ASV vs CPAP for Chronic Insomnia

[BarryKrakowMD]

Wanted to share with you our publication today at https://www.sciencedirect.com/science/a ... via%3Dihub or at https://www.thelancet.com/journals/eclinm/home. Either link should work. Also, if you want to read our press release, it's at www.shhi.org. It's been a quarter century in the making, once we first realized the deep connections between insomnia and sleep apnea, and this study alone consumed the past six years. We hope many insomniacs will benefit from this knowledge, and we trust their providers and insurers will realize most chronic insomniacs need sleep testing.
Rest Wishes,
Barry Krakow, MD

[ChicagoGranny]

Thank you.

From the press release:

Krakow.JPG

[LSAT]

That's great, but try and get insurance to pay for a $5000 machine.

[Miss Emerita]

Thanks for posting. I appreciate the chance to read the report of this study.

[Smargie]

What a comprehensive, well researched article! Thanks you for sharing it here.

I hope that it reaches the hands of many sleep specialists and other providers, though. It takes a very open minded doctor to take patients seriously when they cite medical research to request expensive testing. And most insurers would much rather pay for meds, being that they are profit driven instead of patient centered.

At least chronic insomniacs with overt Complex Insomnia--those who read medical studies to try to get closer to a true diagnosis when all treatments are failing, anyway--will be likelier to ask for and get a sleep study.

[ChicagoGranny]

That's great, but try and get insurance to pay for a $5000 machine.

What if chronic insomnia caused you to miss out on a $20,000 promotion or, worse yet, get laid off? Better quit the Starbucks lattes and local IPAs and buy the machine.

[Arlene1963]

Thanks for posting this.

I had a pretty horrible sleep study and my sleep efficiency (SE)was dismal at about 72% as I recall mainly due to wake after sleep onset (WASO)

So I always look at these numbers when I see PSGs posted here.

I am therefore surprised to see that the SE and WASO numbers are virtually identical pre and on treatment for both groups Or at least very close so as not to be statistically significant. (I am specifically referring to the numbers given under "PSG sleep indices" and not "Sleep diary" numbers)

Why? I would expect to see major improvements in these objective PSG measurements with treatment, especially in the ASV group?

Please feel free to correct me if I am wrong or not reading these results correctly.

[LSAT]

That's great, but try and get insurance to pay for a $5000 machine.

What if chronic insomnia caused you to miss out on a $20,000 promotion or, worse yet, get laid off? Better quit the Starbucks lattes and local IPAs and buy the machine.

Lattes? No problem. IPAs? Never.

[chunkyfrog]

I'll raise a glass to Dr. K. for addressing the problem with insight.
Insomnia is like an "orphan disease"--except it is ridiculously common;
and insurers are maddeningly reticent about recognizing it as a medical disorder.
Here's hoping that relief is in sight. (See what I did there?)

[ChicagoGranny]

Lattes? No problem. IPAs? Never.

Do you have chronic insomnia?

[BarryKrakowMD]

Some comments:

1. Regarding price, a lot of used or even new ASV devices are sold at markedly discounted prices on direct to consumer websites.
2. Qualifying for ASV is the way to get insurance to cover the device, but remember insurance coverage doesn't tell us how much the insurance covers. Qualifying for ASV generally requires 10 central apneas with a CAI of 5.0 or greater where the CAI/AHI ratio is greater than 50%. And, nowadays, this qualifying is made easier when the sleep lab scores central hypopneas into the mix.'
3. Regarding SE and WASO, I never put that much stock in what individual sleep studies show objectively in dealing with insomnia patients in the lab. What's more reliable is how much better the patient reports sleeping with one mode or another. In this study of the 21 CPAP patients who eventually had the chance to use ASV (because the device they used could be switched to ASV or CPAP after the conclusion of the study), 18 of them eventually wanted to remain on ASV, not CPAP. Of the 19 ASV patients who started on ASV, only 1 even tried CPAP. As we've long instructed our patients and our colleagues, SLEEP QUALITY is where it's at, so if someone is using a mode because they are sleeping better, then in many instances the SE and WASO will eventually improve as well, notwithstanding co-morbid conditions like leg jerks.

[Arlene1963]

Thanks for your reply, Barry.

I made the mistake of concluding that a PSG is a rather infallible and objective measure of " exactly what is going on" and am very glad to read that subjective experience of sleep quality trumps the numbers for insomnia patients (An aside here: the night I had my very first in lab PSG I thought I slept okay, and then got the dreadful report that indicated poor SE and WASO! )

Although you did state :"We hypothesized ASV would be more efficacious than CPAP in significantly decreasing insomnia severity by restoring sleep quality subjectively and objectively" (Objectively referring to PSG results?)

As you say, these measures might improve long term. Will you be providing follow reports at any time in future?

This study doesn't reflect very well on straight CPAP adequately treating complex insomnia, especially compared with ASV, so as someone who has intermittently battled what I now believe likely to be complex insomnia this study is of great interest.

I would like to know if you think that APAP could fare better than CPAP when it comes to treating complex insomnia?
Also, did the straight CPAP group have the EPR option on their machines and was it used?

Thanks to your research, I am thinking of buying a second hand ASV and giving it a whirl. I love EPR and think I might benefit from ASV.
Thanks so much again for sharing your research and taking the time to answer questions.

[slowriter]

I'm new to all this, after recent UARS diagnosis, so I wonder if you could answer this question for me:

How would you advise people here to think about ASV vs ABPAP?

Just that many people may benefit from higher pressures, and PS, than they think, but that those settings will often induce centrals that ASV can largely resolve?

But if the airflow curves reported by our machines (one key piece of objective data we have access to as patients) are, in fact, rounded, without significant centrals, then ABPAP is a good solution?

[brookfox]

Wanted to share with you our publication today at https://www.sciencedirect.com/science/a ... via%3Dihub or at https://www.thelancet.com/journals/eclinm/home. Either link should work. Also, if you want to read our press release, it's at www.shhi.org. It's been a quarter century in the making, once we first realized the deep connections between insomnia and sleep apnea, and this study alone consumed the past six years. We hope many insomniacs will benefit from this knowledge, and we trust their providers and insurers will realize most chronic insomniacs need sleep testing.
Rest Wishes,
Barry Krakow, MD

How do you reconcile your study with studies like this one from Dr. Thomas at BIDMC: https://academic.oup.com/sleep/article/ ... 33/4868556

He pretty consistently reports improved outcomes using EERS and straight CPAP over ASV.

I'm confused.

[silverpines]

Thank you, Dr. Krakow for contributing to this forum. I am a fan.