apnea. Each case that is documented adds to the knowledge and approval basis, and I think this forum contributes to that by identifying people with complex apnea issues that used to simply quit or go undiagnosed. Just look at these approval criteria for a device with backup rate (ASV) E0471, compared to bilevel E0470 or CPAP E00601. Note the criteria include that you must "fail" CPAP for 61 days before being considered for a more effective treatment. That's ridiculous. The HCPCS codes and approval criteria are easily researched online, and for most insurance coverages.

https://www.bcbsnc.com/assets/services/p...es_osa.pdf
https://www.resmed.com/us/dam/documents/...F_RADs.pdf

[Esq.]

Thanks all. I'll keep everyone posted. I'm not sure about the insurance issues, but my doctor seems to think an ASV may be in my future. One question - will insurance look at what treated AHI has been with the CPAP, or what untreated AHI is with the PSG?

My home study showed an AHI of 6, so mild, but oxygen desat of 81%, so boderline severe. I'm curious to see what the PSG shows on all of this. I'll also zoom in on the SleepyHead data around the time of some of the CA events and post those when I get some time.

[Sleeprider]

Esq, this thread b Amdx64 is a good read. He ended up with ASV, even though he optimized CPAP. http://www.apneaboard.com/forums/Thread-...e-centrals

The criteria for approval are not so much numeric (but can be), and tend to be based on diagnosis, doctor's statement of medical necessity, and inability to achieve satisfactory results with CPAP and Bilevel options. Your specific insurance probably has a published policy on approval that you can obtain on request.

[PaulaO2]

My AHI often looks the same. Right now, my AHI is well below 5, stays around 2-3. Some nights, I have more CA than OA and HI combined. Other nights, they are even. But it has always been this way for me.

Try turning off the EPR and see if that made a difference. I did a study of my sleep once where I turned off the EPR for 2 weeks then did 1 for 2 weeks, etc. I think I determined that an EPR of 1 or 2 did best for me.

I need to re-do that study again I think.