Need Adjustments

[Gideon]

believe me, there is no intent to shock you.

The normal path to ASV because of insurance rules is to 
FAIL CPAP
FAIL BiPAP
FAIL BIPAP w timed backup 
Succeed with ASV

Hopefully, you can bypass several of the steps.

Are you self paying or are you using insurance?

We can help you locate the lower priced machines.

[Melman]

You definitely need to follow Sleeprider's advice and contact your Dr. In the meantime, in my opinion, you should continue using the machine. It seems to be providing some improvement over what was seen in your sleep study and your Dr. and insurance may want to see more data from this machine. Sleeprider or Bonjour may have additional advice.

[jaswilliams]

I would keep using the machine but talk to your dr. Using the machine shows you are trying despite the difficulties this will help the dr make a decision in moving to the next stage

[Gideon]

OK, let's try a fixed pressure tonight, set both min and max to 11 and still no EPR.  Yes I realize that this will likely increase your Obstructives slightly.  But let's try to get you as comfortable as we can with the machine you have.  It is important too let us, and your doctor, know how you feel.  The purpose is to document your failure at being successfully treated.  The end goal is to get you on an ASV machine.

[Gideon]

I'm going to move this back to the forum.  The forum has its checks and balances in that others like Sleeprider will bring in other points of view.

Your sleep study tells me that you have mixed or complex apnea, They said the impression was obstructive apnea.  If it was just obstructive apnea the machine you purchased was the best machine that you could have purchased.

To get Medicare to fund the proper (ASV) machine you will need an ASV Trial at a Sleep Lab.  The info that you are generating will help to justify that.  
Identify a sleep doctor that prescribes ASV machines, all of them do not.  You state that you have Mixed and Central Apneas and are currently failing to get satisfactory results with an Auto CPAP.

[Sleepless Night]

Your analysis would be most appreciated.
From our last discussion the Apnea Board thought that I might not have the right machine for my particular case of Apnea. Since then I have had a titration sleep study. (see attachment)
From those results my Dr. changed my machine settings from auto to continuous pressure at level 8 ramping from 6.  Since then I have had no better results. (see attached Sleepyhead screens)

Effects of the current setting are to wake me at 5 - 6 hrs of sleep with my chest feeling tight and my body feeling warm and moist. I have been unable to fall back asleep after that awakening in most cases, and just remove the mask.  I have intermittently been using CPAP and instead using a sleeping drug every few nights to get more sleep. I have bumped up the level to 9 and 10 with no real change in sleep.
Unfortunately, the Dr. visits are 4 wks apart so no real time adjustments are occurring. In the meantime Dr. has asked me to keep a sleep log.  I am looking for any suggestions, next Dr. visit 2 wks out and I am about to abandon the cpap and just take OTC drugs. Is this the normal process to get to a solution, it seems to be taking much too long to me. 

[Sleeprider]

Your sleep study is a classic example of making the wrong conclusions based on seeing exactly the opposite of what actually happened.  It's bizarre!  It was recommended that CPAP pressure be administered to resolve obstructive apnea and that you take conservative measures to avoid sleeping on your back and lose weight.  The facts are that you had zero obstructive apnea and a number of central apnea and never slept on your back (supine). Not to mention you have a completely normal BMI.

The lowest oxygen saturation ocurred during CA events near sleep transitions from wake to sleep and are equally prevalent on your left or right side.  You were only tested at pressures of 8 and 9 cm and only 5-minutes at 7.  Somehow you had 3 CA and 1 H events at a pressure of 7.0, zero events at 8.0 and 6 CA + 2 hypopnea at 9.0 cm. Ultimately, they recommended a pressure that was not tested and determined you have obstructive sleep apnea in spite of the fact zero obstructive events were recorded.

Impression: This study, along with the clinical history, is
consistent with obstructive sleep apnea. CPAP titration was
performed and this patient's sleep disordered breathing was
significantly improved with minimal residual respiratory events.
Recommendations: Recommend CPAP at an empirically higher pressure
setting of 11 cmH2O with heated humidity. A ResMed AirFit F20
full face mask size medium was used during this study.

Implement conservative measures such as weight loss, sleeping
with a positional device (to avoid the supine sleep position),
and optimizing any underlying pulmonary and/or sinus disease as
indicated clinically

It looks like the results were either written looking at s different patient's data or was boilerplate used for everyone. The impressions do not reflect the observations.  Your actual results confirm primarily central events that occur randomly at different pressures evaluated, and a high degree of sleep disruption. Nothing was resolved here. I'll be interested in Fred's take-away.

[Gideon]

Your Titration Sleep study: You were tested at CPAP pressures of 4,7,8,9.  At pressure 7 you had an AHI of 48, and NO apnea at 4 or 8.  If you were having OSA you should see some at 4 and 8, and 9 which was mostly CA.  I strongly suspect the 48AHI during your sleep study was positional apnea from chin tucking since it is very prevalent in your sleepyhead charts.  No mention of the Central Apnea but that is fairly common.  And what crystal ball were they using to come up with an Rx for 11 cmw when it was never tested and especially in the presence of CA.
Overall impression: What a piece of C***.  

Your Sleepyhead charts show that most of your OSA is strongly positional.  The recommendation for that is to use a soft cervical collar, loosely fitted to prevent your chin from tucking.  
What you are left with is CA which with this machine will be consistently inconsistent.  The flow rate between 2 and 240 may be flow limits but I would want to see you flow limit chart to confirm it.    Drop Mask Pressure and add Flow Limits, and Snores charts, shrink the charts vertically to fit these in, we don't need much detail on these unless we request a detailed view.

SleepRider, what do you think?

Fred

[Sleeprider]

Gosh Fred, you took the words right out of my mouth. I especially like the "consistently inconsistent" part.

Tom

[Gideon]

The below is from a wiki article Justifying_Advanced_PAP_Machines
Pay attention to the list of symptoms, not all of them indicate apnea but all can impact your quality of sleep.
I want to see your sleepyhead charts without the positional apnea before we go headlong down this journey

It is very likely that you are here because someone referred you here because after reviewing your Sleepyhead daily charts and/or your Sleep Studies they felt that you are a candidate for an Advanced PAP machine such as one of the Bi-Levels. There are two paths to treatment and the choice is yours.
Path 1: The path that you were thrown into whether you realize it or not. That is to treat your apnea, whatever types of apnea that you have, with the machine they gave you, a CPAP, preferable an auto-CPAP either the ResMed or the Philips Respironics machines. New members of the forum come here looking for help with intractable apnea and discomfort from these problems. The forum members and "gurus" are very good at optimizing therapy to reduce these problems, and increase comfort with the therapy.
Path 2: Take the often difficult and lengthy journey to procure an advanced PAP machine. The new member that has been advised they have central or complex apnea needs to be aware that optimizing may provide significant immediate relief from symptoms and improve AHI, but improved therapy results can disqualify them from higher levels of therapy (ASV), that might be possible without this self-optimization. Sometimes individuals resolve central and complex apnea with CPAP and find long-term comfort, however, if results are inconsistent, or produce good AHI but not comfort or relief from other symptoms, The forum optimization should be discontinued as soon as possible to avoid disqualification from higher levels of therapy. This path frequently requires failing at CPAP, then failing at BiLevel E0470, before succeeding at ASV E0471

For Central Sleep Apnea the Medicare requirements for issuing an ASV machine.

• Therapy Optimization should be discontinued and the original settings, from the doctor, restored.
  
  
• Document a central apnea-central hypopnea index (CAHI) is greater than or equal to 5 per hour also apnea-hypopnea index (AHI) greater than 5'
  
  
• Document The sum total of central apneas plus central hypopneas is greater than 50% of the total apneas and hypopneas
  
  
• Document the presence of at least one of the following symptoms: These symptoms are specifically noted by Medicare. These are key symptoms that we look for by asking "How do you feel?". Do not limit your answers to the following and do not fabricate the answers.
  

1. Sleepiness, "How do you feel?"
   
   
2. Awakening short of breath, "How do you feel?"
   
   
3. Difficulty initiating or maintaining sleep, "How do you feel?"
   
   
4. Frequent awakenings, or "How do you feel?"
   
   
5. Nonrestorative sleep, "How do you feel?" Nonrestorative sleep is defined as the subjective feeling that sleep has been insufficiently refreshing
   
   
6. Snoring, Can be documented on Sleepyhead
   
   
7. Witnessed apneas Most of us have this one with our significant others
   

Symptoms
Note that these are not all specific to Central/Mixed/Complex apnea. They are symptoms that impact our sleeping, arousals, and yes apnea too. Think of these, but do not limit yourself to these when you get asked "How do you feel?"

• Daytime hypersomnolence;
  
  
• Excessive fatigue;
  
  
• Morning headache;
  
  
• Cognitive dysfunction;
  
  
• Dyspnea, etc.;
  
  
• Fatigue;
  
  
• Insomnia;
  
  
• Difficulty going to sleep;
  
  
• Difficulty falling asleep;
  
  
• Wakening during the night;
  
  
• Daytime Sleepiness;
  
  
• Excessive Daytime Sleepiness (EDS);
  
  
• Poor concentration;
  
  
• Difficulty with balance;
  
  
• Shortness of breath;
  
  
• Dry mouth;
  
  
• Restless Sleep;
  
  
• Non-Restorative Sleep;
  
  
• Snoring;
  
  
• Obstructive Sleep Apnea;
  
  
• Restless Leg Syndrome;
  
  
• Nocturnal Leg Cramps;