ASV News Dated 5/15/17

[SarcasticDave94]

I found This ASV article I wished to share with anyone interested in newer info/news on the ASV. See below for the link access. Interesting read IMO.

Sleep article

Dave

[Sleeprider]

Not surprising that compliance improved for patients with CPAP emergent central apnea, when switched from CPAP to ASV. As you know, we have seen a lot of misery from attempting to use the wrong therapy. We can only hope the professional community catches up and begins to recognize this problem sooner than later. Currently most doctors and sleep professionals blame their patients for failure.

[SarcasticDave94]

While it would be nice for the medical pros to catch up, I'm not holding my breath on it.

Oh, and I certainly agree that compliance goes up when you're on the right machine. That isn't a theory, I've proved it myself.

Dave

[Hojo]

I'm there with you, I feel much better on ASV, as a matter of fact, I was in such dire straights with the CPAP machine that I recently gave up on it after and started setting my alarm to wake me up at the hours I tend to have the most CA events, then reset the alarm for an hour later (3am, 4am, 5am...if I was able to stay in bed that long).

I've seen the study on ASV with patients having an EF <45% and I have my own doubts, I feel so much better with the ASV machine that my heart isn't straining with all the CA events.

[SarcasticDave94]

I'm with you on that, Hojo. I'll admit I've got some sort of heart issue, but it's not ASV related, but rather high blood pressure and/or some other issue. Since I've got a cardiac specialist looking into it, and he's aware I'm using ASV, I've got precautions in place. But I'm again certain ASV is only doing good for me. I'm more readily compliant and the therapy is keeping my Mixed Apnea AHI numbers low.

Dave

[Shin Ryoku]

I'm really not looking to pick a fight; but in my opinion - based on admittedly a brief membership here - is that this forum is a bit too quick to push ASV for CSA, especially treatment emergent CSA.


In particular, I think there are a couple misconceptions here about the safety signal from SERVE-HF:  

First, people with CHF and EF < 45% are not on death's door.  As a physician, I have many patients with EF < 45% who live for many years.  Some of them even have a return to normal EF.  

Second, since the medical / scientific community does not know what caused the increased risk of death with ASV in CHF patients with reduced EF, we don't know what that safety signal means for ASV safety in other groups besides the one with that heart condition.  There seems to be an assumption by many in this forum that it is definitely safe except for people with that heart condition, but sleep medicine experts by and large do not agree with that assumption.  

ASV remains an option in patients with hyperventilation-related CSA and a preserved ejection fraction, although treatment decisions in such patients should be individualized, and there is a paucity of direct data in these patients [15]. 

Patients who are already using ASV for other indications (eg, heart failure with preserved ejection fraction, primary CSA, treatment-emergent CSA) should be informed about the safety signal from the SERVE-HF trial; in some cases the balance of risks and benefits may still favor ASV therapy, particularly in patients who are responding to therapy and have failed prior CPAP.

As an aside, by extension many experts also have concerns about BPAP-ST safety - especially in patients with CHF and reduced EF - since it has in common with ASV the use of bilevel PAP with backup rate.


None of this is to say that ASV is the wrong choice for CSA, whether treatment-emergent or otherwise.  All I am saying is that when a sleep specialist suggests an extended trial of CPAP before a form of bilevel with backup (whether that be ASV or BPAP-ST), it may not have anything to do with them lagging behind the science, being ignorant of studies, trying to save money, being lazy, or blaming patients.  

I am no sleep specialist, but I do take seriously the principal of "first, do no harm", which includes a careful consideration of both proven and unproven risks of any treatment.

[jerry1967]

I'm really not looking to pick a fight; but in my opinion - based on admittedly a brief membership here - is that this forum is a bit too quick to push ASV for CSA, especially treatment emergent CSA.


In particular, I think there are a couple misconceptions here about the safety signal from SERVE-HF:  

First, people with CHF and EF < 45% are not on death's door.  As a physician, I have many patients with EF < 45% who live for many years.  Some of them even have a return to normal EF.  

Second, since the medical / scientific community does not know what caused the increased risk of death with ASV in CHF patients with reduced EF, we don't know what that safety signal means for ASV safety in other groups besides the one with that heart condition.  There seems to be an assumption by many in this forum that it is definitely safe except for people with that heart condition, but sleep medicine experts by and large do not agree with that assumption.  

ASV remains an option in patients with hyperventilation-related CSA and a preserved ejection fraction, although treatment decisions in such patients should be individualized, and there is a paucity of direct data in these patients [15]. 

Patients who are already using ASV for other indications (eg, heart failure with preserved ejection fraction, primary CSA, treatment-emergent CSA) should be informed about the safety signal from the SERVE-HF trial; in some cases the balance of risks and benefits may still favor ASV therapy, particularly in patients who are responding to therapy and have failed prior CPAP.

As an aside, by extension many experts also have concerns about BPAP-ST safety - especially in patients with CHF and reduced EF - since it has in common with ASV the use of bilevel PAP with backup rate.


None of this is to say that ASV is the wrong choice for CSA, whether treatment-emergent or otherwise.  All I am saying is that when a sleep specialist suggests an extended trial of CPAP before a form of bilevel with backup (whether that be ASV or BPAP-ST), it may not have anything to do with them lagging behind the science, being ignorant of studies, trying to save money, being lazy, or blaming patients.  

I am no sleep specialist, but I do take seriously the principal of "first, do no harm", which includes a careful consideration of both proven and unproven risks of any treatment.


I do see that you use one. For what reason?

[Walla Walla]

Shin Ryoku, I don't think anyone is pushing for ASV unless it's called for. The problem is the average sleep center out there is a cookie factory pumping out prescriptions for CPAP's. They don't take the time to actually look at progress of the patients but are more concerned about the patient getting his 4 hours a day on the machine so the insurance will continue to play the bills.

Are there good Sleep Doctors out there? Sure. But not enough! I don't know if it's because they're overloaded or if it's because sleep medicine as become a landing spot for mediocre Doctors. Probably a little of both.

[ajack]

In fairness to Shin, he did say "treatment emergent CSA"
I did post a video of a leading doctor lecturing other doctors on asv. In it he said that most pressure induced ca resolve and asv isn't needed/then needed. This is also seen on the forum and is often said by 3 months.

The death rate was related to the ejection factor, the worse it was the more they died. As Shin said, it was observational and speculative on why they died. There are some ideas.
I would recommend anyone interested in asv to watch the main asv videos on this page
https://www.youtube.com/user/emjreviews/videos

My personal view is if you want one, get one, I also got a VAPS while I was at it. A good question to answer with an o2 recorder is, are the induced CA causing o2 desaturations? I would guess most cases they don't

[Shin Ryoku]

I do see that you use one. For what reason?

I use BPAP without a backup rate.  Not ASV.  I changed to a BPAP machine mainly to see if I'd feel more comfortable with a little pressure support.  My current minimum EPAP is 17, and I'm still working out how much PS is optimal for my comfort and for my central apnea index (I have some treatment-emergent CAs without meeting the criteria for diagnosis of treatment-emergent CSA).