Recommendations for new BIPAP machine

[Sleeprider]

Insurance will usually require you fail bilevel before purchasing ASV. It would clearly help if your diagnosis was more appropriate to the high presence of central apnea. There is an outside chance you will be fine on bilevel, but it is the exception, not the rule Acs long as you have good insurance and can afford to follow the procedures to justify advance PAP, that is a good way to go, just understand the process and don't be frustrated or surprised if bilevel therapy is not working.

[Shvitzer]

Insurance will usually require you fail bilevel before purchasing ASV. It would clearly help if your diagnosis was more appropriate to the high presence of central apnea.  There is an outside chance you will be fine on bilevel, but it is the exception, not the rule Acs long as you have good insurance and can afford to follow the procedures to justify advance PAP, that is a good way to go, just understand the process and don't be frustrated or surprised if bilevel therapy is not working.

So - I think I'll explore the ASV possibility first, and if it seems to be a dead end, I guess my next step would be to shoot for an Air Curve 10  V Auto.  With that machine, and if the therapy demonstrably doesn't solve the problem, I gather that I would be able to show the need for upgrading to ASV.  Question- does that ability to upgrade hinge on the first machine being a rental, rather than a outright ownership?

One thing I may (???) have going for me is that my insurance is Medicare plus a good supplemental.  Given my age, health, and the fact that I am not chancing a sleep study, maybe things might be a tad easier.  My understanding is that Medicare has recently suspended the sleep study requirement.

[sawinglogz]

Be aware, there is a cardiac contraindication for ASV if you have low ejection fraction. If you've had an echocardiogram, the report will include the ejection fraction they measured.

[Sleeprider]

Medicare is actually pretty rigid in progression starting with CPAP then bilevel and finally bilevel with a backup breath rate. Like you, I pay nearly nothing for health care with a CalPERS supplemental plan. I’m on my phone right now but will provide the Medicare CMS requirements for qualifying for ASV. Your PSG test is sufficient but the diagnosis needs to be changed. Be fairly aggressive with the sleep doctor that signed off in disagreement with that diagnosis and eventual need for ASV. Candidly tell him you are willing to suffer the trials and failures of COAP and BiPAP but want to be in the best possible position of those therapies fail and you require ASV. Do this and he should treat you wit some respect you know what you’re talking about. If not, fire him and go to a competent physician.

I can’t explain why most sleep specialists never actually see a patient but instead sign off on technician reports. You just have to figure out if you are actdealing with a concerned physician or a guy making money for nothing. They are out there, both good and bad.

[Shvitzer]

Thank you so much for the info.  Will check with my primary doc.

[Shvitzer]

Thanks again.  What an education I'm getting!  Got my work cut out for me in the upcoming days/weeks.

[Shvitzer]

Well - it's been some months, and I haven't made my selection.  From what was posted on the Forum, it makes sense for me to get an ASV, but my hesitation has to do with the cardiac contraindication.  My last echo-test showed a normal ejection rate, (about three years ago) and I have another echo coming up next week.   My primary doc (who happens to be a cardiologist) says he'll back me up on whatever machine I want (including ASV)...but my concern with an ASV remains the eventuality of a decrease in ejection rate, resulting from deterioration in my cardiac function. To what extent is the Resmed ASV switchable to "regular" bi-pap function, in such a case?  Could it then operate like an Aircurve 10 Auto?  Funny - my primary doc isn't worried about this, but I am.  Many thanks.

[Sleeprider]

The main reason the ASV cannot duplicate the Aircurve Vauto is that minimum pressure support must be at least 5 cm higher than min PS. Also the Vauto is completely passive during apnea and does not trigger IPAP, the ASV will.  I think you really need to consider that the SERVE-HF study had many faults and among other things used an older generation of ASV machines. The cohort identified as vulnerable to the cardiac failure were all severe congestive heart failure patients with LVEF less than 25%, but the advisory was conservatively set at 1.5 times that value at 45%.  A new study ADVENT-HF in progress since 2010 has not found the risk factors exist with a cohort of CHF patients can be duplicated using more modern ASV machines, properly titrated with compliance monitored. https://www.advent-hf.com/  You are simply not in the at-risk group, even if we take the warnings of the SERVE-HF at face value. https://pubmed.ncbi.nlm.nih.gov/28371141/

[Shvitzer]

Thank you so much, Sleeprider, for this very informative response and update.  I will share it  (and the video) with my primary doc.  This information certainly has helped move me in the direction of the ASV machine.

[Sleeprider]

Glad you found that useful. There is a lot more to dig into, but my specialty is risk assessment, and I don't see where you have a great deal to fear from ASV. While an older study identified a risk that resulted in termination of the the study, and a general warning for using ASV with individuals meeting LVEF impairment, that result has not been duplicated in a study on a similar cohort, using properly titrated contemporary machines with documented compliance rates. None of those conditions existed for SERVE-HF. I think the current cautionary statement fails to consider the significant benefits of ASV to individuals suffering central apnea, Cheyne-Stokes respiration and complex apnea when combined with CHF. Out of an abundance of caution, ASV has been precluded from a significant population that might benefit most from its use, but that are identified in a single, unduplicated study to have a significant risk of cardiac failure for for unknown reasons that do not appear applicable to individuals with modern ASV therapy, monitored for compliance and properly titrated. Somewhere in that problem solving morass lies an answer, however I must come back to the fact you are not in the risk cohort.