ASV for complex apnea - VA says increases chance for heart problems?

[TexasTiger]

My last recent sleep study confirmed mixed/complex apnea (was in my first test as well) and I was seeking to change from my current APAP to an ASV but was informed by the VA that they "no longer provide an ASV because of a study that indicated a higher incidence of heart problems with the ASV as compared to treatment with APAP".  I know and believe that the event numbers are not as important as how we feel with our current treatment, but, I am fighting insomnia problems and looking for any and all possible solutions.  I would like to hear what others believe on this treatment for apneas with a central event component.  Any solutions that have worked well for others with this same problem will be greatly appreciated.

I'm currently on Airsense 10, AirFit F20, and average about 4.5 events/hr. most times but seem to be doing better with my last settings.  No EPR, tweak and manage the max for least CA and min for least OA - (8.4-11.4) has worked best since help on this here over a year ago - MANY THANKS.

[Sleeprider]

I'm very disappointed that the VA has alleged the ASV has any relationship to heart problems. In fact, ASV potentially has a higher risk for individuals that already have heart failure with left ventricular ejection fraction less than 45%. Without that risk factor, ASV is fine.

Appeal! Tell them "show me the VA policy that states this absurd direction".

[TexasTiger]

Good idea Sleeprider - May ask them if they won't provide it to at least give me a script to buy my own! I still believe that most comments here support using ASV if there are documented Centrals in the sleep study - your thoughts on percent of CSA that might warrant purchase of an ASV?

[CB91710]

Keep in mind that not all Centrals are "real" Centrals.
There is a lot of "crap" around the time that we are not fully awake, but not fully asleep, that can result in sensed centrals that are not "real".
For me, this is particularly noticeable in the morning when I sleep in. My normal workday schedule, I get up at 4:30-5:00, but weekends, I'll often sleep until 9 or 10... but I often wake up and "could" get up at 8. Those last 2 hours are often packed with "centrals"

If your insomnia is because you are concerned about your numbers, remember that anything below 5 is considered "treated" and anything below 11 normally does not qualify for treatment (as far as insurance covering it).

[sheepless]

post some sleepyhead charts so we can see proportions of central and obstructive and if we can tell what's waking you up. the sleep study results would also be useful.

not my place to advise but fwiw I'll tell you some of my story. in 1987 I was diagnosed with moderate central apnea but never had treatment until 30 years and 40 pounds later when diagnosed with severe obstructive apnea even though I had only a few less central than obstructive events during my 2016 at-home test. I struggled with apap for about 19 months but continued to feel sick and tired even though my long term ahi was around 5-6, with daily's ranging from about 3 to 19. centrals fluctuated but did not often occur in much greater numbers than obstructives. doc couldn't explain reduction in centrals and never looked at the data to know I was still getting them in about the same proportion as during the sleep test, or that I was having quite a bit of periodic breathing every night, and he never addressed my periodic limb movements or severely fragmented sleep (other than to tell me to find a cognitive behavioral therapist for the latter) but was happy with the results even though I wasn't.

anyway, with help from apnea board members I bought a used asv and now my ahi is always well below 5 and usually below 1. I no longer feel sick which is half the battle but I still feel tired because so far neither apap nor asv has fixed my fragmented sleep (although I optimistically believe I'm seeing a very slow trend toward longer sleep sessions).

I'm 62 and while I might be a candidate for heart disease (weight, cholesterol, blood pressure, lifelong untreated apnea...) I've had no symptoms or diagnosis of such.

5 points:

a) I would characterize my experience with asv as enormously superior to apap even though I probably would not have met the insurance and medical establishment ahi criteria for asv.

b) asv has completely resolved my clear airway events and periodic breathing to which I attribute feeling so much better.

c) asv may or may not help with awakenings depending on what's causing them.

d) my limited understanding of the heart issue is that it's based on a small study that included only people already diagnosed with heart disease. resmed's titration protocol says titrate if no history of heart disease; if history of heart disease, do the test to make sure you are above the threshold; don't use asv if below the threshold.

e) asv is more expensive than cpap, apap, vpap and it seems relatively few sleep labs have the training or expertise to titrate them so providers' instincts are to steer folks toward less expensive and complicated machines. folks like me and maybe you have to strenuously work the system or work around the system to get what we want/need.

[SideSleeper]

I have an ejection fraction of 45% but do not have congestive heart failure according to my cardiologist. They don't always go hand in hand.

[Sleeprider]

Wow, numbers...If you have complex apnea, and two separate sleep studies have determined that to be a fact, the ASV is absolutely the right therapy unless you are in the risk category that precludes ASV. If LFEF% is greater than 45%, all of this is bull- S*!t. You can have a normal night of sleep and not experience central or obstructive apnea.

To me, this is all about avoiding legitimate health care costs, and it's particularly offensive that veterans should be qualified for the right treatment any differently than the rest of us. Mr. Trump would not approve.

[SarcasticDave94]

IMO if you had the heart problem(s) that makes docs resist a script to dispense an ASV, you'd likely already have some cardiac related issues that are manifesting themselves. Symptoms of congestive heart failure likely are at the top of the list for concern.

I'm not getting into whether or not you're needing an ASV machine for centrals, but I'm conveying what I know about getting an ASV machine and the heart test, called an echocardiogram, echocardiography or diagnostic cardiac ultrasound.

The heart echo test is an ultrasound where the tech uses a wired wand to push around ones chest above the heart to capture images and sounds. The test is about 45 minutes, with the patient lying on an exam table. Typically, the test is in a hospital within or near the diagnostic/X-ray dept.

After the test, results typically get handed off to a cardiac doctor to review and decipher the test results. He or she will do a write up on the results and pass a copy to whomever is deciding your sleep apnea therapy. You can ask for your own copy of these.

What result are you focused on regarding ASV? Left Ventricle Ejection Fraction or LVEF of 55% or higher equals you'll be deemed safe for ASV. BTW mine was exactly 55% last year.

[TexasTiger]

I'm not going to post any charts at this time - they are the same as posted 18 months ago. I feel very confident setting my own pressures after all the great help from Sleeprider and others on this forum. I'm currently on Airsense 10, AirFit F20, and average about 4.5 events/hr. with some CSA over 50% and some days with CSR and some with AHI over 15 with no leaks or mask problems. Settings = no EPR, tweak and manage the max for least CA and min for least OA - (8.4-11.4) has worked best since help on this here over a year ago - MANY THANKS AGAIN TO ALL ON THIS FORUM.

I started with PAP treatment almost 20 years ago at an AHI of 24. In December of 2016 I started having a lot of sleep problems and developed insomnia. I convinced the doctors that I needed another sleep study to help find the problem (off and on nights of high events with some CSR as well). The new study now has me at what they list as "Extremely Severe" - AHI=64/hr. & RDI=70/hr. Out of 8 hr. testing only 3.5 hr. possible sleep and no REM sleep (no PAP treatment attempted during the study). The mean O2 was 91% with a nadir of 82%. - 10.7 minutes were spent under 87% O2. The Central Index noted was 5/hr.

I am certain as these are real centrals as they have now been confirmed by 2 sleep tests. I am not looking to improve my current settings as I am certain that I have hit a wall on any further improvement with APAP treatment - looking for as much information to attempt to get someone to approve or provide a script for an ASV.

I do not have any heart problem other than BP & cholesterol controlled by meds and SVT (Supra Ventricular Tachycardia - heart rate jumps quickly to 200+) also controlled by meds. I have had 2 Echos and they did not show any problems so no reason to deny getting an ASV. I'm going to continue to look into options to get my ASV as I believe all that I have heard from here and been able to Google that that is the best option to improve my sleep quality.

[greatunclebill]

It must be a government or military thing.

TRICARE may cover CPAP machines for:

Obstructive sleep apnea syndrome
Respiratory insufficiency

TRICARE doesn't cover:

Variable Positive Airway Pressure (VPAP)
Adaptive Servo-Ventilation (ASV) machines