Seeking Advice - To Be Prescribed ASV

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
cattledog
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Seeking Advice - To Be Prescribed ASV

Post by cattledog » Mon Nov 03, 2014 4:12 pm

The end of last year, I had a home sleep study and was diagnosed with OSA. I had an in-lab sleep study for CPAP titration and prescribed a F&P CPAP. With only 30 hours of use, this failed miserably as my body couldn't tolerate it and I stopped using it. I suggested to a new sleep doc that I'm fairly certain I have a central component, due to some personal observations. Another in lab sleep study confirmed CSA primarily and OSA secondarily as well as nocturnal hypoxemia. I believe it's all considered mild, but I haven't had a good night sleep in years, resulting in low concentration most of the time and brain fog, sometimes severe, usuaually when under high stress or significant lack of hours in bed. My memory, more so short, but also long has severely suffered and I feel as if I've been dumbed down over they years. I've since had a follow-up study for ASV titration.

Here are my results after CPAP failed.

Baseline included room and Oxygen supplementation.

Overall
Apnea-Hypopnea: 12.3
central apneas 7.1
hypopneas: 5.3
RDI: 24.9

Room Air
Apnea-Hypopnea: 17.4
RDI: 12.3
mean saturation 89.6%
min saturation 81%

2L Oxygen
Apnea-Hypopnea: 0.9
RDI: 27.4
mean saturation: 94.9
min saturation: 92

CPAP Titration
RDI 25.7 or above at all pressures
The Apnea-Hypopnea Index at 7 was 7.7, at 9 was 5.1 and at 10 was 19.7, with 16 central apneas and 1 hypopnea at 10 cm
At 9 cm Apnea-Hypopnea Index of 5.1 and an RDI of 25.7.

Follow-up ASV Titration
Optimal setup is a ResMed ASV with EEP of 5 cm H2O, PS min of 4, PS max of 15, normalizing AHI to 0.9 RDI to 1.2 events per hour.


When I had the CPAP titration and subsuquently tried using CPAP at home, the therapy did not seem to eliminate my episodes and I'd still catch myself not breathing as I lightly dosed. I'm a light sleeper (maybe due to CSA) and had to stop the CPAP therapy just to get some semblance of sleep. With the ASV titration, I could finally tolerate the mask, but still slept much worse than a typical night at home. I had a good number of minutes in REM sleep, but it felt as if I slept very little and woke with every toss and turn I had that night.


I haven't yet been to the doc for a follow-up to the ASV Titration. But to prepare for my visit, I hope to equip myself by asking a few questions.

1) I don't have a known issue causing CSA. Is it typically worth investigating the underlying cause?
2) Can the OSA component be a results of CSA and not necessarily a separate issue? I'm am only slightly overweight at 5'10 180lbs
3) How accurate are sleep studies? Could two different sleep studies yield significantly different results? This is a theoretical question..but curious as to why my CSA wasn't picked up during original CPAP titration. Could this be that my original sleep study was a home study and my secondary study was CPAP titration with no baseline and they weren't looking for centrals?
4) I need perfect conditions to sleep (no light, extreme quiet, comfortable bed, multiple pillows, no stress, alone in bed). I'm hoping once CSA is treated, I will be able to sleep easier, but being conscious of my inability to sleep, I might request nasal pillows to keep the wearables as small and simple as possible. During all three titrations, I used a nasal mask. What are your thoughts here? Should I stick with the NM?
5) The ASV titration report recommended a Resmed ASV with Mirage FX nasal mask. I'm hoping the Aircurve will be available in a couple weeks when my DME appointment is scheduled. Any recommendations here? I know there are only a couple options. But I travel frequently, either for work or frequently to GF's, so looking for something simple.
6) Would it be wise to get an oximeter or unnecessary?
7) What do backpacker do? Do they go off treatment for their time on the trails?

Thanks in advance. I've been reading the board the past few days and a lot of good information here. I'm hoping I can be of help to others as I gain more experience and understating of my condition
Last edited by cattledog on Tue Nov 04, 2014 12:22 am, edited 2 times in total.

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cnaumann
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Re: Seeking Advice - To Be Prescribed ASV

Post by cnaumann » Mon Nov 03, 2014 7:22 pm

You have a lot of good questions, some of which simply cannot be answered here.
I am no expert, but I will take a crack at a few of them.

1) Unless you are a heroine user (in which case I would suggest you seek treatment) or are suffering from congestive heart failure (in which case I would suggest you see a doctor) it is probably not worth trying to determine the underlying cause of Central Sleep Apnea.

2) OSA and CSA can be linked. When they are linked they are called complex apnea. The phenomena is not well understood, and it is not clear if one is causing the other.

6) I have a recording oximeter. It is a neat gadget and I find it useful. I don’t think it is really a wise or necessary thing to have, as decent xPAP machine will give you enough data to track your progress.


Many people have a condition where they have unstable breathing and central apnea when they are transitioning from awake to asleep. On its own, this is generally not considered harmful or dangerous unless it is interfering with your ability to go to sleep. It does not sound like this is your only issue, but it might explain your 'forgetting to breathe' when falling asleep. (I do the same thing.)

I am a little curious as to your insurance situation. You are going straight from CPAP to ASV without a BiPAP trial. Many insurers require that at least try BiPAP before they will consider covering ASV. Have you tired BiPAP?
Last edited by cnaumann on Tue Nov 04, 2014 5:55 pm, edited 2 times in total.

cattledog
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Re: Seeking Advice - To Be Prescribed ASV

Post by cattledog » Mon Nov 03, 2014 11:41 pm

cnauman,

Thanks for the informative reply! My doc took me direct from CPAP to ASV titration after it was confirmed I had CSA..maybe they did a bi level titration unsuccessfully in my previous study, but not certain. As for insurance, they did approve the ASV titration, although I can't remember if ASV was highlighted as part of it or just as a general sleep study. I guess I'll find out after the device is prescribed, if insurance will cover it or not.

And yes. I'm certain part of my issue is forgetting to breath while falling asleep, but then I still forget to breath while sleeping. MY GF Identified my long pauses in breathing (no snoring) and I've had a few recent surgeries where my O2 kept dropping below normal, while coming to, setting off the low O2 alarms. A nurse (or GF) had to keep waking me and reminding me to breath, until I was fully aware....wonder if I would have suffocated if left to own devices. I'm not sure if O2 was an issue during surgery or not. But in hindsight, these were all clues that my condition was primarily central in nature. I wish I connected the dots before the first couple sleep studies and CPAP use; maybe I could have saved a few coin and got to this point much quicker.
Last edited by cattledog on Tue Nov 04, 2014 12:19 am, edited 1 time in total.

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Mr Bill
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Re: Seeking Advice - To Be Prescribed ASV

Post by Mr Bill » Mon Nov 03, 2014 11:59 pm

That would be my nightmare to have surgery and have the post op people not realize what it really means to have central sleep apnea. Glad they woke you to remind you to breath.

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EPAP min=6, EPAP max=15, PS min=3, PS max=12, Max Pressure=30, Backup Rate=8 bpm, Flex=0, Rise Time=1,
90% EPAP=7.0, Avg PS=4.0, Avg bpm 18.3, Avg Min vent 9.2 Lpm, Avg CA/OA/H/AHI = 0.1/0.1/2.1/2.3 ... updated 02/17/12

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Mr Bill
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Re: Seeking Advice - To Be Prescribed ASV

Post by Mr Bill » Tue Nov 04, 2014 12:17 am

cattledog wrote:.

1) I don't have a known issue causing CSA. Is it typically worth investigating the underlying cause?
2) Can the OSA component be a results of CSA and not necessarily a separate issue? I'm am only slightly overweight at 5'10 180lbs
3) How accurate are sleep studies? Could two different sleep studies yield significantly different results? This is a theoretical question..but curious as to why my CSA wasn't picked up during original CPAP titration. Could this be that my original sleep study was a home study and my secondary study was CPAP titration with no baseline and they weren't looking for centrals?
4) I need perfect conditions to sleep (no light, extreme quiet, comfortable bed, multiple pillows, no stress, alone in bed). I'm hoping once CSA is treated, I will be able to sleep easier, but being conscious of my inability to sleep, I might request nasal pillows to keep the wearables as small and simple as possible. During all three titrations, I used a nasal mask. What are your thoughts here? Should I stick with the NM?
5) The ASV titration report recommended a Resmed ASV with Mirage FX nasal mask. I'm hoping the Aircurve will be available in a couple weeks when my DME appointment is scheduled. Any recommendations here? I know there are only a couple options. But I travel frequently, either for work or frequently to GF's, so looking for something simple.
6) Would it be wise to get an oximeter or unnecessary?
7) What do backpacker do? Do they go off treatment for their time on the trails?

Thanks in advance. I've been reading the board the past few days and a lot of good information here. I'm hoping I can be of help to others as I gain more experience and understating of my condition
(1) The wikipedia entry is pretty good. But no doctor I know of will bother trying to find out which of the three regulating centers are out of wack.
(2) Maybe but maybe not. Some people think that while apnea creates obesity, its an underlying loss of critical muscle tone that creates OSA.
(3) I think it depends on how well wired you are for the sleep study. Some studies have you wired for sound and others are very minimal.
(4) If you can tolerate a nasal mask (not a mouth breather), I think its ideal. Nasal masks fit more easily with less tendency to leak that full face masks. However, I've never used nasal pillow masks, but others can speak to that.
(5) I guess it depends on pressure. I have a rather small mask and being nearly pure csa, I have very low pressures. If the recommended mask is comfortable, go for it. I like my mask because if I wake during the night its easy to reach behind my head and hitch it up so it takes the pressure off my sinuses. This makes breathing for me much easier.
(6) I found that having a recording pulse oximeter gave me the verifiable certainty that every time I took off my mask to be "more comfortable" I was also denying myself actual sleep. I had a hard time adapting I was claustrophobic (thank you ashtma) and it was a struggle for me to reach 6+ hours a night masked up. My pulse oximeter helped me hugely to get there.
(7) There are posts for rigging up a battery for sleeping. That said, I think our ASV units require more power and it may be more difficult to find a setup that works.

_________________
Mask: EasyLife Nasal CPAP Mask with Headgear
Additional Comments: Devon Medical PC68B Recording Pulse Oximeter, APC Back-UPS RS 1500
EPAP min=6, EPAP max=15, PS min=3, PS max=12, Max Pressure=30, Backup Rate=8 bpm, Flex=0, Rise Time=1,
90% EPAP=7.0, Avg PS=4.0, Avg bpm 18.3, Avg Min vent 9.2 Lpm, Avg CA/OA/H/AHI = 0.1/0.1/2.1/2.3 ... updated 02/17/12

cattledog
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Re: Seeking Advice - To Be Prescribed ASV

Post by cattledog » Tue Nov 04, 2014 5:01 pm

Mr Bill...thanks for your responses! Once on therapy, is there an issue with stopping therapy for a few days? Is there a significant health risk to stop for just a few days, considering I've haven't yet been on therapy for years? Would a temporary stoppage typically put me out of compliance? Current my healthcare insurance doesn't appear to follow-up on compliance, but that could always change. I"m thinking of the backpacking scenario. The thought of carrying a 3lb device plus a battery big enough to support it over 2-3 nights seems unrealistic, considering both space and weight requirements.

TIA

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photonic
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Re: Seeking Advice - To Be Prescribed ASV

Post by photonic » Tue Nov 04, 2014 5:04 pm

My insurance company (BCBS) only wanted to know about compliance once I ordered new supplies. Had to bring my card in to the DME.
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Pugsy
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Re: Seeking Advice - To Be Prescribed ASV

Post by Pugsy » Tue Nov 04, 2014 5:44 pm

Find out directly from your insurance company what they need or don't need for any compliance requirements.
It can vary between insurance companies and even different plans within the same company.

Typically if there are requirements they will usually mimic Medicare's requirements which is 70 % of the nights within a 30 day period, the use must be greater than 4 hours a night. So essentially 21 out of 30 nights you need to have used the machine for at least 4 hours. You don't get credit for using it 8 hours one night and zero hours the next night. Once compliance requirements are met the insurance is pretty much out of the picture unless your insurance requires something special. Best source of this information is from your insurance company directly. DMEs won't know each company's requirements unless you happen to have Medicare and pretty much everyone knows what those are.

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Starlette
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Re: Seeking Advice - To Be Prescribed ASV

Post by Starlette » Wed Nov 05, 2014 10:32 am

Welcome to the forum, I have prepared a welcome wagon just for you: Hot chocolate milk and chocolate chip cookies, and peppermint schnaaps for flavoring. NOTE: You will be carded since alcohol is provided. When you arrive, please sign in (your login name) so we'll know you stopped by. Then my post will return back to the top of posts for other newbies to stop by for a treat.

Newbie Welcome Wagon



Enjoy!

Starlette

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cattledog
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Re: Seeking Advice - To Be Prescribed ASV

Post by cattledog » Tue Nov 25, 2014 7:39 pm

Again thanks for everyone's responses. I just got my device yesterday: S9 VPAP Adapt w/ h5i. First night, AHI was .57, so looks good (much better than when on CPAP), with only 3 unknown apnea events recorded, but I tossed and turned most of the night. The three events may have correlated with when I temporarily got up, so I assume these are truly non-events. Now I just need to get used to sleeping with a device attached to me, so I can finally feel refreshed..

I went with the Airfit P10 mask, since I had already had a nasal mask with little use on it. Wow, this was much better than the nasal mask. There seemed fewer problems with leaks and it was much less distracting.

Two simple follow-up questions:

-How often do you change the filter in the S9 VPAP Adapt? I've seen conflicting info from every 2 weeks to every 6 months.
-I was given the slimline tube. Is there a significant advantage switching to the climateline?

Thanks.

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palerider
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Re: Seeking Advice - To Be Prescribed ASV

Post by palerider » Tue Nov 25, 2014 8:33 pm

cattledog wrote: -How often do you change the filter in the S9 VPAP Adapt? I've seen conflicting info from every 2 weeks to every 6 months.
-I was given the slimline tube. Is there a significant advantage switching to the climateline?

Thanks.
the manual says every 6 months, or as needed... the web page where you can see supplies to buy says every month.

I like to take mine out every now and then and if it is getting dirty looking, change it, and I tend to put more weight on whatever engineer had input into the manual than the marketeer on the website

the advantage of climateline is that you can turn on heat to keep from having rainout, if you don't have rainout, then there's no advantage to the climateline. lots of people swear by the climateline hoses... with the adapt, I'd think you'd probably be better with the regular size hose, or climateline max, due to the asv pressure swings... maybe not enough better to really make much difference though

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