Central Apneas appear with the start of BiPAP Treatment

[-SWS]

As of today my 20 day average AHI is 22.12 on BiPAP at my current settings (18/12) and I'm scheduled to see my new doctor who prescribed this machine/settings this coming Monday.

From what I've seen online I don't qualify for an ASV machine since my Centrals only make up 43 percent of my total apneas and it needs to be greater than 50 percent to meet the requirements for Complex Sleep Apnea (CSA). I do however meet all the other requirements for CSA.

I thought I remember seeing something (which I can 't find now that I need it) which stated that an ASV machine could/would be approved on a trial basis if an ASV tritation was perfomed and it showed significant improvement over current CPAP/BiPAP usage results.

Are my current stats 'bad' enough to be considered a failure on BiPAP?

Since I don't meet the CSA criteria is there any other way to be considered for an ASV machine?

Thanks again to everyone....

If it were me I would bring printouts of these two documents and ask the doctor whether you might fit into any of those reimbursement-criteria categories:

http://www.resmed.com/us/documents/LMN_ ... riodic.pdf

http://global.respironics.com/UserGuide ... 043494.pdf

Alternately new ASV machines can be purchased out-of-pocket---with a doctor's prescription---for $3000 to $5000 after price-shopping vendors. Another approach is to vacation to an out-of-state clinic where the doctors are well-versed in treating central apneas and properly qualifying diagnostic criteria.

Good luck with your upcoming doctor visit, Tom.

[Tom W]

Thanks -SWS!

[JohnBFisher]

Tom W,

Sometimes it just takes a doctors letter of medical necessity to the insurance company. For example, most of my central sleep apneas are sleep onset. Normally doctors ignore those. But when THOSE disturb normal sleep, then even they must be managed and treated. For example, when I fall asleep, I typically stop breathing for a minute or more at a time. This would cause my BiLevel machine to stop .. assuming I was no longer wearing the mask (with the Auto Off feature enabled). Now, normally insurance companies would not cover that. However, with me that meant I was getting one or two hours of sleep a night, my blood pressure was through the roof .. and caused kidney damage too boot. Of course, in such times it is medically necessary - even when it's not 100% to the guidelines. And I doubt that an untreatable AHI of 22+ will be ignored. At least it should not. If your doctor won't go to bat for you .. find one that will.

Best wishes!

[avi123]

I agree with John Fisher. If your Doc finds out that you are ill and need an ASV machine but your insurance would require the "failing" procedure then it is up to your doctor to "fail" you on CPAP and BiPAP, leaving the only alternative left which is an ASV machine. There are several ways to do that. For example the CPAP, APAP, etc., your Doc can say that you can't stand the expiration pressure, and for the BiPAP (BiLevel) the Doc can say that the machine leaves you with UARs which are not treated, or the machine does not treat the flattening of your respiration waves, etc., or to cite this study:

http://www.ncbi.nlm.nih.gov/pubmed/16236867

A sure place for you to go and get tested properly, and also most likely, end up with an ASV machine (insurance paid) is this:

http://sleeptreatment.com/index.php

(Fill up the "New Patient Registration" (green box on top right)

[Tom W]

My doctor has scheduled me for an overnight BiPAP ST and ASV titration next week.

Should I bring any of my past CPAP/BiPAP data (printouts) with me?

On one hand it isn't really relevant but on the other hand I've had 4 previous CPAP titrations over the past 13 years that concluded/confirmed that all I need is straight CPAP with a pressure of 12cm but I now have a year's worth of data which states otherwise.

I'm sorry if I seem paranoid but I feel as though I finally have a chance for some relief and I want to make the most of it.

[JohnBFisher]

My doctor has scheduled me for an overnight BiPAP ST and ASV titration next week.

Should I bring any of my past CPAP/BiPAP data (printouts) with me?

On one hand it isn't really relevant but on the other hand I've had 4 previous CPAP titrations over the past 13 years that concluded/confirmed that all I need is straight CPAP with a pressure of 12cm but I now have a year's worth of data which states otherwise.

I'm sorry if I seem paranoid but I feel as though I finally have a chance for some relief and I want to make the most of it.

I would bring the data .. explain your concerns .. and openly discuss your situation. I suspect he already believes you, since he scheduled the overnight BiPAP S/T and ASV titrations. But it would not hurt to have some of the information (in a summary form) that he can place in your files.

[Tom W]

My AHI seems to be uncorrelated to pressure but seems to be inversely correlated to periodic breathing (my AHI seems to be lower when my PB is higher).

It's not uncommon for AHI to be more severe in REM. Nor is it uncommon for PB to be largely NREM based. So that inverse correlation just may be a reflection of how much time you spend in NREM versus REM.

I might have stumbled upon this relationship by chance. I've found on nights that I often wake for mask leaks my AHI tends to be lower. I assume the constant arousals reduce the amount of REM sleep I experience during the night. I do notice that on those nights with very low (for me) AHI I usually feel like a train wreck the next day.

[

Is my glottis reacting to the higher pressures by closing and negating the effects of the higher pressure?

Dr. Rapoport may have described an important characteristic of your obstructive component in that second link presented above:

Instability, we are now told, contributes importantly to the underlying pathophysiology of obstructive as well as central sleep apnea, at least in some patients.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3014238/

bump for others

I did stumble across this article a few months back:

http://jap.physiology.org/content/79/1/186.abstract

In the following flow patterns you can see both OA's and CA's that look pretty similarly shaped. I assume from the response of the pressure pulses that sometimes the airway is clear and sometimes it is closed. I'm beginning to think that perhaps the only difference is the position of my glottis. I don't really have any experience in this field besides trying to improve my own sleep but in these examples even the OA's seem to be central in nature. The apparent (to me) deliberate starting and stopping resembles a pattern of breath holding that I occasionally do during the day but obviously I can't hold my breath that long/often when awake. Just throwing some thoughts out for discussion. Feel free to tell me I'm wrong, crazy, etc..

I had my BiPAP ST/ASV titration last night but I won't share that experience fully until I hear back from my doctor.

Is it possible in the above examples of my airflow patterns that I'm awake?

The first reason for asking this is that the 'classic hump' between exhalation and inhalation when you're asleep is missing.

The second being that this morning the sleep technician said I went over 5-1/2 hours at my current treatment settings without an event. I know all things are possible but my BEST AHI since being on my new settings (35 days) is 10.34. My average is 23.4. I'm not saying that it's impossible but it's not probable that I would go from an average of 128 events in 5-1/2 hours to 0 - is it?

[Tom W]

Post-Holiday Bump...

[-SWS]

The second being that this morning the sleep technician said I went over 5-1/2 hours at my current treatment settings without an event. I know all things are possible but my BEST AHI since being on my new settings (35 days) is 10.34. My average is 23.4. I'm not saying that it's impossible but it's not probable that I would go from an average of 128 events in 5-1/2 hours to 0 - is it?

I can think of a few possibilities explaining scoring discrepancies between home machine and PSG. Wakefulness is one possibility as you already pointed out. Sleep labs tend to discard central apneas that occur with wake/sleep transitions---whereas your home machine can prolifically log them as centrals. If you're inclined toward sleep-onset central apneas, and you present them throughout the night during even brief awakenings, then the machine-scoring and PSG scoring are going to be at odds.

Single-channel PAP machines versus multi-channel PSG studies are necessarily at data odds regarding scoring criteria. A home machine lacks multiple PSG data channels essential for proper event scoring. Lopsided data-channel comparisons aside, basic algorithmic processing error from the home machine is possible and so are ordinary heuristic errors from the lab techs. Both scoring-error scenarios happen, with the home machine generally being more error prone than well-equipped techs in the lab.

Another possibility is that some patients do not present representative sleep in the lab. Worse, some patients can't manage to sleep in the lab. Another similar scenario explaining scoring discrepancies is that of high variability in a patient's SDB presentation. As an example, if a patient's central apnea tendency happens to be episodic, then that episodic central tendency can be missed altogether in a single PSG night. These two scenarios favor multiple-night home machine scoring versus single-night PSG scoring.

Lastly, many sleep studies do not score post-arousal central apneas. The home machines cannot differentiate post-arousal central apneas from primary central apneas. This post in Z's thread discusses why treating post-arousal central apneas rather than root-cause is not always a good idea:
viewtopic.php?f=1&t=78147&p=711288#p711288

The post below, discussing conjecture by researchers, steps through the sequence of a certain type of post-arousal central apnea. Bear in mind there are various types or origins of post-arousal central apneas. This particular type, sequenced toward the end of the post, has origins in a CO2 arousal: viewtopic.php?f=1&t=77581&start=30#p712127

Again, a sleep study would not usually score that central apnea, since it is epiphenomenal of the arousal---which the PSG scoring tech will usually count instead. In that case scoring and attempting to fix the AFTER-effect central apnea, doesn't really help sleep or the primary problem----that is unless the post-arousal centrals are severe enough or frequent enough to pose hypoxemic risk.

[Tom W]

I had my ST/ASV titration last week and just received a call from my DME provider to schedule an appointment for "a pressure setting adjustment" on my BiPAP machine. This wasn't exactly the news I was hoping for.

I need to schedule an appointment with my doctor to discuss the results of my PSG but it appears that I was never titrated for ASV because I didn't have any events during the first 5-1/2 hours of my study thereby not requiring ST/ASV treatment?

My sleepyhead numbers are as follows:

CPAP/APAP (330 days)

OAHI 10.36
CAHI 0.94

BiPAP (42 days)

OAHI 12.49
CAHI 8.33

I understand now that the PSG and the machine score events differently but in which direction should I head now? Perhaps somewhat ironic my new BiPAP setting is 12/8 and all (four) my CPAP titrations have determined a CPAP setting of 12.

Should I insist on an ASV trial based on the numbers from the CPAP machine or should I be looking on seeing a neurologist to find out why I'm having so many arousals during the night (assuming this is the reason the events weren't counted)?

Should I get an Oximeter to see how low my O2 level is falling?

Should I purchase an ASV machine on the used market and see if it improves my numbers?

I'm not really excited about spending more money on tests if my doctors (two) are going to ignore the CPAP/BiPAP data....

There is always the possibility that I experienced a freak night during my PSG but the odds seem slim at best plus it doesn't quite explain why they didn't titrate me on ST/ASV sooner during the night considering that is why I was there in the first place.

Still tired - Still frustrated

Thanks for listening.

[-SWS]

Tom, two forthcoming sets of information appear to be: 1) a written summary from your PSG, and 2) SleepyHead results at the suggested 12/8 pressure. If it were me I would wait just a little longer for those two pieces of information before deciding what to do.

There are multiple outcome scenarios. One possibility is that stabilizing sleep itself might turn out to be your prime goal---toward stabilizing central apneas that are sleep-disturbance based (e.g. post-arousal central apneas or wake-based central apneas). In that scenario correcting the flow waveform itself, using BiLevel S/T or ASV, stands to do little for your primary sleep issue. So I'd suggest sitting tight just a little longer to hear what the PSG summary has to say.

Be sure to ask that your printed sleep summary includes a histogram of sleep architecture, your titration pressure table, and a table of sleep events, including arousals. I know it's frustrating... Hang in there!

[Tom W]

Quick Update:

I'm scheduled to see my sleep doctor a week from yesterday to review my PSG.

AHI on 12/8 (12 days) is 17.03

Centrals are down to 1.37
Obstructives are still high at 15.39

My AHI is fairly consistent (although far from stellar) with the best being 13.3 and the worst being 25.2 over this period.

I will stick this out until next week so I have enough data to review with the doctor.

I'm curious to see my sleep study report to see if anything (arousals, PLMS, sleep cycle ratios) stands out as being totally out of wack. More importantly I'm curious as what's going to be required to resolve it.

In the meantime I've stopped (as of today) taking one of my allergy medications as I've read that pseudoephedrine can disrupt your sleep even though I only take it first thing in the morning and it should be out of my system by 5-6 at night.

I'm also in the process of reviewing some national sleep disorder clinics just in case I can't find anything better to do with my vacation time and I can't get my AHI consistently under 10.

If you've been to one that you can recommend I'd appreciate hearing from you. I'm looking for one that can diagnose me without me having to tell them what to look for.

I do know I have/had RLS/PLMS, bruxism, impossible task night terrors and night time groaning (catathrenia?) so it is possible that my doctors and I have been going about this all wrong - Maybe my sleep is affecting my CPAP therapy more than my CPAP therapy is affecting my sleep?

Thanks again for all the assistance.

[JohnBFisher]

... I do know I have/had RLS/PLMS, bruxism, impossible task night terrors and night time groaning (catathrenia?) so it is possible that my doctors and I have been going about this all wrong - Maybe my sleep is affecting my CPAP therapy more than my CPAP therapy is affecting my sleep? ...

In fact, those other issues might trigger the transition from sleep to wakefulness (and then back again to sleep). In those cases, the central apneas are perfectly normal. What's not unusual would be the frequent awakening.

So, yes. It sounds as if those issues must be addressed.

Best wishes!