Any medical reasons *not* to use a BiPAP?

As I have posted before, I'm relatively new to this. I was tritrated at 16cm and found the exhalation pressure on a standard CPAP to be intolerable. I am going back to my doctor this afternoon to see if I can convince him to let me try a BiPAP as others on here have suggested. I am trying to go in with as much documentation/ammo that I can get my hands on.

So other than the fact the it gives him more paperwork, is anyone aware of any medical reasons the doctor may be reluctant to give me an Rx for a BiPAP? I'd like to be prepared to respond to as many reasons as possible.

Thanks!
--John

only thing I've read is it you have Central apnea, it can sometimes make the condition worse.

but if you had central apnea you wouldn't be at 16cm pressure, so I doubt that would be a problem for you.

No guts, no glory, go for the Bipap Auto!!

I thought that the bilevel is prescribed for Centrals over the cpap???

John, some may have trouble with the differnt pressures (grasping on straws as to why not)

Found this paper while doing my research. Section 7 covers Bi-PAP. Although the paper is a few years old, I think it basically says that for people with OSA as their only sleep disorder BiPAP is neither better nor worse that straight CPAP with respect to compliance and reduction of AHI.

In other words, boo! Doesn't help my case, nor does it reflect the actual experiences of the people here.

Study Link

JohnK,

The primary reason folks get put on BiPAP seems to be high pressure. For reasons known only to insurance companies, the patient first has to fail CPAP use though. At that point the doc prescribes BiPAP and everyone's happy.

Your argument to your doc needs to be that you can't tolerate CPAP use because of the high pressure, and you want/need "something" changed.

Once you get the BiPAP script, then simply request the BiPAP-auto from your DME. DME's don't seem to mind providing the BiPAP-auto because the cost to them is about the same as a regular BiPAP.

Regards,
Bill

Your doctor "may" have to show where the Bipap is "medically necessary" in the form of a letter to your Insurance company. Give your doctor the "ammo" he/she needs should that be necessary:

You have already satisfied one of the minimum requirements of insurance that is a trial on cpap. If you don't use it, therapy has failed. No big deal, compliance and failure rates with this therapy is high, you won't be telling them anything new.

If you go back to your doctor complaining of aerophagia and difficulty sleeping due to the pressure waking you up, then your doctor has several "medical" reasons.

1. Compliance. Therapy is only going to be effective if you "use" the device.

2. Aerophagia: If you cannot use the machine because of bloating and abdominal pain from aerophagia.

3. High Pressure: If you find you are waking during the night, it may be due to the high pressure. If your pressure is over say 14cm (even 12cm is a good argument) you can say it wakes you during the night. The exhale relief offered by the Bipap can make that higher pressure easier to tolerate. If you can tolerate the higher pressure where it is comfortable, you will sleep longer and hopefully uninterrupted.

4. Positional sleep: Tell the doctor you sleep on your side, stomach and back. Look at ever PSG ever printed, it shows you have fewer events sleeping on your side and stomach vs. supine. A machine blowing a single pressure over treats you when sleeping on your side. If you were taking a drug, you would be over-dosed.

Again, it boils down to compliance, don't use the machine, no therapy.

Go to Respironics and Download a Bipap Auto brochure, print it out, know what you are talking about. Know more than your doctor. take it into your doctor and show them where it may help you become "Compliant" with that machine.

Note: These damn doctors don't know squat about algorithms. If they pull that number on you, have them explain it to you (guarantee you they can't).

Bottom line is its about compliance, the Bipap Auto will allow you to set a range if needed when pressure is high and only deliver it when needed, same if you sleep on your side or stomach. If my pressure was 15cm as determined by a PSG and I found I only spent 3-4 minutes there per night needing that pressure and only 9cm the rest I'd drop the pressure to 9cm, screw that, higher pressure means more noise, greater leaks, and less tolerance to cpap.

You will only use it if it becomes comfortable.

P.S. Now don't tell me now your pressure is only 6cm. Tell your doctor the above and they will think you are an idiot.

More "Medical Necessity" ammo:
http://reimbursement.respironics.com/Medical.asp

One fairly recent retrospective study found that BiPAP can either cause centrals/CSR/periodic breathing (PB) or make them worse if they were there to start with. They aren't saying it can't be or shouldn't be used, just that it should be used with caution and only when necessary.

It is important to recognize that BLPAP [BiPAP] and PSV [Pressure Support Ventilation, which BiPAP is one form of] worsen central sleep apneas in some patients, placing them at risk for adverse cardiac effects and sleep disturbance. Based on our results and current literature, we believe that CPAP should be the primary treatment for OSA and CSR. For patients who cannot tolerate CPAP due to difficulty with exhalation, exhalation pressure relief should be tried first, then BLPAP. BLPAP without a backup rate may be effective for patients with OSA, but should not be used to treat CSR.... Hospitalized patients receiving BLPAP or PSV should be observed for central sleep apneas. Our findings support Medicare guidelines that BLPAP should only be used to treat sleep apnea if the patient has failed to respond to CPAP. Our findings do not affect the standard practice of using BLPAP with a backup rate for patients with primary central sleep apneas with hypercapnia.

In summary, we found that many patients acquiredor had worsened CSR and non-CSR central apneas when treated with BLPAP [BiPAP]. Patients with baseline CSR or PB are more likely to have worsened CSR with BLPAP than those without baseline CSR or PB. CSR often persisted despite using a backup rate with BLPAP. Central apneas consistently improved during REM sleep. Since CSR has detrimental health effects, by the principle of "do no harm," it is important to ensure that treatment for SDB does not create more problems. BLPAP should be used with caution to treat OSA, particularly if there is periodic respiration or CSR at baseline.

http://www.chestjournal.org/cgi/content/full/128/4/2141

Thanks for all the input! Just got back from the doc's.

I brought a bunch of printed practice guidelines from http://www.aasmnet.org/ where I had gone through and highlighted all the applicable criteria, as well as printed copies of my insurance carrier's Clinical Guidelines relating to OSA also highlighted and indexed with little sticky tabs. I also had typed up my sleep log and a list of my symptoms, and printed out product pages on APAP and Auto Bi-PAP devices.

I also told him that I wanted to get the highest quality of care, even if that meant paying out of pocket in the event insurance failed to cover.

It was great, every time he mentioned something I was able to immediately flip to documentation I had researched on it.

After that he totally changed his tune. He's going to start me out on an APAP for two weeks and then if that still causes me problems he said he will write me a script for an Auto-BiPAP and write a letter of medical necessity to my insurance.

No real excuse for his initial behavior, but I got the impression that he has been beaten down by insurance companies denying claims for treatment he has prescribed so many times in the past that he sticks to standard, baseline treatment in most cases.

PS - Snoredog, my pressure is currently at 16cm

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CPAPopedia Keywords Contained In This Post (Click For Definition): auto, APAP

The thing that I don't understand is that my insurance co. will balk at a bipap unless you have another sleep study (which probably cost more than the bipap).