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Papit · Post by **Papit** » Sat Aug 03, 2013 1:55 am

tiredintenn wrote:
fiberfan wrote:The data guide for the S9 Elite and AutoSet has the following definition for a flow limitation.

Flow Limitation is a measure of partial upper airway obstruction.

This measure is based on the shape of
the inspiratory flow–time curve. A flat shape suggests upper airway obstruction.
From looking at my data, I am pretty sure flow limitations are seen over multiple breaths. I find them very helpful since my problem is RERAs (respiratory effort related arousals) and not OSA. With guidance from my sleep doc, I have adjusted pressures to minimize flow limitations and improve the quality of my sleep.

Fiberfan, how have you done that? Increased pressure? If so, to what? What is your inhale and exhale? When did you stop? When you saw no more FLs?

The above, Fiberfan, is from an earlier thread in which you (like me below) expressed curiosity and concern about your high flow limitations even while your AHI was looking low and good (same with me using the S9 VPAP Adapt although not on Auto). I couldn't find your reply to Tiredintenn's questions. Can you let us know here what guidance your doc gave you? Increase or decrease pressure? From what settings to what new settings? How did it work out in reducing frequency and amplitude of your FL's? Thanks.

NateS · Post by **NateS** » Sun Jul 07, 2013 11:10 pm

Also, here is a handy little slideshow on the subject:

http://tinyurl.com/mg5y6yt

In particular, see pages 28 thru 35.

Best wishes, Nate

NateS · Post by **NateS** » Sun Jul 07, 2013 10:56 pm

avi123 wrote:It seems to me that the above suggestions by Chunky, Nate, and Papit are wishful thinking that are not going to materialize any time soon. At present time there is a specific policy by Medicare for OSA treatment and the pathway to Bilevel conversion and guidelines for qualifying for Respiratory Assist Device. It's not up to doctors or patients or anyone else's to carry out any changes or do whimsical tricks to shortcut it. So let's not mislead newcomers.

Check it here:

Sleep Lab Titration Guide by Resmed

http://www.resmed.com/us/documents/1013 ... -guide.pdf

You are mistaken, avi. We are talking about CSA not OSA.

Check it here:

http://www.resmed.com/us/documents/1013 ... et_rad.pdf

Central Sleep Apnea or Complex Sleep Apnea
Prior to initiating therapy, a complete facility-based, attended
PSG must be performed documenting the following:

A. The diagnosis of central sleep apnea (CSA)4 or complex
sleep apnea (CompSA); and

B. Significant improvement of the sleep-associated
hypoventilation with the use of an E0470 or E0471 device
on the settings that will be prescribed for initial use at
home, while breathing the patient’s usual FiO
2.
If all above criteria are met, either an E0470 or E0471 device
(based upon the judgment of the treating physician) will be
covered for patients with documented CSA or CompSA for the
first three months.

Follow-Up Documentation Requirements
Continued Coverage for E0470 and E0471 Devices
Beyond First Three Months of Therapy
The following items must be obtained no sooner than
61 days after initiating use of the device to document
continued coverage beyond three months:
1. Signed and dated statement completed by treating
physician declaring that the patient is compliant,
using the device an average of four hours per
24-hour period, and that the patient is
benefiting from its use; and
2. Progress of relevant symptoms.

Regards, Nate

Papit · Post by **Papit** » Sun Jul 07, 2013 9:47 pm

avi123 wrote: In Papit's case I keep wondering what took him so long to land on an ASV machine? By looking at his graphs from 2 years ago it was clear that he was either a CSASnick or a CompSAnick.

Your 'diagnosis' about a year ago was spot on, Avi, and I thought so at the time as well. Unfortunately, my doc seemed un-inclined to upgrade my machine so aggressively; and he expressed reservations he had about xPAP adaptive servo-ventilation (ASV) machines. That cost me time and as is often the case, it took me awhile to find a more astute and quicker-acting sleep doc. You can't just snap your fingers and land on an ASV machine. In hindsight, had I Nate's insight and letter-writing skills, I probably would have been able to get one from my first doc.

NateS · Post by **NateS** » Sun Jul 07, 2013 9:17 pm

avi123 wrote:It seems to me that the above suggestions by Chunky, Nate, and Papit are wishful thinking that are not going to materialize any time soon. At present time there is a specific policy by Medicare for OSA treatment and the pathway to Bilevel conversion and guidelines for qualifying for Respiratory Assist Device. It's not up to doctors or patients or anyone else's to carry out any changes or do whimsical tricks to shortcut it. So let's not mislead newcomers.

Check it here:

Sleep Lab Titration Guide by Resmed

http://www.resmed.com/us/documents/1013 ... -guide.pdf

In Papit's case I keep wondering what took him so long to land on an ASV machine? By looking at his graphs from 2 years ago it was clear that he was either a CSASnick or a CompSAnick.

avi,

I did not engage in any "whimsical tricks" and I'm confident that my sleep doctor is very ethical and competent and did not engage in any "whimsical tricks" either.

Where in that ResMed Titration Guide above does it quote all of Medicare's rules? I don't see it. That is just a titration guide - one I believe I pointed you to at one time in the past. It is not the official Medicare rules.

My doctor was honorable, ethical and smart enough to know, from my titration study on CPAP, that putting me on straight CPAP for weeks or months would have made me terribly ill, much worse than no treatment at all; and he obviously knew of Medicare rules which did apply in such a situation. Furthermore, even in the absence of Medicare or other insurance, I'm sure he is smart enough to know that it would be malpractice to knowingly put a patient on a regimen which would horribly aggravate and worsen the condition they came in with!

The "path" you describe above is of course the one normally taken, but I think you are perpetuating a myth to assert that you know there are no lawful exceptions permitted by Medicare or private insurance companies. In any profession, you never hear the professional person at the top of the pyramid use terms like "This is what we always do." It is only office personnel who use terms like this, because they are trying to understand and interpret protocol based solely on their personal observations working there, and not on the years of education, training and experience of the guy or gal at the top.

Furthermore, I was not advocating that everyone should go in and demand a machine they don't need. I was advocating that everyone should read and study what can be learned on cpaptalk and other resources, sufficiently to understand and interpret their sleep studies, so that they can intelligently evaluate what the sleep lab personnel tell them. There is too much "Just tell me the bottom line, Doc (or nurse or office mgr.)" and not enough "Please let me go through and read and understand the steps you went through to arrive at your recommendation."

Regards, Nate

avi123 · Post by **avi123** » Sun Jul 07, 2013 12:55 pm

It seems to me that the above suggestions by Chunky, Nate, and Papit are wishful thinking that are not going to materialize any time soon. At present time there is a specific policy by Medicare for OSA treatment and the pathway to Bilevel conversion and guidelines for qualifying for Respiratory Assist Device. It's not up to doctors or patients or anyone else's to carry out any changes or do whimsical tricks to shortcut it. So let's not mislead newcomers.

Check it here:

Sleep Lab Titration Guide by Resmed

http://www.resmed.com/us/documents/1013 ... -guide.pdf

In Papit's case I keep wondering what took him so long to land on an ASV machine? By looking at his graphs from 2 years ago it was clear that he was either a CSASnick or a CompSAnick.

Papit · Post by **Papit** » Sun Jul 07, 2013 12:04 am

Outstanding, Nate. Your post should be "framed" here somewhere as an important instructive in how a new-comer can deal effectively with sleep docs and DME's. You're no doubt one in a thousand in devising such a great detailed professional approach, and the doc on the receiving end was therefore highly likely to sit up and take notice. Newbies, read his post below -- twice, regardless of the type of machine you're headed for if for no other reason than to get cued in on how better to establish a good relationship with sleep docs and equipment suppliers. You may or may not be so lucky as was Nate, but at least you'll be much better informed. See Sir NoddinOff's observation below too.

NateS wrote:
Sir NoddinOff wrote:
NateS wrote: I was very lucky to be able to persuade my doctor to let me go straight to ASV. It only happened because I first came to cpaptalk, read and learned to insist upon a copy of my full sleep report(s) before accepting the machine first prescribed for me, learned what to look for when I got my report, followed up on recommended reading and then wrote my sleep doctor a letter quoting from my first and second studies re centrals and politely making my argument to go straight to ASV, which resulted in a very amicable phone conversation with him, a 3rd study to support my/his request for authorization to Medicare.
Best wishes, Nate
My emphasis above: Glad to hear your ASV plan worked out so well for you, Nate. However I'm a little shocked that Medicare went along with this. It's my general understanding that one must have months of documented failure while using conventional APAP, then the same for BiLevel, before even remotely qualifying for an ASV machine. Maybe I missed some trick? And certainly my sleep doctor hasn't enlightened me on this topic.
Actually, I wrote two letters. The first one was directed to the sleep center and not the doctor personally, so that I would not appear to question his judgment. In that letter, I told them to stop calling me every day to come pick up my machine, because I didn't want any machine until I studied my reports from the diagnostic and titration nights, and saw a concrete recommendation and had a chance to discuss it eyeball to eyeball with the doctor; that I had asked for my reports and was told it takes many weeks for them to be typed up, so how would I know whether I wanted any machine? To quote, I said: "I do not know about your other patients or your customary protocol, but I do know that this is my decision, and that I do not make decisions this way."

Then I got the reports, studied them on the basis of what I had learned here and elsewhere, and wrote the doctor directly complimenting him on the thoroughness of his reports; then I told him how horrible I felt the day after the CPAP titration (which matched the symptoms of central apneas) and much worse than anything I had experienced without treatment; and said something to the effect that since CPAP treatment during the test did not improve my sleep architecture and efficiency; and your diagnosis from the test results includes central apneic episodes; and considering my history of atrial flutter, etc.; as well as my personal difficulty in contemplating adjustment to treatment, would you consider recommending or advising that I go directly to an adaptive servoventilation system?

He called me early the following morning after the letter was delivered, was very very pleasant on the phone, joked that I shouldn't have had to study to become a doctor in order to get to talk to him; spoke highly of his office staff but said he would have a talk with them; and set me up for Test#3 which he explained Medicare would require, etc. and everything went smoothly from that point on; and from that point on I have gotten along wonderfully with everyone in the sleep center, from the office manager down to the receptionist and in between.

I was just lucky to have struck the right balance between assertiveness and diplomacy, and to have a doctor I could reason with who understood that there was no way I was going to accept standard CPAP at home for even one night let alone weeks or months after how miserable it made me; and who knew the Medicare rules and exceptions very well. He said I made sense and he agreed with me. He made clear that he didn't want me to walk away with untreated apnea.

Regards, Nate

avi123 · Post by **avi123** » Sat Jul 06, 2013 6:44 pm

Nate S, if I was suffering from CSAS, for example b/c of a congestive heart failure, I think that I could convince at least 4 of my physicians to write me an Rx for an ASV machine (as my 2nd XPAP), especially, on the condition that I would pay for it from my pockets, instead of asking Medicare to pay for it.

NateS · Post by **NateS** » Sat Jul 06, 2013 4:03 pm

Sir NoddinOff wrote:
NateS wrote: I was very lucky to be able to persuade my doctor to let me go straight to ASV. It only happened because I first came to cpaptalk, read and learned to insist upon a copy of my full sleep report(s) before accepting the machine first prescribed for me, learned what to look for when I got my report, followed up on recommended reading and then wrote my sleep doctor a letter quoting from my first and second studies re centrals and politely making my argument to go straight to ASV, which resulted in a very amicable phone conversation with him, a 3rd study to support my/his request for authorization to Medicare.
Best wishes, Nate
My emphasis above: Glad to hear your ASV plan worked out so well for you, Nate. However I'm a little shocked that Medicare went along with this. It's my general understanding that one must have months of documented failure while using conventional APAP, then the same for BiLevel, before even remotely qualifying for an ASV machine. Maybe I missed some trick? And certainly my sleep doctor hasn't enlightened me on this topic.

Actually, I wrote two letters. The first one was directed to the sleep center and not the doctor personally, so that I would not appear to question his judgment. In that letter, I told them to stop calling me every day to come pick up my machine, because I didn't want any machine until I studied my reports from the diagnostic and titration nights, and saw a concrete recommendation and had a chance to discuss it eyeball to eyeball with the doctor; that I had asked for my reports and was told it takes many weeks for them to be typed up, so how would I know whether I wanted any machine? To quote, I said: "I do not know about your other patients or your customary protocol, but I do know that this is my decision, and that I do not make decisions this way."

Then I got the reports, studied them on the basis of what I had learned here and elsewhere, and wrote the doctor directly complimenting him on the thoroughness of his reports; then I told him how horrible I felt the day after the CPAP titration (which matched the symptoms of central apneas) and much worse than anything I had experienced without treatment; and said something to the effect that since CPAP treatment during the test did not improve my sleep architecture and efficiency; and your diagnosis from the test results includes central apneic episodes; and considering my history of atrial flutter, etc.; as well as my personal difficulty in contemplating adjustment to treatment, would you consider recommending or advising that I go directly to an adaptive servoventilation system?

He called me early the following morning after the letter was delivered, was very very pleasant on the phone, joked that I shouldn't have had to study to become a doctor in order to get to talk to him; spoke highly of his office staff but said he would have a talk with them; and set me up for Test#3 which he explained Medicare would require, etc. and everything went smoothly from that point on; and from that point on I have gotten along wonderfully with everyone in the sleep center, from the office manager down to the receptionist and in between.

I was just lucky to have struck the right balance between assertiveness and diplomacy, and to have a doctor I could reason with who understood that there was no way I was going to accept standard CPAP at home for even one night let alone weeks or months after how miserable it made me; and who knew the Medicare rules and exceptions very well. He said I made sense and he agreed with me. He made clear that he didn't want me to walk away with untreated apnea.

Regards, Nate

JohnBFisher · Post by **JohnBFisher** » Sat Jul 06, 2013 2:18 pm

Papit wrote:... Do I still feel tired and sometimes sleepy during the day despite my new ASV having almost fully reduced my sustained high centrals, and the few obstructives I had, to near zero? Yes, I do. I notice no significant change in that after nearly a month. ...

While I agree you should pursue this further with your doctor, don't forget that getting out of shape (as we often do when we have uncontrolled sleep apnea) also drains our energy. It can take quite some time (months) to reverse that impact. But hang in there. You should be able to feel more rested and in better shape if you continue to work toward it.

P.S. Don't forget that "great" nights don't always happen. "Horrible" nights can also occur.

chunkyfrog · Post by **chunkyfrog** » Sat Jul 06, 2013 1:27 pm

My thought: A good doctor should be able to adequately convey the medical necessity of proceeding with the proper treatment,
as opposed to subjecting a patient to an extended period of inadequate treatment, with all the risks associated with that.
Kudos to Nate for persevering until he got the results he needed.
I would certainly hope that Medicare could be found liable if their "rules" result in harm to the patient.
A competent doctor's input is invaluable.

Sir NoddinOff · Post by **Sir NoddinOff** » Sat Jul 06, 2013 1:05 pm

NateS wrote: I was very lucky to be able to persuade my doctor to let me go straight to ASV. It only happened because I first came to cpaptalk, read and learned to insist upon a copy of my full sleep report(s) before accepting the machine first prescribed for me, learned what to look for when I got my report, followed up on recommended reading and then wrote my sleep doctor a letter quoting from my first and second studies re centrals and politely making my argument to go straight to ASV, which resulted in a very amicable phone conversation with him, a 3rd study to support my/his request for authorization to Medicare.
Best wishes, Nate

My emphasis above: Glad to hear your ASV plan worked out so well for you, Nate. However I'm a little shocked that Medicare went along with this. It's my general understanding that one must have months of documented failure while using conventional APAP, then the same for BiLevel, before even remotely qualifying for an ASV machine. Maybe I missed some trick? And certainly my sleep doctor hasn't enlightened me on this topic.

avi123 · Post by **avi123** » Sat Jul 06, 2013 10:09 am

The damaging effects from hi Flow Limitations (FL):

In 2011 while on an S9 Elite (plain CPAP at a pressure of 7 cm) my FL was above average:

As a result, you can see in the following Minute Ventilation (MV) top graph, that the FL caused a drop of more than half in the MV.
The FL just robbed me of breathing air:

Raising the pressure on the S9 Elite to around 13 cm (with EPR = 3) did eliminate the FL.

The above has direct connection to the following by -SWS:

As a side note the initial S9 ASV model does not offer ASV-auto mode, whereas the most recent model does. ASV-auto mode refers to this obstructive-addressing aspect of the latest S9 ASV algorithm:

Resmed wrote:In ASVAuto mode, the EPAP also responds to flow limitation, snore and obstructive apneas on the next breath, in proportion to the severity of the event.
http://www.resmed.com/us/products/s9_vp ... s&sec=true

That means the initial S9 ASV model will not adjust EPAP in response to FL, snore, or OA. Rather, those must be manually addressed/titrated with a fixed EPAP. Similarly, the latest S9 ASV model will not raise EPAP in response to FL, snore, or OA *if* legacy "ASV mode" is enabled rather than "ASV-auto mode".

But since an auto machine is contraindicated for CSAS patients, it means that the manual version of the ASV mode is the one to go by but the EPAP pressure needs to be set and fine tuned to treat (eliminate) most FLs.

NateS · Post by **NateS** » Sat Jul 06, 2013 9:41 am

Papit wrote: So if anyone's sleep doc floats the notion of upgrading from a cpap machine to ASV after less than stellar treatment effectiveness on cpap for several months, I would say go for it. And don't linger.

I was very lucky to be able to persuade my doctor to let me go straight to ASV. It only happened because I first came to cpaptalk, read and learned to insist upon a copy of my full sleep report(s) before accepting the machine first prescribed for me, learned what to look for when I got my report, followed up on recommended reading and then wrote my sleep doctor a letter quoting from my first and second studies re centrals and politely making my argument to go straight to ASV, which resulted in a very amicable phone conversation with him, a 3rd study to support my/his request for authorization to Medicare.

I was very fortunate, thanks to this group, not to have to mess around with a straight CPAP machine first. I know how unsatisfactory that would have been because, by accident, I spent one night on CPAP mode by accident a few months ago, and what a negative experience and terrible events graph!

Best wishes, Nate

Papit · Post by **Papit** » Sat Jul 06, 2013 1:03 am

JohnBFisher wrote:I tend to agree with -SWS. In general, if you feel fine to brilliant, then don't sweat the FL or hypopnea values. If you still feel tired, explore it. But remember, being tired may be due to other issues than just sleep.

John, -SWS, Avi and all, thanks so much for your continued input. Do I still feel tired and sometimes sleepy during the day despite my new ASV having almost fully reduced my sustained high centrals, and the few obstructives I had, to near zero? Yes, I do. I notice no significant change in that after nearly a month. And so I will continue to explore this with my doc. Although I'm disappointed that I'm still tired, as you say, that may well be due to other issues. And I am very much comforted to know that I am now probably far less likely to expire in my sleep due to lengthy apneas, especially central apnea in my case. That's huge.

So if anyone's sleep doc floats the notion of upgrading from a cpap machine to ASV after less than stellar treatment effectiveness on cpap for several months, I would say go for it. And don't linger.

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