10+ CA's and a bad "doctor". Left to fend for myself, should I ASV, ST, or CPAP?

[Akeyla]

TLDR: (Too Long Didn't Read)
 
Yesterday used CPAP, AHI 12.4, felt like trash but was reasonably awake.  Despite numerous CA's didn't consciously waken from them.
Today used real ASV, AHI 2.77, don't feel like trash, but extremely tired so far during the day.  That said, I work several times last night having to adjust my mask for leaks due to higher pressures of ASV.  I'm sure that doesn't help and is probably some of the hypopneas showing on the chart.
Can't win either way.
 
Long version:
 
First, yes, I'm getting the reports.  Sadly, I work for the Hospital that is doing these tests, though in IT.  There are good people here, but the doctors largely suck.  It's has a reputation for being a a crappy Hospital to generally avoid, small town though, it's what we have.  (More on this shortly) 
 
July 31st, I have a compliance appointment.  I'm going to use ASV flashed AirCurve until then.  On appointment day, I will bring with me my machine and show her that yes, in fact I can and did change its firmware (so she doesn't think I'm crazy.)  I have her compare the results of the couple months of CPAP/APAP with ASV and request a proper RX and new device.  Different provider than last time, I fired her, so we'll see.
 
November, I have an appointment at a reputable sleep clinic, it's not close, but it's necessary.  I'll have them re-evaluate.
 
I'm going to see what insurance will say if I get a new machine scripted halfway through 13-month payment period.  Their answer will help determine if I keep compliant, or return the thing, and use my own equipment until November.
 
Partially, I'm making these posts for myself, to help myself form a plan, and look back on things.  Of course, I genuinely appreciate all feedback, for better or for worse, so any replies are helpful.
 
For now, I'd like to make my hypopneas disappear.  Part of that is going to be getting a mask on correctly to handle the pressure.  I have a p10, p30i, n20, n30, n30i, f20, f40, lowenstein lena, and f&p vitera.  Lena is made to allegedly handle higher pressures, I'll try that, otherwise go back to n20 and mouth tape.
 
Thank you

edit: Just notice I have the wrong EPAP set on ASV, suppose to be 6-8, not 6-20...

[SarcasticDave94]

While not perfect, the leak with the ASV isn't totally terrible.

To address Hypopnea, I think on the ASV and other bilevel, you'll want an increase in PS. I've not used ASV for 4 years, does PS only do full steps 3 to 4, etc.? If it'll to fractional .2 steps, consider trying either EPAP or PS min up fractionally to see which addressed Hypopnea and doesn't minimize comfort.

If we get this ASV tuned well enough, you'll probably not need that November do over. The benefit though might be to get CA as an on-record issue.

If the script changes to a different machine, insurance would go with it I'm sure.

[Jay51]

Good plan Akeyla.  Since you work at a hospital, you know the routine better than most people.  

Who Can Write a CPAP Prescription?
To receive a CPAP prescription, you can make an appointment with your:

• Medical Doctor (MD)
  
  
• Doctor of Osteopathy (DO)
  
  
• Psychiatrist (MD Only)
  
  
• Physicians Assistant (PA)
  
  
• Nurse Practitioner (NP)
  
  
• Dentist
  
  
• Naturopathic Physicians
  

Prescriptions written by the following medical practitioners are not accepted:

• Chiropractor
  
  
• Podiatrist
  
  
• Optometrist
  
  
• Psychologist
  
  
• Registered Nurse (RN)
  
  
• Respiratory Caregivers
  
  
• Medical Assistants
  

While your prescription can simply be written on a standard prescription pad, we also offer a General Prescription Form to send to your prescribing physician.
What Does My Prescription Need to Say?
There are quite a few things that need to be on your CPAP prescription, and if you have the wrong phrases in the wrong places, it could affect your ability to get the right equipment for your needs. To help simplify this, we’ve gathered a list of everything your prescription needs to have on it.
Here are a few basic requirements of any prescription for any CPAP equipment:

• Your physician’s contact information/NPI
  
  
• Your physician’s signature
  
  
• The patient’s full name
  
  
• The Date of the Order
  
  
• Length of Need
  
  
• Diagnosis
  

How Long Is My Prescription Valid?
Some prescriptions for a CPAP machine have a finite expiration date or can be valid for life as judged by how many “refills” your doctor writes on the prescription.
If your prescription states that it is valid for a “lifetime,” then you are able to use it as many times as you need (this is also expressed as PRN, LON, 99, or 99 months). However, many prescriptions will have an “X” number of refills, meaning if it states five refills, then you will have to see your doctor again on your sixth. Some prescriptions may also have a “valid until” date, which means it cannot be used after the expiration date.

[Akeyla]

Jay:
 
I work in IT, I keep a select set of systems up and running, upgrades, and fix problems when they arise.  I am almost completely detached from the medical side of things.  The only special favor I was able to curry was getting to the top of the wait list for my sleep test.  The sleep techs are great, the sleep 'doc' (not MD) was trash, but she's not here anymore, new lady now (PA, still not MD, we poor hospital) I haven't seen.  She might be useful, I don't know, but I'm not getting my hopes up.  Seriously, the general consensus of our community is if you're not dying and can make the couple hour drive to the "other" hospital, do so.  (Being vague-ish just in case).
 
I'll say this though about the hospital I work at, I used to get my primary care here, it was terrible, and I switched to the alternative due to lousy care.  So yeah.  Cafeteria food is surprisingly good though.

Thank you for the info though, I'll pester my new PCP if the new sleep 'doc' is as bad as her predecessor.

[Akeyla]

For posterity's sake I thought I might as well update with last nights Oscar's.


At this point, just want to sort out the Hypopnea's.  Earlier it was mentioned to raise my EPAP from 5 to 6 to help with them, should I try increasing my EPAP again, or increase PS as mentioned more recently.

One of the pics I posted I circled an area, to my (untrained) eye, it resembles a lot of the other hypopneas or UA's.

Anyways.  Feeling better again.  Been using now a Lowenstein Lena, ordered from Australia, took a couple weeks to get here, but it handles the pressure much better than the Vitera I was using before.

[SarcasticDave94]

You could try first increase in PS Min, then revert it and increase EPAP min. See which feels better and/or gives better results.

Your EPAP range is using most of its range as is, going from 6 to 9.88. I'm supposing an increase in PS might give a slightly better leverage against Hypopnea.

As always, if what you changed doesn't work as planned, change it back and try another direction.

[Akeyla]

I've more or less got things dialed in, at least with this mask.  Medication issues are why I wake up several times in the first half of the night and then not in the second half.  Tried sleeping sitting up slightly, pillows propping me up.  I heard this helps keep the aerophagia down, and it certainly made a difference.  Also, I feel good today.  It's funny to me, the "doctor" could have got me sleeping like this had she cared enough too, but CA's being my own fault (her logic), well, I digress.

This Lowenstein Lena mask, I very much like it, problem is I live in the US, and since it's not (yet?) sold here I'm waiting on order from Australia for extra cushions and to try a different size.  Anyways, pretty much good for now, I really want to thank everyone who helped me out.

[SarcasticDave94]

Looks good except for the pauses, which you're aware of them.