When is a BiPAP contraindicated over an APAP?

[srwilsn3]

I have used a (secondhand) BiPAP for over a year now to great effect (FL better managed, subjective sleep quality increases). My pulmonologist, upon finding this, insisted I cease use of the BiPAP and is wanting to prescribe me an APAP with no pressure support. She is saying that I BiPAP is not appropriate for me (based on a titration study showing my apneas were < 3 with CPAP pressure of 12), and BiPAP is just for people with central apneas or other complex breathing problems.

Is it true, in any sense, that there are contraindications for BiPAP over APAP/CPAP? She is now the second pulmonologist to say this, based purely on the fact that my AHI is less than 5 with CPAP. I hoping to make her see reason so I can have insurance cover my machine and supplies but it's feeling hopeless.

I have consulted Deborah K.'s thread for how she got insurance to cover her machine but my main impediment is convincing my physician a BiPAP is not making my sleep worse and is not contraindicated for most people.

[Nightynite]

I went to a pulmonologist in quest of a script to purchase a vauto. I took Oscar charts and a resmed titration guide for the Vauto. With in 5 min. we were done. He tried to tell me they were only for people with heart failure. My take is, they are simply better off as far as liability by just sending you to get a sleep test and let those sleep docs prescribe what is needed.

[SarcasticDave94]

It seems we're talking a standard bilevel, so there should be few to no reason the bilevel would be contraindicated. Your doctor doesn't seem to understand CPAP machines all that well.

Question, is the bilevel working for you? If so, why allow yourself to be talked out of successful therapy? You should counter insist the bilevel is better with pressure support.

[jdougc]

Nightynite , your primary care physician can write any script you need for your time cpap equipment. This works for me as my pulmonologist retired .

[Dormeo]

In addition to your PCP, your dentist or a nurse practitioner can write you a prescription. My PCP, in the Kaiser system, wrote one for me, even though there was no way a bilevel machine would have been approved for insurance coverage.

As for causing harm: I'm sorry to say your pulmonologist is completely wrong. In addition, the considerations she cites aren't potential harms; they are her (incorrect) views about when a bilevel machine is most appropriate.

[car54]

I recently requested a aircurve to replace my self bought aircurve with many hours on it. I showed my doctor all the charts and she gladly wrote the prescription but it was turned down because  I was well treated with normal cpap. I have COPD and NEED higher pressure support. The doctor talked to the district supplier and was told that around September 2024 Medicare tightened their standard to receive one. If my AHI was above 5, I might have a chance to get an aircurve.  The doctor was upset by this change because it could affect people with heart problems. She filed a complaint with one of the government agencies.
I will use my aircurve as long as I can and daily I look on  facebook marketplace for one with  low hours.

[Dormeo]

With a prescription, and with enough money, anyone in the U.S. can buy a bilevel machine on the web. Of course, the problem for many people is that a bilevel machine is out of financial reach.

It's always worth looking at sites that sell used machines. There are several on the Suppliers List (see the banner above).

[Sleepster]

Living in a large urban area, I can easily find a seller on craigslist. The sellers nowadays tend to be in the business of selling used and new machines. The buyer needs to be educated, experienced, and prepapred. I went in there with my own mask and hose, hooked it up the his machine, and we were off to the races. I made sure the machine had low run hours, no odor, and was quiet. He had to replace the air filter housing door because it was broken. He was asking $250 for an AirCurve 10, I offered $200 and he took it. I don't recall the number of run hours but I think it was about 2500.

Those pulmonologists described in the OP are full of it. I told mine years ago that I needed an auto-adjusting bilevel machine because I had aerophagia. I told her what machine I wanted and what pressure settings I wanted and why and had the data to back up my claims that the auto-adjusting bilevel machine I had (a ResMed S9 VPAP Auto) was effective in treating my apnea along with my claim that it was effectively relieving my aerophagia.. A few weeks later the DME delivered it to my home. The DME later tried to overcharge me. I had to lodge a formal complaint because the price I was quoted was far less. I prevailed.

[Sleeprider]

Very simply, your pulmonologist is uninformed about the place of bilevel therapy in uncomplicated obstructive sleep apnea and upper airway resistance syndrome (flow limitations). She is completely committed to this opinion and you will not persuade her otherwise. She has no argument or data to support this position other than his opinion is is for central or complex apnea and she infers a bilevel positive pressure device is somehow only beneficial to these individuals.  You started on CPAP and had demonstrably poor results, with high flow limitations, frequent interruptions in therapy due to intolerance of CPAP pressure, resulting in poor sleep to the extent you spent your own money to upgrade to bilevel.  You began this thread with the statement "I have used a (secondhand) BiPAP for over a year now to great effect (FL better managed, subjective sleep quality increases)."

Why are you even seeing a pulmonologist. Normal, healthy people don't need to see a pulmonary specialists, particularly for sleep disordered breathing that is resolved.  I am using your doctor's own tactic here, providing an opinion with no rational backup.  So here is some backup in the form of several peer reviewed journal articles showing bilevel is beneficial to certain individuals with obstructive sleep apnea that have poor results or do not tolerate CPAP.  

https://pubmed.ncbi.nlm.nih.gov/24666419/
https://www.webmd.com/sleep-disorders/sl...p-overview
https://pmc.ncbi.nlm.nih.gov/articles/PMC9992565/
https://pubmed.ncbi.nlm.nih.gov/12046572/
https://pmc.ncbi.nlm.nih.gov/articles/PMC6374080/

I suggest you will not succeed if you continue to see this physician, and any doctor, not just a sleep specialist, can provide the prescription you are looking for.  I certainly don't want to see you repeat your experience with the iBreeze.  You of all people know what would result from the use of CPAP, and you can do it if you wish by changing the mode on your Aircurve.  In support of her opinion, it is difficult to establish bilevel therapy will have "clinically significant" benefits over CPAP.  Clearly the benefits are often qualitative in the form of comfort, rather than measurable in terms of hypopnea, or apnea.  Sleep specialists are not trained to look for these kinds of benefits, and many will conclude that if you can't prove a therapy is quantitatively better in a PSG sleep study, then no benefit is demonstrated.  There are physicians out there that are much more open-minded, and you need to find one of them.