[CPAP] Beyond ASV with Overlap Syndrome!

[SarcasticDave94]

Appreciate your thoughts on Respironics SV Auto, but there's 2 strikes against it for me, foam gate and the ResMed overall pattern is better for me. I'm holding out for ST-A iVAPS. The ST-A does feel different as EPAP is single pressure with all the ranging going on in PS.

I think this is the one fail for ResMed. VAuto has the time set, ST-A has it, but ASV no.

My untreated Central events in '17 were 124. I don't yet know about this newer test as they won't release the report until I send back a release signature. That's going out today.

[Sleeprider]

The biggest fail of the Resmed ASV is the dependence on an automatic algorithm for both respiration rate and volume. Individuals with COPD and other disorders that my overlie a central apnea problem (overlap syndrome), can experience a diminishing minute vent target through the night. This can progress to the point where the ASV no longer targets an appropriate respiration rate or volume. The automatic algorithm of the ASV is very effective and comfortable for healthy individuals with central or complex apnea, but it lacks the ability to intervene when a minimum manually set target is not met. In addition the lack of setting for rate and volume, Resmed does not include inspiration timing or sensitivity which are features of its S and Vauto Aircurve line. The Philips algorithm has both an auto algorithm, and can be set to provide a minimum backup rate and tidal volume. Philips is not perceived to be as comfortable by many people because is uses a square-wave bilevel pressure that is only slightly modified by the BiFlex or rise time set for the machine. The Philips machine is slower to provide an increase in pressure support to supplement respiration during hypopnea or central apnea. It takes up to 4 breath cycles to reach the maximum pressure support. This compares to the Resmed ASV which can accomplish this on a breath by breath basis.

The Resmed VPAP ST-A has an iVAPS algorithm that works with adaptive pressure support and an intelligent breathing rate (iBR) that accomplishes everything the ASV is missing, and it is intended to treat COPD, neurological and thoracic muscular disorders. The biggest problem seems to be a lack of familiarity and training of doctors to understand and appropriately prescribe these advanced machines. To be honest, it would not take much training for a pulmonologist to fully understand this, but oddly there are very few that really understand the differences in therapeutic applications and benefits.

[SarcasticDave94]

Yep I totally get it and without the doctorate, yet those with one don't, can't, or won't get it.

Maybe it's because I've used these machines I understand what works vs what fails. I can't see old square waves as comfortable, and yes I will eliminate it just for that.

Be assured I'll get my own ST-A soon enough. I KNEW the UPMC low pressure PAP and you don't have CA anymore was totally bogus, because the symptoms were still present.

So at least this new team recognizes CA still present and that ASV is a right answer, but I'll give them choice B the ST-A. I'm going to introduce the info that if HCPCS code E0471 is written, it can point to either ASV or ST-A. EPAP won't be a range, and just give me default timing and I'll figure it out. Trigger high is ok, it does make the IPAP and PS drop to EPAP fairly more quickly than I'm used to, but I'll be OK with it.

I'm thinking EPAP 6 or 7 just for the "air" that I was used to on ASV, PS 3-20 or so giving me IPAP 9 or 10 to 26 or 27.

I forgot to write down the timing but Ti was .8-2.0 I think, medium cycle, high trigger, I tried the Auto configure the target and it was way off likely I wasn't doing relaxed breathing, the RR was too high at 18, I reset to 8 and it was more natural. Note I am slow breather at 10-12 RR.

[SarcasticDave94]

I'll need to scan in my Titration data sometime later, as I have received my detailed copy of the report today.

Here's a few highlights:

Diagnosis G47.37 Central Sleep Apnea/Complex Sleep Apnea

Sleep efficiency 82.1% 103 Arousals...

Events:
AHI 40.6, Apnea index 39.7, Hypopnea index 0.9
227 total events, 1 Obstructive Apnea, 0 Mixed, 5 Hypopnea, 0 RERA, 221 Central Apnea CSR N/A
RDI 40.6 Avg event length 15 seconds
Supine RDI 59.3 non-supine RDI 33.94
PLM 0.7

Tech tried 3 BPAP pressure sets but concluded optimal pressure indeterminate.
I'll leave the rest to the scan, but it appears my CA are alive and well.

[Sleeprider]

It sounds like you were titrated on various BPAP pressures. Did these include backup or the types of therapy provided by iVAPS?

[SarcasticDave94]

Just regular BPAP, Negative on with backup rate or iVAPS. Test prescribing medical team member was influenced by the misguided UPMC tests a year ago that said no CA and minimal pressures. I say misguided due to CA dominant history and ongoing similarities of symptoms when untreated.

I have a visit with the pulmonary CRNP 11/9 at my new care team in Harrisburg, a satellite office of Penn State Hershey. I plan on discussing ST-A vs ASV, both available on the same HCPCS code E0471 and that ASV hasn't time control I lack due to overlap of respiratory disease.

The tech that did this test seemed to understand my statement that CA was really the issue, that UPMC botched the last test, so he said he'd go through the test protocol but would allow CA evidence to show if that occurred. He wasn't going to fudge or cover up events. Upon wake time, he'd stated I was correct, very much CA only.

Tech tried 10/6, 11/7, 12/8 but all have elevated AHI/RDI. Lowest was the 11/7, but with AHI and RDI being equal at 14.0 and he concluded Indeterminate pressure, redo with SV Auto/ASV.

[cathyf]

Wow, this sounds like real progress!

[SarcasticDave94]

Thanks yes it does, at least now (again really) my CA dominant issue is in black and white. I dunno a 1 OSA event means I possibly still have Obstructive Apnea.

PS the sleep session was nearly 8 hours, 10:56 PM test start with sleep onset of 12.9 at 11:09 to 5:45 AM. More than enough test time it appears.

[Gideon]

Dave, we have seen sleep studies here with very similar numbers including 1 obstructive event being classified as OSA.
Looks like you may have beat that nail to death.

[SarcasticDave94]

Ah, nothing quite as refreshing as the country air at Old McQuack's farm. They're right around the corner from Cookie Cutter Therapy, Inc.