I Left My Sleep Study -- Undone.

[Papit]

I've learned in this Forum to take some responsibility and try to assure that the most relevant and appropriate medical care is being provided me. My sleep study was tonight, but I got out of bed and left after the tech described the scope of tonight's study. I explained that after 15 months of looking at my data, which I shared via SD card with my new doc, that the doc told me (what I already knew) that I have definite symptoms of CA and that a bipap or ASV machine was likely to be needed. I told the tech that if she insisted on spending the entire night doing only a CPAP Study, that that was unacceptable to me, it went against my expectations (I suppose due to imperfect doc-patient communication) and I would need to leave unless she could additionally spend part of the night doing a Bi-Level and/or an ASV Study. (Turns out she's not certified to do ASV studies. The medical practice has another office where they do ASV in addition to CPAP and Bi-Level.)

From home, I called and left a message for doc re. my aborted sleep study. Before I see her, I have some questions that I hope you more experienced folks can help me with.

1. Why would a CPAP Study be indicated? Might there be a very good reason for my doc to have ordered a CPAP Study instead of a Bi-Level or ASV study? Perhaps for insurance purposes? My insurance is quite good (BCBS Federal).

2. When are Bi-Level studies or ASV studies called for in lieu of CPAP studies?

3. In my case, isn't a Bi-Level or ASV Study more appropriate? Wouldn't they provide more relevant and specific insights into the type of therapy needed for my CA condition? We already know from many months of SD card data that OA was reduced by CPAP and then APAP (using the S9 Autoset) from the 20s to well under 5.

4. If tonight's CPAP Study was completed and the results confirmed that CPAP can (do what it has done) clear up the OA to under 5, but in the presence of CA at an elevated level that is three times higher (approx. 17), what do you think is likely to then be ordered next? Another study (Bi-Level or ASV)? And then a separate ASV Titration? Or a combined Bi-Level or ASV Study with a Titration?

5. The tech's supervisor believes that once the CPAP Study is done, an ASV Study including (combined with) a Titration for an ASV machine would come next. Is this the most ideal scenario?

Very perplexed. Please help me out with your thoughts and advice on this. The more the better.
Thanks in advance.

[2 B Sleeping Soundly]

Mike,

I don't have any advice or knowledge to give to you about your sleep study or the use of ASV machines, but I just wanted to encourage you to continue to hang in there. Sometimes the first response you have in such important situations like this can indeed be the correct one, and after all, who knows your body and what it needs better then you! I believe there will be a time fairly soon when you will look back upon this experience and will be glad you kept trying, kept fighting to get the proper PAP machine and optimal therapy. It will hopefully all feel worth it to you then and you will be much better off because of it.

John

[stage0]

The lab may have had protocols and policies to in place to place you on cpap first then try other devices and/or intervinetions befor going to bi-pap or asv. Your insurance may also have to be involved, being that asv machines are considerably more expensive.

At our facility, the medical director has to be called before the ASV is started on a patient. Even before this. cpap first, then different masks and desensitation techniques,, then bi-pap, then other pressures, chin straps, ..the last line of intervention is the asv.

[purple]

Medicare requires that before getting a bi-level machine, that an individual have one of a few medical conditions (like MS) or that an individual fail CPAP. Having failed CPAP treatment at home might not qualify, in that the presumption is that you might have the wrong settings. I do not know what insurance you have, but a lot of insurances use a lot of Medicare rules. If that is what they were doing, they should have informed you before sending you off on something that you would realize was a waste of time.

[Denial Dave]

my newbie understanding is that every titration starts with CPAP....

Bi-level only comes into play if the pressure needed to stop apnea/obstructions exceeds 15cm or if the patient is having trouble exhaling against the pressure.

I'm not sure but I believe that ASV come into play when there is evidence of other issues like centrals,etc

I'm not a doctor, but I stayed at a holiday inn recently..

[Nooblakahn]

I believe most insurances require you to fail a cpap/bipap titration before moving to bipap st and then bipap asv. Und does anyways... that's who I have

[NotLazyJustTired]

It's sounds from your text, that your doc is prepared to write you a script for a BiPAP/ASV. However, if you are looking for insurance coverage, it is doubtful they will comply without a PSG in a certified lab. While data from PAP machine is certainly indicative of symptoms of CSA, it is likely not something the insurance company will embrace unless your doc can write a really good appeal.

I suspect that they need to see residual CAs during a straight CPAP titration to diagnose you (formally) with CSA, but that is speculation on my part. Hopefully one of the more experienced PAPpers will come along to confirm...

[LaurieRenz]

My first sleep study was with CPAP, which I failed. I had to go back for a second study with the BiPAP.

[Nooblakahn]

It sounds like the dr should have been more clear in his or her communication to you.

Bipap asv might be likely needed. But in my case, they had to get pre auth every step of the way. They did the psg then did the cpap /bipap titration. Then had to get auth for bipap st. Again then had to get bipap asv. Alot of sleep labs don't even do asv... so at east your lucky enough to be in a lab that has that as an option.

Hope it all works out for you in the end.

[Pugsy]

I suspect that an in lab confirmation of the presence of too many centrals (per their criteria) was the object of the plain cpap sleep study.
I don't know how much weight the presence of centrals reported by a home cpap machine would carry with anyone. It does have some limitations.

That said, I feel they should have had ASV available "just in case" and have a tech doing the test that was certified to do ASV titration also "just in case".
They should have been prepared to proceed with the Bilevel machine and/or ASV type of machine.

[Jimster]

To say the least, this is one interesting question for those like me that don't have any clues as to what is going on in the many areas of the CPAP World.

The question I have is what can be done about Centrals. I thought that a Central had to do with one's brain?

O = is when you are blocked

H = sort of a short of swallow breath

C = Brain Problems????? or What ( Is C also Centrals? )

What is ASV?

Bi-PAP vs. ASV ??

What's the Difference in these two Machines ??

Please correct me if what I am thinking is not right.

Right now I only have questions, but I am trying to find out about some other stuff that when I do I will let everybody in on it.

Have a Great Day.

[khauser]

To say the least, this is one interesting question for those like me that don't have any clues as to what is going on in the many areas of the CPAP World.

The question I have is what can be done about Centrals. I thought that a Central had to do with one's brain?

O = is when you are blocked

H = sort of a short of swallow breath

C = Brain Problems????? or What ( Is C also Centrals? )

What is ASV?

Bi-PAP vs. ASV ??

What's the Difference in these two Machines ??

Please correct me if what I am thinking is not right.

Right now I only have questions, but I am trying to find out about some other stuff that when I do I will let everybody in on it.

Have a Great Day.

Hi Jim,
I don't think it is that simple, ESPECIALLY if we're talking about the data presented from an xPAP system.

Generally, yes:
O = Obstruction. More accurately the machine sensed no breath for (I believe) at least 10 seconds and using pressure pulses determined the airway to be blocked.
H = Partial obstruction, which is a limited breath (not sure of timing issues). Machine differentiate this from Flow Limitations, and snore detections, and in some way can have some or all happen at the same time.
C = Clear Airway. It's not possible for the machine to declare it a central apnea ... all it knows is that for at least 10 seconds a breath wasn't drawn, and pressure pulses determine the airway to be open.

There are many reasons we might not draw a breath. The diagnosis of central apnea requires correlation of Oxygen saturation, EEG and breath patterns. A central apnea is when you SHOULD have taken a breath but didn't. The machine just doesn't know for sure that you really needed to take a breath...

[NotLazyJustTired]

To add what Kevin said...
Sometimes we hold our breath while rolling over, for example. The machine can detect that the flow has stopped and that the airway is open so it flags it as a CA. Clearly this is not a "brain problem".

Also, what I have learned is that our breathing pattern is more or less driven by the amout of CO2 detected in our blood. When our O2 staturation is high, the CO2 saturation is low and the brain may instruct our diaphram to cease breathing momentarily. It is not a "brain problem" but a necessary adjustment to keep the O2 levels stabilized. OTOH, neurological problems can result in centrals. Most of us however, do not have such issues, but we see "normal" centrals as the brain regulates our O2/CO2 levels. That is why oximetry and EEG are really necessary to diagnose central sleep apnea to separate the normal from the abnormal.

[MagsterMile]

I believe insurance may require that a formal cpap test be taken. I know that Medicare requires it and most insurers follow -suit. In my case I had the sleep study at $3,000 a pop (found osa, csa & complex), went back for the titration for cpap (another $3,000) and finally a 3rd visit ($3,000 again!) for the vpap asv titration. I was confused and thought the provider had billed Medicare an extra time so I called Medicare. They investigated and found out that indeed the whole thing cost $9K. Incredible!

[chunkyfrog]

Insurance may be working against their own best interests, but . . . whatever.
Hope you don't get stung for the aborted sleep study--I know some insurance companies will do that.