Bunch of CAs

[atipene]

Hi CPAPTalk Forum,

I'm new to CPAP therapy and self diagnosed. I've been using my Phillips System One Auto for 2 weeks and got my AHI from 30 to less than 8. I get a bunch (5-6) of CAs normally an hour after I go to sleep and and hour before I wake.

Does anyone know what this pattern could mean and how I could treat it with my CPAP? I am running between 8 and 10 pressure.

Thanks

Andrew

[LSAT]

These are called "sleep/awake junk". You are usually restless during that time and tend to hold your breath for short periods while turning over and moving, These are also known as "clear airway" events. Unless you have very large clumps of CAs with a high AHI, there is no need to worry about them. You have a few...not a bunch. Yours are insignificant. You cannot treat these CAs.

[ajack]

There are also pressure induced CA for new cpap users, these will settle down within 12 weeks.

[robysue]

There are also pressure induced CA for new cpap users, these will settle down within 12 weeks.

=======

sometimes they do sometimes they dont

The fact that sometimes pressure induced CAs in new CPAP users do resolve within a few weeks (i.e. 2-3 months) is a GOOD reason to wait to see if they resolve, particularly if the number of CAs is not too excessive. It's also worth noting that learning to sleep with an ASV can be even more challenging than learning to sleep with a CPAP/APAP. That's another good reason to wait to see if CAs resolve within the first 3 months or so ..

about 35% of people will not get used to the pressure and the centrals will not stop
those folks will need an ASV

Yes, about 1/3 of the people who develop pressure induced CAs after starting CPAP therapy will need to be moved to an ASV.

But that also means that 2/3 of the people who develop pressure induced CAs after starting CPAP therapy will NOT need to be moved to an ASV.

Hence there's a good reason to wait for a few months and work with a new CPAPer who is experiencing a lot of CAs right after starting CPAP therapy: There's a good chance that the CAs will resolve on their own given a bit of time. And if they don't resolve, then the necessary work to get the patient an ASV can be done after it's clear the CAs are not going to resolve on their own.

And a good sleep doctor (yes, there are a few of them out there) will understand that if an OSA patient is still experiencing clinically significant numbers of CAs after 8-12 weeks of consistent CPAP/APAP use, then it's time to start fighting the patient's insurance company for getting them the ASV (and ASV titration study) that is needed to resolve the patient's problem.

[ajack]

so at the moment you aren't on a machine?
you have been given numerous sources that the generally do resolve, none of them from a DME or insurance that I recall

how does the typical short CA without a significant o2 drop, because then are normally balancing the o2/co2 and not a central nervous system disorder. affect the sleep of the new user?

[robysue]

nonsense

why make 1/3 of people suffer withOUT proper treatment so they can save some money on the others

why suffer with no sleep for 3 months hoping they will go away
when an ASV will let you sleep better right now

Because the ASV has a good chance of making the lives of the 2/3 of the people who do NOT need it even HARDER.

Seriously, many people find that it takes far longer to adjust to sleeping with an ASV harder than learning how to sleep with a CPAP/APAP. And if you're in the 2/3 of papers with CPAP-induced CAs that will resolve with a bit of time, moving them to an unneeded ASV not only is expensive, but also has a good chance of increasing their adjustment problems rather than fixing them.

I'm sorry that you've had such a hard time with PAPing.

Finally you write:

its all about money
insurance doesnt care if you suffer or get good treatment
as long as they can claim they helped some at the cheapest price

You have a habit of telling people that they are "libtards" all the time. And I fully expect that's what you'll call me after I say what I'm going to say, but ...

Medical care and medical equipment are not free, even in a fully implemented government funded national health care system like most of the rest of the world uses. Someone has to pay for it, and the question is "Who should pay and how much should they pay?"

In a national health care system, the taxpayers pay for everybody's health care expenses and the governmental agency that runs the health care system spends a great deal of time and effort into maximizing care for the most people for as little money as they can. And in some cases, people are told, "No, the national health system won't pay for that" or "You have to wait your turn."

Here in the US, due to the high cost of health care, most Americans are dependent on a health insurance company to pay a substantial part of their bills. And the Republicans have made it clear that they prefer a market-based health insurance system. And in a market-based health insurance system, the company's bottom line is all that matters: If a company pays out more money (in terms of benefits, salaries, overhead, and costs of record keeping) than they take in through premiums, they won't survive. Hence, profit (net gain) becomes the primary motivator in the company's decisions about what services to provide (beyond those mandated by state or federal laws) and what paperwork and copays to require their customers to pay to obtain "authorized" treatments.

But it goes beyond health insurance. The GOP, in fact, wants a "market-based health care system," not just a market-based health insurance system. And for any market-based system, the bottom line is profit. In a "market-based health care system" that means profit is the motivation behind every decision about an individual's health care needs at every step of the process.

Profit is the motivator for physician decisions: If doctors are penalized for sending too many patients for sleep tests, they'll stop sending patients with marginal symptoms for sleep tests. If sleep doctors make their profits by running sleep tests under conditions that don't make patients feel more comfortable, then the patient's comfort goes out the window.

Profit is the motivator for CPAP companies and DMEs: They make far more money making and selling bricks than they do full data machines, and that's why most newbies get stuck with bricks.

And Profit is the motivator for the insurance companies: They will look for any way they can to reduce the total cost of what they pay for. And so insurance companies, who are beholden to their share holders and not their patients, issue lots of "denial of coverage" letters every day for all kinds of things. And yes, they have rules about who can be moved to more expensive machines and what kinds of hoops a doctor or patient must jump through in order to get coverage for something the insurance company doesn't want to pay for.

And if Trump and the GOP manage to pass some version of the Senate healthcare bill so that Trump can sign it, all those problems will get worse not better.

Because the GOP and Trump want the health insurance companies to operate with a Profits for the company mindset.

I'll get off my soapbox now. And I'll add: Your inevitable name calling will not hurt me: I've been called far worse than "libtard" over the years, and Buffalo Knows the Power of a Million Snowflakes.

[Okie bipap]

When I first started treatment, I had a few centrals, but they have mostly cleared up. I still register two or three every night, which is common for most people. My wife started have a load of central when they first titrated her to her required pressure. They brought the pressure down, and put her on a bipap machine at much lower than her optimum pressure. The pressure was brought up slowly and the central have mostly cleared up. She still has night when she has quite a few centrals, but they usually show up during that time of the night she is having trouble sleeping.

[LSAT]

so at the moment you aren't on a machine?
you have been given numerous sources that the generally do resolve, none of them from a DME or insurance that I recall

how does the typical short CA without a significant o2 drop, because then are normally balancing the o2/co2 and not a central nervous system disorder. affect the sleep of the new user?

==========

i have only seen one source
and it says to do it because it is cheaper

it is clearly not better
only cheaper

damage the health of 1/3 so they might be able to give a cheaper machine to the others even if they suffer until they allegedly adapt to it

I have only seen one source also...and it's you! As far as you are concerned if any CAs show up, the person needs an ASV machine....You are full of BS.

[chunkyfrog]

Because of the last four letters in the term "libtard", I feel it is inappropriate in a healthcare forum, maybe anywhere.
It demeans the mentally challenged, and borders on HATE SPEECH.
Question to the Goodman's: is this term offensive and HATEFUL enough that we could safely use our spam button?

[atipene]

Thank you all for your replies. I would have never been able to search a useful response.

Good to see a debate kick off. Disregarding the tone, everyone has an opinion and it's all good food for thought. "A smart person knows half of what he reads is true, a wise person knows what half is the truth".

[Pugsy]

If your central/clear airway count is limited to a couple of brief clusters during the sleep session (assuming you were definitely asleep when they are flagged) then they may or may not be "real" in the sense we think of centrals that are potentially troublesome.
Obviously awake/semi awake breathing centrals aren't "real" and are omitted from the evaluation process. It's not unusual to have these awake/semi awake flags because our breathing is much more irregular when awake/semi awake, even though we don't realize it, when compared to asleep nice regular breathing.
We call these awake/semi awake flagged events SWJ or Sleep/Wake/Junk.
The machine doesn't know if you are awake or not. It only measures air flow and the irregular breathing can sometimes cause the machine to think something is going on that isn't really going on.
These are usually fairly easy to spot on the reports when they are in close proximity to a known awake time like when you turn the machine on or off.

Harder to evaluate are the central flags that occur when we are for sure asleep.
It's normal to have an occasional "real" central...like during sleep stage transitions or what we call sleep onset centrals. I handful of them is actually normal and not usually a problem and doctors won't usually do much unless they are causing problems. Problems might be that they are so numerous you keep bouncing out of sleep and don't go into the other deeper stages of sleep or they are so numerous and prolonged that oxygen levels drop.

Also we often will wake during the night and not remember it. Arousal from sleep mean that we get to go through another chance for sleep onset centrals to happen when we go back to sleep. So the flagged central might be SWJ post arousal or it might just be another sleep onset central.

I once had 17 centrals flagged in 17 minutes and about an hour before I woke up. I don't know why...I thought I was asleep but when I looked at the flow rate up close it sort of looked a bit irregular so it's possible that I was half awake and don't remember it.

In general a handful of centrals, even if they are for sure 100% all real centrals, isn't necessarily a cause for alarm.
It's normal to have a few anyway and doctors won't do anything unless they seem to be creating a problem.
So if you are sleeping good and feeling decent then it is unlikely that your doctor would be concerned.
If they are SWJ centrals...the doctor for sure won't be concerned because they aren't real anyway. Hold your breath for 10 seconds...that's pretty much what a central is. The airway is open but no air is moving and most of use can hold our breath longer than 10 seconds without issue.

It's sometimes hard to figure out for sure if we are looking at SWJ centrals or the real deal centrals but if a person is having a relatively small number even if they were all real there isn't necessarily cause for alarm.

Pressure triggered centrals...it can happen with some people but those people are in a relatively small minority. Once thought to be a by product of high pressures but in truth can happen with as little as 5 cm pressure if it is going to happen.
If this were your situation you would most likely be seeing much larger numbers of centrals happening all through the night and not just during a couple of short segments of time. Based on what you have said with the clusters being random and short lived I really doubt that your centrals (even if real) are caused by cpap pressure itself. If they were you would be most likely complaining of much higher numbers of centrals and you would be seeing them pretty much all night.

[Pugsy]

20-40% of cpap users get centrals from the pressure
you can dismiss that as a small minority if you choose

My last reading showed numbers of 10 to 15%.
And usually when it's pressure caused centrals the centrals happen all night instead of just in a couple of brief segments of the night.
We haven't seen any reports from the OP to get any idea for sure but it sounds like he only has a couple of brief segments during the nights with a small handful of clustered centrals that he apparently sleeps right through....so they aren't causing a problem.
Are they "real" or SWJ? Don't know at this point but 3 to 5 centrals over 30 minutes a couple of times a night won't buy anyone a move up to the high dollar machine even if every single one of them was "real".

fully 1/3 of the cases do NOT resolve in spite of insurance companies thinking they will if you just tough it out long enough

that fact is not in dispute.
But at this point we have no idea if OP's centrals are pressure caused or not. We don't even know if they are "real" or not.

Please note that I am not poo pooing off the original poster in this thread about his centrals. They may or may not be "real".
But if they aren't "real" and are indeed awake breathing irregularities getting flagged then they don't make it into the evaluation process. It's sleep apnea that we are dealing with and not awake apnea.
Sleep onset centrals or sleep stage transition centrals are indeed real....but unless they are numerous enough to create a problem then no one is going to want to do anything about them.

you may not be someone with central issues
but i am and i want them treated properly not told to get used to being tortured with treatment that does not help me feel better but has a nice AHI number

Your particular situation really has no bearing at all or no relevance to the OP in this thread. This thread is about him and his concerns and your being tortured really doesn't matter in this thread. He doesn't mention torture or even difficulties falling asleep or staying asleep which I would assume he would have mentioned if that was a problem.
His original statement led me to believe that he is seeing only small clusters of centrals maybe 2 or 3 times a night and he was wondering if it was something to worry about. No mention as to any other problems which I would assume would be brought up if present. You continually project your personal issues onto other people into these threads and I can't understand why. It doesn't help the OP at all to have your issues muddying up things.

And contrary to what you might think I feel about ASV machines...I actually feel it would be nice if everyone got a machine that could do everything and all it took was some tweaking of the settings on ASV machines to get it done. It would be nice but it ain't gonna happen because that's not how the medical community does things. They didn't consult me or you when they decided what criteria a person has to meet to qualify for one of the high dollar machines.

We have no choice but to deal the hand we are dealt and most people won't have the funds to go the DIY route so they have to deal with the constraints. Instead of belaboring the fact that ASV could "do it all" I choose to try to help people make the best of what they have at the moment. Is it always "ideal" ...of course not but it doesn't help to keep harping on you should be using so and so when so and so simply isn't an option.

Remember...I do use ASV and I have my own reasons for using it and I actually wish everyone could have one because they can be tweaked to pretty much treat everything fairly easily. But no one cares what I want and they don't care what you want either. Cold hard facts of life.
And then there's that little matter of cardiac ejection rate potentially muddying up dispensing ASV to everyone. I have my own concerns about how that study was conducted but again they didn't consult me and came up with the contraindication for ASV treatment for those cardiac patients without my input. It is what it is and again it's the hand we are dealt.

[Pugsy]

my case has everything to do with this discussion

Not really. And certainly not to the point of harping on it continually. State your case and move on instead of continually dredging up something that may or may not even be relevant to the OP in this thread.
Your centrals are real most likely.....his might or might not be.

the point is that centrals are caused and a significant number of people have a permanent problem
so that situation needs to be kept in mind and not cavalierly dismissed as swj -

Assuming the centrals are "real" the fact that there could be multiple causes has been covered in this thread more than once.
and SWJ ....if it really is SWJ...can be dismissed because it simply isn't real.
Now figuring out what is real or not....that's another discussion.
SWJ isn't what I call sleep stage transition or sleep onset centrals. SWJ to me is awake/semi awake breathing irregularities getting a flag that in a sleep lab wouldn't be flagged because the person wasn't asleep.

and yes...centrals can be a significant problem for some people and also be a permanent problem but there is no evidence at this point by this OP that there is a problem....remember we don't know for sure if they are real or not or how many we are talking about or how long of a duration or if they are messing with sleep. There's a lot we don't know so why go beating a dead horse assuming stuff we don't know.

If the OP is still concerned about the centrals he sees then he should see his doctor and have a chat about them...which is something I probably should have mentioned but didn't simply because to me that is just common sense and I tend to assume that most people here have some common sense when maybe they don't.

[robysue]

total nonsense

the ASV can do anything a bipap or cpap can do and does it better

As long as we have a market-based health care system, the cost of equipment will remain a significant factor in deciding what equipment to provide a newly diagnosed patient.

Facts are: Most people with sleep apnea do not need an ASV machine and the cost of an ASV machine is about 6 times the cost of a top of the line APAP machine. Even for those of us with quality insurance, the difference in our out-of-pocket expenses between an APAP that lists for $1000 and an ASV that lists for $6000 (or more) is substantial. (Brand new brick Resmed/PR CPAPs list for $500 or less; that's why so many newbies get stuck with them.)

In the long run, it is more cost effective for the insurance company and for most new OSA patients to start people out with CPAP/APAPs and see if they need a fancier machine.

Yes, if you are one of the unlucky new PAPers who develops persistent pressure induced CAs that do not resolve, the fact that they start every one off on CPAP/APAP is very frustrating and leads to more misery in dealing with improperly treated complex sleep apnea while dealing with the jumping through hoops process to qualify for an ASV machine.

It would be nice if our health system could provide everyone who is diagnosed with OSA with a $6000 machine rather than a $500-$1000 CPAP/APAP. But someone has to pay for the equipment, and as long as ASV machines list for $6000, insurance companies simply cannot afford to authorize an ASV to every person who is newly diagnosed with OSA.

[robysue]

true that most people dont need an ASV but up to 40% of them should have one
at a minimum every machine should be auto

You and I agree that every machine should be an auto. The difference in cost between $500 and $1000 is not going to break the bank.

But who is going to pay for an ASV machine for everybody? You keep pushing the idea that every newly diagnosed sleep apnea patient ought to be started out on an ASV machine, but you've yet to address the question of who should pay the drastically increased cost.

what is frustrating is the DME telling me i have to use it 4 hours a night for 21 days or else
and my insurance rep echoing their medicrap rules when my policy has no such requirement for compliance at all

Your insurance company sets the rules for your policy, and if it's a standard policy, they can pretty much change the rules on a whim, as long as they notify their customers. And most people are not fully aware of all the rules their insurance company actually has.

If a rep from your insurance company tells you that you have to meet the medicare usage requirements, then somewhere in the fine print of your policy, there's language that says you have to meet the medicare usage requirements.

everyone with osa could get a cheap machine that is auto
making more good machines then fewer of two different ones would save costs

Again, I agree that all newbies should be set up with APAPs. The Medicare insurance code for APAPs and CPAPs is exactly the same. Any DME that wants to, can set up a patient with a script that says CPAP @x cm with an APAP machine. And there are a few DMEs that actually do this.

I got my original equipment from a small DME in WNY called "CPAPXpress". They set up all their new customers with APAPs, no questions asked. They understand that by starting their OSA patients out on APAPs, they minimize problems caused by needing to swap the patient's machine out for a doctor ordered "auto-titration" as well as maximizing the chances that their customers become compliant, long term happy PAPers.

Most DMEs are not that good.

and the incremental cost for auto is negligible
they just use that as an excuse to charge more

I agree. But it doesn't fit the standard DME's business model. Unlike CPAPXpress, most DMEs handle CPAPs as a small part of their overall business. And they often see high failure rates among their CPAP customers---the standard assumption is that 50% of new PAPers return the machine before the end of the rent-to-own period. And way too many DMEs do not understand that a large part of that high failure rate is because of the lack of support when a newbie runs into trouble. (And lack of support includes the failure to provide a machine that records full efficacy data.)

But here's the sad truth: The DME doesn't care because they, like most American businesses, only look at the very short term picture: Providing bricks at that list at $500, but which can be billed at the same rate as an APAP that lists at $1000 gives the DME much more (short term) profit. They don't seem to understand that taking a hit on the short term profit from the sale of the machines increases the chances their customers will return for CPAP supplies (filters, hoses, masks, humidifer tanks) for years to come ---if they become long term happy PAPers. And that in the long run, the profit from all the stuff that has to be replaced will make up for the lost profit from providing the APAP.

ditto for ASV
the added cost for the machine is not the big multiplier they charge

This I disagree with. The ASV machines list for $6000, which is five times as much as an APAP. ASV machines require more investment for the company that makes them in terms of verifying the algorithms because they are in fact non-invasive ventilator machines, which an APAP is not.

and i dont care what they give for osa
they need to stop telling us with COMPSAS mixed complex apnea with primary centrals to get used to a bipap cause it might go away in a few months of never sleeping at all

You need to get a grip on who the "they" you are complaining about is.

DMEs cannot sell an ASV machine to a person who has a script for bi-level because of legal regulations. There are different billing codes, and if the DME sells the wrong equipment, they can get into serious legal difficulty. So unless a doctor has prescribed an ASV for you, no DME can legally sell one to you.

If your doctor refuses to prescribe an ASV, your gripe is with the doctor. I won't speculate on whether the doctor has his/her reasons for not being willing to prescribe an ASV. Some doctors do attempt to work within the rules of a patient's insurance company so that the patient is not rudely surprised with a bill of several thousand dollars when they go to pick up their equipment. When I was switched from APAP to bi-level, my sleep doctor did have to fill out paperwork and write a letter of medical necessity that explained why he thought I needed to be on bi-level therapy instead of CPAP/APAP. That letter was easier to write because of data that showed (a) I was using my APAP every night, (b) my AHI was under control, (c) I was NOT feeling any better, and indeed was feeling worse after starting CPAP/APAP, (d) several things had been done to see if my adjustment problems would resolve and they had not, and (e) a bilevel titration test had been done that showed that I was more comfortable with bilevel than APAP/CPAP.

Insurance companies have the right (under our system) to set up whatever rules they want to set up for when they will or will not pay for a given piece of equipment. Some insurance policies don't pay anything at all for any CPAP machine (or any other durable medical equipment). If your insurance company is unwilling to pay for an ASV until certain conditions have been met, then your gripe is with them and not the DME.

more likely i will go away permanently long before they are happy which is what their die gramma die strategy really wants as us old people cost more and they want us to die to get more profits from the younger folks

Again, who is the "they" you are talking about?

Our insurance companies behave the way they do because our system is set up as a market-based system. Hence the insurance companies are responsible for keeping the amount of money they spend on benefits in line with the premiums they can charge. Right now, the problem is that too few younger, healthy folks are willing to buy health insurance on the market-place. Hence the premium dollars are not enough to pay for the benefits, plus the company's other expenses (salaries, overhead, etc.)

You want a system that meets your needs better than the current one does? Then start working to elect Democrats---yes, those hated "libtards" are the only ones in Washington who think that there's something wrong with companies making a profit off of denying people health care. Trump and the GOP are peachy-keen with the idea that insurance companies should not have to cover anything they deem as "too expensive" to cover.