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Seeing if I can further reduce my AHI
#1
Seeing if I can further reduce my AHI
Good day Apnea friends,

I've been reading this forum for a long time, and have tried to glean as much information as I can.  However at this point I wanted to post my story and screenshot and see if there are any suggestions for me.  

I've been on a Dreamstation CPAP Pro with the full face mask since last June and have been Sleepyheading since about that time.  We started with my Dr. giving me an at home sleep test.  The AHI was over 60 and my O2 level dropped at points to being below where he wanted.  This place is sort of hands off so they prescribed an APAP and just let it do it's thing.  Yes, I know a CPAP Pro isn't an APAP but I'll get to that in a moment.  

In October, I had gastric bypass and have lost 115lbs since then.  The largest challenge here has been that my face keeps changing shape and I have to keep cranking my mask straps down or I leak and that annoys my wife and makes me not sleep as well.  I was hopeful that the weight loss would solve the apena and while my pressures are much lower, I don't think I'm getting off the machine.  I recently did a follow up sleep test, but woke up at 4 AM with a massive headache (it was my first night off the machine since June) and I took off the test gear and put the CPAP back on.  I have to go back to the Sleep doctor but wanted some input from this group first.  

One mistake I made early one was thinking that the CPAP Pro was an APAP if you keep flipping into A-Trial mode and I used all of them up.  The Dr office said they gave me an APAP, and well, mea culpa.  My insurance is rent to own and I'm two months from owning the CPAP Pro.  I asked if I could switch that out for the APAP and pay the difference but they were a bit confused on that.  The Dr originally said I could but the DME person said basically I'd have to start over on a new rent to own.  I'm not sure what the truth is there but the first question is whether a real APAP vs the CPAP Pro would help me.  I may have enough FSA money this year where I could buy the base APAP Dreamstation and hopefully move the humidifier I have from the CPAP Pro to the APAP and then just keep going.  In that case, I will pay off the CPAP Pro and get the APAP direct out of pocket.  

My AHI is usually under 5 or around 5.  I recently figured how CPAP+ mode works in that it adjusts pressure every 30 hours so maybe the "baby-APAP" mode of CPAP Pro is enough.  However based on my prior time in A-Trial mode and my AHI graph, the early morning hours do better cranking pressure up to deal with that time of night.  

Here is my sleepyhead chart from last night.  I'm at 6 fixed, flex is off, and I have a smartramp set to 15 minutes just so I'm not blasted right after I hit the on button while I get the mask settled etc.  

   

Overall I'd say the CPAP has been great.  I sleep better and feel rested in 8 hours sleep instead of 10+ which I wanted before and thought was "normal".  I'm just seeing if there's anything I should be doing to make things better.  I see example Sleepyhead charts with AHI under one and nearly empty of events so seeing if that's what I should be aiming for.  Should I bother considering the APAP?
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#2
RE: Seeing if I can further reduce my AHI
Congrats on the amazing weight loss! That is really fantastic, and the question is, do you feel good with the weight loss, or was the liquid and restricted diet a difficult process to tolerate?

Okay, your questions on apnea. The auto CPAP machines are really great as your needs for positive pressure change. Your weight loss is clearly one of those circumstances, and I suspect that your doctor can support the medical necessity for an Auto CPAP to replaced your fixed CPAP. This would be justifiable, from the perspective of avoiding another sleep study, which would actually be more expensive than the replacement APAP. The criteria for APAP needs to be to get one that is responsive to changing pressure needs, and in your case, one that provides some bilevel pressure (separate inhale and exhale pressure) to resolve the flow limitations that I'm going to show you have, and are what is keeping you from achieving the much lower AHI you want.

First, neither your DME nor your doctor can answer the questions regarding machine rental and what will be allowed. You must contact your insurance provider and confirm whether they require rent-to-own, and what rental period is required, if any. The DME makes much more money renting a machine, and it's not unheard of for them to tell their custormers that it is the insurance that requires it. Often, that turns out to be a lie. Second, you should consider whether you should go through the DME at all. Consider the hassle and deductibles and copays, then consider a new Resmed Airsense 10 Autoset will cost about $600 from Supplier #33, or a used machine, for example the Autoset listed in the Fredricksburg Craigslist for $300 with 8-days of run time, might be a better solution. There are many ways to get the device that would serve you better, and these are just a couple ideas.

WHY the Resmed Airsense 10 Autoset? You have flow limitations. Try zooming in on your flow rate chart to the point your can see the individual breaths. You will quickly see your breathing is irregular with a flat or downward sloping inspriation peak. I know this because your events are predominately hypopnea, and you have a lot of RERA. The solution to that is not more pressure, but a difference in pressure between inhale and exhale. The Resmed machines use EPR (exhale pressure relief) to provide up to 3-cm difference between inhale and exhale, and it is delivered just like a bilevel (BiPAP) machine. This difference is enough to resolve flow limitation and significantly reduce hypopnea. Read the wiki http://www.apneaboard.com/wiki/index.php...Limitation

The last question regards your mask. Have you ever tried nasal therapy? A nasal pillows mask is not sensitive to your changing facial structure and can be very comfortable, as long as you don't leak through the mouth. In any event, there is no question you should talk to your DME about a new mask and get a new size or model that fits your new face.
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: Seeing if I can further reduce my AHI
Thank you for that insight!

The weight loss process was a process.  While the liquid diet of the first few weeks was a challenge, I actually thought it was harder to fast the 3 days before my surgery where I got to eat essentially nothing that wasn't a clear liquid.  After my body was ok with just doing the small protein shakes while it figured out what was going on.  Today, six months later I can eat more normal food.  I had chicken and veggies for lunch.  I do feel much better overall.  Similar to how when you first get on apnea therapy; you just feel better overall.  

Zoomed in, the flow graph looks essentially how you described.  The top is "chopped off".  

   

That's pretty interesting to me.  I turned off the Dreamstation's Flex completely as I thought that improved things but I guess it's not doing me any favors.  I've turned it back on the default setting just now and we will see what happens with that.  I'm still certainly open to changing out hardware, but since I have this machine, I figured I'd flip that back on.  I don't know much about the Resmed side of things; I'll have to look at those machines.  I don't even have a prescription for an APAP yet but I'm planning on getting that and holding on to it for later in the year.  I am willing to change out hardware if it'll make things better though.  

In terms of getting a new machine, my hope is to have enough in FSA must-spent by the end of the year to just buy one and be done with it.  No insurance or DME or any other headaches.  Just once and done Smile.  

In terms of the mask, I think I'm ok with the full face Dreamview.  I actually rather like it.  The challenge has been that as my face shrinks, it's not tight enough or too tight when I crank it down, etc.  Endless tinkering to get it spot on and then I change.  However that phase should end soon as hopefully I'm reaching the bottom of my weight spectrum.  My BPI is now back in normal range and I can't imagine there is that much left to go.
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#4
RE: Seeing if I can further reduce my AHI
With your current machine, I think your pressure actually needs to be closer to 8.0 cm or higher. My suggestion is that you start increasing pressure in 0.5 increments and observe the changes in how you feel and the AHI. This should help to open up your airway a bit and relieve residual restriction. CFlex cannot do what EPR does. CFlex drops pressure by up to 2-cm at expiration, but returns to CPAP pressure before inspiration begins. That is why exhale sometimes feels cut off prematurely. A Flex setting of 1 always worked best for me with the Philips machines.

I'm a strong believer that the Resmed Autoset is superior therapy device, for several very good reasons that I touched on earlier. If you do start looking to change machines, we can get into it in more detail. A prescription for CPAP will always work for auto CPAP. They are both CPAPs and actually are billed to insurance under the same code. The reason most people end up with a fixed pressure CPAP is that they are less expensive and the DME makes more money. Be sure to obtain copies of any sleep tests and prescriptions for your files. These things tend to disappear over the years, and they can meet your needs to avoid a new study for many years to come.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Optimizing Therapy
Organize your OSCAR Charts
How To Attach Images And Files to your posts
How To Deal With Equipment Supplier
Mask Primer
Beginner's Guide to Sleepyhead

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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#5
RE: Seeing if I can further reduce my AHI
Thank you again!

So I've pushed the pressure to 6.5 for tonight and set flex to 1.  The last pressure I had from the last A-Trial period was 7.5 but it was coming down so I extrapolated based on that decent each month and kept going.  I've gone too far I guess.  

My lesson learned from all of this was I should have gone in earlier with a clearer sense of what I was getting.  However I was in a different mindset then.  It was my initial diagnosis and I really did it to make my wife happy who was tired of worrying about dying in my sleep.  I didn't expect to feel that much better and if I did I was only going to need the machine until after my surgery and it was going to go away.  It turned out far different.  I should have gotten the APAP from the start if they were the same price and just gone with that.  I feel like I was hosed by DME which will never happen again.  

I called insurance and their guess was that I'd basically paid the machine off.  It's been 10 months and they say after that it's mine so good/bad at least that is settled.  They said that if the Dr thought I really needed an APAP they could try and generate a letter of medical necessity BUT insurance wasn't sure that would be covered even then.  To be fair, insurance has paid like $90K in the last year for me for the bariatric surgery so you know, I've probably got my money's worth there.  

So the plan ahead is to try do to what you suggested with my Dreamstation and look at where FSA balance (and my Sleephead/OSCAR charts look like) is in the fall.  I like what I'm seeing with the Resmed, particularly the light sensor for the display.  The Dreamstation lights up the whole bedroom whenever the display turns on and bugs everyone (I know that's minor but sometimes the little things ...)  

I'm going to go back to the doctor in a few weeks and get both of my sleep test results and a copy of a prescription.  Both sleep tests I've had were at home with the little unit you strap on your chest.  I've never had any fancy titration or any of that.  They just threw a machine at me and see if the numbers got better.  They did so I guess they left that be (plus they knew I was having surgery and I guess that could change anything going forward).  I went from 60 to 5-ish and I guess that's good enough for them to check the box anyway.  

I've ordered a finger SleepyHead compatible PulseOx (the D+) to try a couple of nights out of curiosity.  Based on what I've read here there's no real reason for me to do that long term, other than I like data and I find the whole Sleepyhead program fascinating.
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#6
RE: Seeing if I can further reduce my AHI
So I've scheduled a meeting with my Doctor next week and I'm probably going to get a prescription so I can buy the Resmed Airsense Auto as recommended.  I called today and they sent me a copy of my sleep study.  This was from last week, after the 115 lbs of weight loss (before it was Severe Apnea).  I knew the night of the test though it wasn't going very well.  I woke up with a headache at 4 AM and put my CPAP back on.  Sleepyhead recorded an AHI of 9 for those 2 extra hours of sleep but I still felt way better.  

   

Should I be worried about those Centrals?  I will add that on this night, our 4-year crawled into bed with us so maybe it's a central, or maybe it's a 4-year rolling over and kicking daddy in her sleep (which happens enough to me it should have it's own flag in Sleepyhead).   Smile

For completeness, here is last night's Sleepyhead.  I've been increasing the pressure slowly and I turned the flex on and to 1 on my Phillips.  Honestly I think I feel worse with flex on so might switch that back off.  I'm not sure the overall picture has changed much, but I've slowly ramped the pressure up to 7.

   

I feel the Resmed Auto will solve much of my issues with flow limitations and my present guessing a pressure.  I just wanted to see an opinion on the Centrals to make sure I don't need to ask about a ASV or something.  That would require insurance help as I don't think I want to swing an AirCurve Auto out of pocket.
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#7
RE: Seeing if I can further reduce my AHI
(03-25-2019, 01:27 PM)Sleeprider Wrote: With your current machine, I think your pressure actually needs to be closer to 8.0 cm or higher.  My suggestion is that you start increasing pressure in 0.5 increments and observe the changes in how you feel and the AHI. This should help to open up your airway a bit and relieve residual restriction.  CFlex cannot do what EPR does. CFlex drops pressure by up to 2-cm at expiration, but returns to CPAP pressure before inspiration begins.  That is why exhale sometimes feels cut off prematurely.  A Flex setting of 1 always worked best for me with the Philips machines.

I'm a strong believer that the Resmed Autoset is superior therapy device, for several very good reasons that I touched on earlier.  If you do start looking to change machines, we can get into it in more detail.  A prescription for CPAP will always work for auto CPAP. They are both CPAPs and actually are billed to insurance under the same code.  The reason most people end up with a fixed pressure CPAP is that they are less expensive and the DME makes more money.  Be sure to obtain copies of any sleep tests and prescriptions for your files. These things tend to disappear over the years, and they can meet your needs to avoid a new study for many years to come.

In this post from Sleeprider I see a lot of similarity to advice that he was giving me about two years ago. Your experience is very much like mine except I have not had the surgery that you have. The APAP that I purchased out of pocket (for the same reasons that you have mentioned) has served me well. You are getting some very good advice, best wishes in your journey.

Stan
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#8
RE: Seeing if I can further reduce my AHI
Your central events are not at a level of concern. Most of your events are hypopnea and I think the Airsense 10 Autoset is going to give us the best shot at cleaning that up, and it will also show us if those centrals are real. We can see your therapy has good and bad cycles through the night, and the RERA is quite high. I'm hoping that automatic pressure is gong to head off these events and EPR (exhale pressure relief) will help you to breathe better. The sleep study is nearly worthless since it does not show sleep stage and we basically see 2-hours on your back. Hypopnea can be obstructive or central, and the test does not differentiate. Your current CPAP reduces events by about 66%, and I think we can look forward to better results on the Autoset.

It's been about 30 years since I had a 4-year old in the house...enjoy it while it lasts.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Optimizing Therapy
Organize your OSCAR Charts
How To Attach Images And Files to your posts
How To Deal With Equipment Supplier
Mask Primer
Beginner's Guide to Sleepyhead

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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#9
RE: Seeing if I can further reduce my AHI
Well, today's visit to the Doctor didn't go very well.  I explained I wanted a copy of my prescription and an APAP and he essentially wouldn't give it to me.  He wants the in-house DME group to see about getting the machine for me.  I left but I'm heated.  I have one more month of this CPAP to rent and then I believe I'd own it.  

That said, if he is able to switch out the CPAP I have now for the Resmed Auto, and my monthly rental price were to save the same the price would be about $200 vs the $600ish it would cost to outright buy it.  So I'm torn between leaving on principle which I feel is the right thing to do, or start a new rental period for another 10 months and saving the money.  The problem is that I don't trust them as the Doctor or DME so I'm not sure I want to prolong the relationship.  I'm not sure my family doctor would feel comfortable writing a prescription for the CPAP.  I see there are telemedicine options for getting a CPAP prescription (and I do have my sleep study as above which pretty much has what would be prescribed on it.  If I had to, I guess I could get the telemedicine prescription, and then do a records release from the DME and move everything over to a new provider.  I'm guessing I shouldn't do that until this CPAP machine is paid off though, unless I want to return it (I have no desire for it once I have the APAP but I've almost paid it off).  

He did agree that I probably don't need a BiPAP or ASV but really this guy isn't a gem in terms of Sleep Doctoring.  More the, "throw a cheap home sleep study at them and get them on DME" type.  

I do appreciate all the advice though.  I do really intend on getting the Resmed once I sort out this paperwork nonsense.
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#10
RE: Seeing if I can further reduce my AHI
jquagga,

If feel your pain. Whatever happens, you really need to be sure you are diagnosed properly and get a prescription for an appropriate machine. I have predominantly Centrals (mixed, but 75% of my events are Centrals) and about 40/hour as recorded on a ResMed VAuto machine.  That was my Sleep Study #5.  #6 was with a ResMed AirCurve ASV machine and dropped the AHI 40/hr number down to 3+/- per hour.  So, bingo!  After 6 Sleep Studies and 9 months later, the big KP here in Sacramento finally nailed my diagnosis and needs.

That said, I'm an out-of-pocket patient when it comes to Sleep Disorders and getting equipment.  I happen to be on Covered California (CC).  It doesn't matter if you have the CC Rolls Royce plan or the CC Hyundai plan.  The big KP won't provide DME if it originates outside the four square walls of their offices.  Of course they jerked me around for another month before I found somebody willing to explain all that to me.

So there I was, 10 months down, 8 masks, 6 machines and Sleep Studies, and I finally got a prescription for a ResMed AirCurve ASV machine, a pat on the behind and out the door without any help thereafter.  Thank you "Apnea Board" and its helpful members, I am forever grateful.

So I found the all powerful ASV machine for $2,149 at Supplier #2 . Oh-jeez  Fortunately I found them on my own, before I knew this Apnea Board existed.  They really had the best price I could find on the ResMed ASV machine.  But, the reason I am saying this, is because it is a very expensive machine.  Don't be quick to think you need an ASV machine since they are so pricy.  Your needs are up to the doctors to determine.  Hopefully you have enough faith in them to at least be able to determine that much.

BTW, I found a mask (F20) very cheap from another online supplier and Supplier #2 matched that price.  So, a lot of money spent.  But it is effective for my Centrals, and I am a happy camper Big Grin  having spent the money to get exactly what I needed.  Hopefully you won't need an ASV, but if you do, I really like the ResMed ASV a lot.  Of course I have no experience with the Respironics equivalent.

Like I said, I feel your pain.  But certainly don't give up.  You will appreciate the results of how you feel and improved health once you get the proper machine and start to get it dialed in for what works for you.  I hope your journey is a bit smoother than mine was.  Push and fight when you need to.  Best of luck.
Sleep-well
Ray
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