[Treatment] Noob; wondering about equipment, info dump below - Printable Version +- Apnea Board Forum - CPAP | Sleep Apnea (https://www.apneaboard.com/forums) +-- Forum: Public Area (https://www.apneaboard.com/forums/Forum-Public-Area) +--- Forum: Main Apnea Board Forum (https://www.apneaboard.com/forums/Forum-Main-Apnea-Board-Forum) +--- Thread: [Treatment] Noob; wondering about equipment, info dump below (/Thread-Treatment-Noob-wondering-about-equipment-info-dump-below) |
Noob; wondering about equipment, info dump below - ZPrime - 03-23-2020 Hello Apnea Board! I'm 38, weigh about 290lbs, 6'3". I've got a beer gut, definitely not a small person. My wife complains about my snoring and breath cessation followed by choking/gasping in the middle of the night. I'm always tired, no matter how long I sleep. I can sleep 12+ hours and still feel tired afterwards. I'm an IT guy and have often had to work weird hours in the past, but my body also seems to prefer late hours. I'd consider myself an extreme night owl. If left to my own devices, I usually don't get tired until 3-4AM and wake up at 12-1pm. This makes normal life pretty difficult, especially when whatever sleep I do get, sucks. Typically a stomach sleeper, sometimes side. Don't like to sleep on my back but do on rare occasions. Definitely a mouth-breather at night; I often feel like I can't get enough air through my nose - sometimes because of congestion, other times I just don't like the whistling sensations I get from my nostrils. Went to my GP, they ordered an in-home test (they call it "HSAT"). Here are the direct results from the MD that reviewed it... the in-home test made it hard to sleep on my stomach due to all of the garbage attached to me. I also woke up and used the bathroom at one point in the middle, which wasn't obvious to them during review (I left the equipment all hooked up). Quote:RESPIRATORY DATA: After the HSAT results came back, a nurse practitioner with my MD's office prescribed a "PAP Titration" PSG. I've never had a "normal" PSG, but from what I gather a "normal" one skips the mask until partway through the test? My titration didn't; they put a mask on me from the get-go, and then told me to try to fall asleep in a crappy hotel bed with 20+ wires coming off of me... Here are the (sleep MD interpreted) results from the lab PSG: Quote:SLEEP ARCHITECTURE: Sooo... given all of this. Do I have any choice in what machine I get? I was surprised that they'd suggest a BiPAP without any "auto" functionality, and irritated at the suggestion of an additional PAP titration in another 8-10 weeks. Why not just prescribe an Auto BiPAP?? Is my health provider just trying to line their pockets with another PAP titration? Since the last order was written by a NP and not an MD, she was willing to write the prescription for what the sleep analysis doctor "recommended," but was not willing to be more specific and recommend an Auto BiPap or anything like that. When I pushed, she said that I would need a direct consult with a sleep doctor for something like that, and put that into my chart and gave me a number to call... and then coronavirus hit and I haven't tried to call yet. I'm also concerned about costs at this point... I was laid off in January, when I was at the beginning of trying to figure all of this out (because it was affecting my job... and then got canned). I then had to go through the process of getting on my wife's insurance, which took forever, and then convincing my giant hospital system that I actually was on her insurance. And now, we have yet to actually see a bill / copay or any other information from her insurance, which has me even more worried about money. I got a very generous severance when I was laid off, but finding a job in the middle of this crisis is a daunting prospect... plus I wanted to get the sleep problems fixed before I went hunting, partially because if I was asked to have a phone interview at 9AM tomorrow, there's no way in hell I'd be able to get up for that. So yeah, sorry this is super long but I wanted to be thorough. TL;DR version: after a PSG suggested BiPap with relatively high pressures (and I was uncomfortable during the PSG due to the high pressure), should I be asking for an automatically adjusting machine? Is it "archaic" to prescribe a fixed-pressure device when all of the auto-learning stuff exists? RE: Noob; wondering about equipment, info dump below - jaswilliams - 03-24-2020 You have mixed apnoea a Bipap was tried as you still had Central apnoea’s these were still there it is likely you will need an ASV but there was no time to do an ASV titration at the same time so you have been prescribed a Bipap without a backup rate. I recommend if you can getting a prescription for a Resmed VAuto as this is the most flexible machine in its class but if as suspected a ASV type machine will be needed at a later date. Stick with the Resmed brand RE: Noob; wondering about equipment, info dump below - DeepBreathing - 03-24-2020 G'day ZPrime, welcome to Apnea Board. I agree with Jaswilliams - you have mixed apnea and should probably be looking at a Resmed Aircurve 10 ASV machine. Unfortunately your diagnosis is wrong: Nurse Wrote:ICSD DIAGNOSIS: The fact is you had a shedload of central apneas in your first test, so they'e not treatment emergent but endogenous. You can play around with bilevel machines till the cows come home, but you won't get proper consistent treatment of your central apnea. You need an ASV. Note that word consistent - treating centrals with the wrong type of machine will often show excellent results for a night or two, but then it will just go bad again. The ASV is designed specifically for this condition and is what you should be using. Now, there is one caution: A recent large study showed that people with severe congestive heart failure (left ejection fraction <35%) died at a higher rate when on ASV. However the study has been pretty much rejected and a new study with better controls and protocols seems to be indicating the opposite. However the guidelines limiting ASV for people with congestive heart failure are in place for the time being. RE: Noob; wondering about equipment, info dump below - SarcasticDave94 - 03-24-2020 I too think that you're going to need the ASV, specifically the ResMed AirCurve 10 ASV. This is what I still have currently, and it will give great results for you. As is, you would need to get a passing grade on the echocardiogram test, an ultrasound audio/visual of your heart. A cardiac doctor will review and issue a write-up with an LVEF grade as a percentage. You will need a 45% or higher to pass. No worries on this, as if you'd not be likely to pass this, you'd know you're in bad shape from heart issues. Be proactive in this as the doctor and others will go blind and not see central and mixed apnea as reasons for treatment with a specialized device like ASV. They also will not see the CA and mixed events. Only obstructive apnea counts to most of these doctors, you will actively make them look at these. RE: Noob; wondering about equipment, info dump below - ZPrime - 03-24-2020 Other than a relatively high resting heartrate (because I'm fat and out of shape), I have no known cardiac issues. My BP is just slightly high but not bad enough that my GP thought it was a concern. Why all the love for ResMed? Are the equivalent machines from Philips somehow lacking? Philips has a fairly large corporate presence near me which is the only (tiny) reason I'd maybe have a preference for them. RE: Noob; wondering about equipment, info dump below - Gideon - 03-24-2020 Welcome to the forum. Your problems start because of your "Official" diagnosis of OSA. It is EXTREMELY IMPORTANT that your home study contained a significant amount of central apnea. You need to continuously bring this up because this was without CPAP and therefore cannot be treatment-emergent sleep apnea. More on this later. Since I was reading this in the summary I thought you were heading down the correct road then I read the incorrect diagnosis of OSA meaning NO central apnea. Your Titration study, which was the correct type of study, was performed with the incorrect knowledge that you had no history of Central Apnea because your diagnosis was OSA thus the conclusion that your central apnea is treatment-emergent. It is not uncommon for a patient with treatment-emergent central apnea to be given a CPAP or BiLevel machine since this form of apnea goes away within 2-3 months as your body adapts. Again, you DO NOT have Treatment-Emergent Central APnea!!! With a CPAP or BiLevel device, (You need an ASV) treatment of the centrals is accomplished by avoiding the centrals. Treatment of Centrals with their proposed device, even the VAuto will be to decrease pressure support and pressure, which will increase obstructive events frequently resulting in a simple fixed CPAP pressure. In other words, the treatment that they are proposing is doomed for failure. Rest assured that we will work with whatever device you get to make the best of it. Talks with your doc have to like. "I understand how you got here, it started with HSAT that, I believe, incorrectly diagnosed no central apnea even though they found significant sleep apnea. Then the titration test HAD to incorrectly diagnose Treatment-Emergent Central Apnea because per diagnosis I had (incorrectly) no central apnea. Can you change that diagnosis after review? I understand that an ASV will treat all of my apnea, both the obstructive and central, HOW DO WE GET THERE?" Any talk with your doc has to be about how to get to ASV. Very likely this will require another overnight to trial an ASV. This is what you want. A PSG without an ASV is worthless to you. You will also need to clear your heart for your LVEF thanks to an earlier study suggesting that low values would be problematic. RE: Noob; wondering about equipment, info dump below - ZPrime - 03-24-2020 Here's the data from the lab PSG, unfortunately I'm not sure of a way to format it more nicely (it shows up in the Epic "MyChart" system as lines of space-separated text so not exactly simple to make into a real table) Code: PAP BUR O2 TST %Sup SupAHI REM RAHI CAI AHI ArIdx Nadir AvgSaO2 Moderator note: Here is the data tabulated in a spreadsheet. [attachment=21315] RE: Noob; wondering about equipment, info dump below - Gideon - 03-24-2020 ResMed hands down. Why ResMed? 1. Faster algorithmic response to events than PR. 2. Lower average pressure 3. Better to avoid Aerophagia. 4. EPR provides for better treatment of hypopneas, RERAs, Flow Limits, UARS, and snores 5. EPR acts like a BiLevel up to a limit of 3cmw and a max pressure of 20 cmw 6. EPR follows your breathing where as Flex predicts it with a feeling of fighting to get a breath when it predicts incorrectly 7. More flexibility in treating a greater variety of Apneas and respiratory events. 8. In general provides better therapy. I have frequently told many DreamStation users that they need to get either the ReaMed AutoSet or. BiLevel to get better therapy. Respironics costs less RE: Noob; wondering about equipment, info dump below - Gideon - 03-24-2020 For the PSG, best to copy, remove personal info, and post the resulting image. Scan then edit to accomplish that, take a pic with your phone as a last resort. There isn't really a cost difference between a simple BiLevel and a VAuto, like the others above I have a preference for the AutoSet in a CPAP and the VAuto as the base level BiLevel, but YOU need the ASV. PR vs ResMed ASV, many users here have used both and nearly all prefer the ResMed. RE: Noob; wondering about equipment, info dump below - ZPrime - 03-24-2020 Also - I truly and deeply appreciate all of the replies here so far, because I'd be totally clueless without all of your help! Very happy I started posting here before moving forward with a sleep MD consult - now I am better armed to have a useful discussion. One of the things mentioned in the info for the HSAT is that it can underestimate obstructive apneas. Would this mean they are then interpreted as central instead, possibly causing my centrals to read higher than they actually were? There was also this line from the lab PSG: "Some respiratory events that were scored as central events in this in-lab PAP titration appear to be related to obstruction in nature when looking at the respiratory flow shape." Is this just the interpreting MD not wanting to believe I'm having that many centrals even on PAP support? |