(06-06-2014 07:25 PM)jcarerra Wrote: I am only one week into CPAP use...was provided a ResMed S9 Elite. A couple of days ago, I got software that lets me see the SD card data.
What a shock. The machine is not stopping the apnea, and frankly I am a bit scared. There was approximately a two hour period last night of obstructive apneas (one central) at a rate of over one per minute--duration generally between 15 and 30 seconds.
With an Elite at least you have
the data that let's you KNOW your therapy is not yet effective.
Just imagine what would be going on if you'd been set up with an S9 Escape: You'd still be feeling lousy, but no one---not you, not the DME, and not the doc, would be able to tell that the problem was that your AHI is still too high and that you are still having clusters of events and that you are NOT leaking. And for the first several months, the doc would likely be telling you nothing but, "It takes time. Just keep trying."
It can take months for a patient with an Escape to finally figure out that something is terribly wrong and get a proper diagnosis of what the real problem with their therapy is.
Quote:The supplier said that is "what the doctor ordered" and they cannot change it. Also that Medicare rules for the ones that DO adjust pressure as needed are very stringent.
The supplier is correct when they say they can't change the pressure: They set the machine to what the doctor wrote in his script and they are NOT allowed to change the settings without further instructions from the doc.
The supplier is NOT correct when they say Medicare rules for getting an APAP are more stringent than Medicare rules for getting a CPAP: Every APAP and CPAP is billed under the same insurance code, and that's the code that Medicare uses. So if you've got a script for a CPAP set at n
cm, all it takes to get an APAP is a cooperative supplier (or DME as they're called around here.)
A really useful blog enrty for you to look at would be What you need to know before you meet your DME
on a blog called Mask Arrayed
Quote:Any suggestions on how to proceed would be welcome.
You do have some choices:
You can pester your doctor with phone calls and bring in a printout of the data that shows your AHI is still too high. Depending on the doc, he'll likely do one of the following things:
- Tell you the AHI may (or should) come down in a week or two, and to let him know if it doesn't. There are many people who do have AHIs in the 10-20 range during the first few days, but the AHI then quickly drops into the normal range and there's nothing else that really needs to be done.
- Order a pressure increase on your Elite. Depending on how closely the doc looks at the detailed data vs. the summary data and how high the AHI is, he may order a minor pressure adjustment of 1-2 cm or (much more rarely) he may decide to increase the pressure by 3-4 cm
- Order a temporary switch to an Auto CPAP for a week or two of autotitration and decide what to do after looking at the data. He'll fax a script over to the DME who will lend you an APAP for the autotitration; you'll be expected to keep your Elite in reserve. The APAP will most likely be set wide open (4-20) during the autotitration. At the end of the autotitration the doc looks at the data. Most likely he'll send a script to the DME telling them to change the pressure on your Elite to the 95% pressure level on the two weeks worth of auto titration data. And then the Elite, with its fixed pressure changed, takes over once again as your new machine.
- Order/request a permanent switch to an Auto CPAP and send a script for the appropriate auto range to the DME. The DME will then swap out your machine. They may squawk loudly about doing this, but if the script is permanently changed, they'll have to honor the new script. And hopefully you'll start with a fresh S9 AutoSet instead of an S9 Escape Auto.
OR you could learn how to change the pressure on your Elite yourself. And increase the pressure by 1-2 cm for a week or two and see what the data looks like. If the AHI comes down to normal, you're good to go. If not, you increase the pressure setting by another 1-2 cm for another week or two. You will eventually find the right pressure, although it may take some time. And, of course, you'll be soundly criticized and whipped with a wet noodle every time the DME or sleep doc sees your data.
OR you could start lobbying the supplier (DME) to switch the machine out for the APAP you want, but, quite frankly, it won't easy to talk them into this without an order from your doc since they've already given you the false line that Medicare won't pay for an APAP.
OR you can try some combination of the above choices.
(06-06-2014 08:59 PM)jcarerra Wrote: AHIs mostly in 10-12 range, remember one 7.x one 2.x.
I don't like AHI because you can have 6-7 hours of good data but 1-2 hours of near death and still have an acceptable AHI. It is an average that includes the "no problem" periods, which skews the number.
Yes, there are all kinds of things that "AHI" by itself tends to ignore. But docs are not in the habit of looking at subtleties. They want something that is relatively straightforward to measure, and AHI is what they've settled on.
Quote:I understand the quibble over the acronym--I think most people call ANY "give you air while you sleep" machine a CPAP, whether it varies the level or not. Even the ones that vary the level seldom lower the pressure to zero, therefore technically they are indeed correctly called CONTINUOUS---there is continuous pressure (as opposed to Constant Level). I don't get hung up over that.,
You are splitting a hair here that the medical community does not split for historical reasons.
The name CPAP = continuous positive air pressure was coined in the early days of treating OSA by something other than "do a trach on the patient if the OSA was a clear and immediate threat to the patient's life" and "ignore it if the OSA wasn't clearly an immediate threat to the patient's life". (And before CPAP, OSA was "ignored" for most patients; the risks+probems vs. benefits of a trach were simply too great to do them routinely on OSA patients.)
Back then no-one was even thinking about trying to design a machine that would automatically adjust during the night. The idea was (and largely remains): Find a (fixed) positive air pressure that keeps the patient's airway from collapsing when they are in REM supine sleep and have them use that pressure all night long, every single night. The "continuous" part of CPAP was that the patient had to have the (fixed) positive air pressure delivered continuously
throughout the night.
And those early CPAP machines literally did NOTHING but blow air at a fixed pressure continuously all night long down the patient's upper airway. They didn't analyze the patient's breathing in any way, and hence they didn't record events that occurred during the night; heck the earliest ones didn't even record usage.
Once the technology advanced enough where it was possible for a CPAP machine to analyze the patient's breathing on a breath-by-breath basis, it was possible for companies to start marketing machines that recorded efficacy data
, which includes both AHI data and leak data. And for the first time a doctor (or a patient) was able to determine whether the pressure arrived at through a manual titration study in a lab was indeed proving to be therapeutic in the patient's own home night after night.
And once it was possible to record efficacy data
, someone eventually got the bright idea of designing a machine that could not only record the efficacy data, but respond
to it. These machines are properly called Auto CPAPs---as in Automatically adjusting continuous positive air pressure machines. They've been renamed APAP for short.
Quote:I have not learned all the other abbreviations/acronyms for functions, data elements, etc. OSA? Quite the lingo here. Learning curve at hand and communication impacted until that is over.
Yes, there is a lot of abbreviations and acronyms. And it does take some time getting use to it all.
To start with: OSA stands for obstructive sleep apnea
. It's the name of the primary condition that CPAP and APAP is designed to treat. OSA is characterized by the upper airway repeatedly collapsing or partially collapsing while the sufferer is asleep. When the airway collapses, the patient continues to try to breathe, but no air can get into the lungs. This can trigger an O2 desaturation in the blood or a mini-arousal or both. During the mini-arousal, the patient arouses just enough to consciously force the airway to open back up so normal breathing can resume. When the airway is collapsed for at least 10 seconds, it's called an obstructive apnea
or an OA for short. A partial collapse of the airway leads to enough of a reduction in the amount of air getting into the lungs to either cause an O2 desat or a mini-arousal or both. Like an apnea, eventually the person arouses just enough to consciously force the airway to open up fully so that normal breathing resumes. When the partial collapse of the airway and reduced airflow lasts for at least 10 seconds, it's called a hypopnea
or an H for short.
You might find some of the entries on my blog Adventures in HoseHead Land
useful. In particular, it may help you to read through Understanding the data in your sleep test report
as a starting place. I do a pretty thorough job of explaining a lot of the various acronyms that you run into on this board.