[CPAP] CPAP, BPAP, or ASV to start with eye towards TECSA

[Nohbotal]

New moderate OSA diagnosis by HST (attached), mild CSA (essentially normal). I am healthy (no cardio/neuro probs), PAP averse and want to start off with the most comfortable machine lest I get discouraged. Rx: APAP (E0601). I hope never to set foot in a sleep lab.

Respiratory Therapist recommends getting CPAP since  “BPAP may elicit treatment emergent central apnea”. I looked through the medical literature, and although BPAP might be more likely than CPAP to elicit TECSA, I suspect that is very unlikely to become a persistent problem for me.

For discussion, let’s imagine I could start with anything I want. Should I aim for ASV, since it would treat TECSA should it develop, and I’m guessing that operating parameters can make a ResMed or Respironics ASV function as auto BPAP or even as CPAP, and a BPAP machine could be made to work as a CPAP if needed? Am I wrong? Seems a bit extreme to aim for ASV to start, no? How about auto BPAP?

Kind experts, in the ideal world, how would you recommend I start off for maximum convenience, treatment, and comfort; and to avoid having to replace machines?


  Study Report.pdf (Size: 270.29 KB / Downloads: 19)

[SarcasticDave94]

Welcome to Apnea Board.

It would be difficult to assume you, myself, or anyone else would not get treatment emergent Central Apnea. I do not recall anything one can say upon seeing certain test or other data that it can't or won't happen. That is except if/when it occurs while using a CPAP class of machine. And by machine that is regular CPAP, APAP, BPAP fixed or ones like VAuto, ST, ST-A, ASV and any other I may have missed.

Unless the ASV is actually needed, it's not a great idea to just jump to that machine. It does treat CA, OA, and Hypopnea quite well. However, it can give less or poorer therapy to those that don't need the CA algorithm in the ASV.

I'm not certain on the best strategy, but a ResMed APAP or the VAuto are probably better choices. Then when you pair that with the free report tool OSCAR, you can see the data and post it to get assistance in pressure edits as needed.

[Gideon]

Welcome to the forum.

To suggest a path going forward it is important to know your insurance situation.

Overall you are rated at just short of Severe OSA
It app-ears that Central Apneas were not separately scored, if included at all they are just a part of the overall AHI, Having any CSR would indicate that you have some Central Apneas, so the 0.0% CSR supports not having any but is not conclusive proof.  Including the RERA (I would) you scored 29.9 which rounds to 30 which is considered severe. We can split hairs ans say you are only moderate.
 Your Oxygen Desats show 11.8 minutes at or below 88%. Without CPAP this should qualify you for overnight supplemental oxygen.  For this reason, I suggest that you purchase an OSCAR compatible pulse/oximeter so you can monitor your oxygen levels.  Do note that your therapy should improve your oxygen levels.

There is nothing in this report to suggest that you have any significant Central Apneas. Therefore ASV is not the correct machine for you.
IMHO the choice is of two.

1. ResMed AirCurve 10 VAuto, a BiLevel intended to treat OSA/ non-compliant OSA. Basically it has more options, a greater range of choices than tn the APAP below.  Insurance is frequently an issue in getting this machine.  Essentially it can do anything an APAP or a CPAP class machine can do plus utilize a greater separation of exhale and inhale pressure and a few other fine-tuning settings.
2. ResMed AirSense 10 AutoSet or AutoSet for her which has an additional mode. This Brand, ResMed, chose to implement EPR in a manner that it can have a differential pressure between inhale and exhale of 0,1,2,3 cmw.  This provides this brand and this machine options that other brands do not have for treatment.

Note: that the ASV is not a replacement for either of the above.  The principles of how and when and how much pressure to apply are radically different.

Respiratory Therapist recommends getting CPAP since  “BPAP may elicit treatment emergent central apnea”.

The same could be said about CPAP and EPR.  We frequently see it!!!.  Based on that logic you shouldn't use any CPAP machine because any of them could cause Treatment-Emergent Central Apnea.  The key is to be aware of it and watch for it.  Simply stated Treatment-Emergent Central Apnea occurs when you device becomes too efficient.  This means that the CPAP Device is providing increased efficiency in your breathing, and thus your oxygen levels go up a little.  It also means it is better at flushing CO2 out of the body which is good, to a point.  When too much CO2 is cleared from your blood, to where CO2 concentration goes below your apneic threshold, you have a Central Apnea.
CO2 levels are the main drive to breathe mechanism for our bodies,  not low oxygen levels (which will make us breathe faster).  These can be dealt with.

does this help.

[slowriter]

I agree with Dave, with preference for the vauto.

[Sleeprider]

The Resmed Aircurve 10 Vauto is unsurpassed for treating obstructive sleep apnea, including hypopnea and RERA which are common with upper airway restriction syndrome (UARS). Treatment emergent central apnea can occur when individuals encounter pressure support in a bilevel machine, and they don't have a tolerance for the change in improved ventilation. The good news is the Aircurve 10 Vauto can produce the same pressure as an Airsense 10 Autoset, or even a straight CPAP. What your therapist is not telling you is that there are even finer levels of adjustment to time of inspiration and sensitivity to trigger inspiration pressure or cycle to exhale pressure. The Vauto is the most flexible machine on the market as long as we're not dealing with central apnea that would appear on any positive pressure device. I like to think that if you have problems, we can solve them, and the more tools we have, the more likely we can optimize your therapy. That wold be the Vauto.

[Nohbotal]

Thanks to all of you for jumping in with such thoughtful advice!  You are all very welcoming, and I am grateful.

The HST obtained with a WatchPat 300 reports central events as "pAHIc", the "p" (I think) because the detection modality involves Peripheral arterial tonometry; and the "c" for central. For the whole night the pAHIc is 5.1.  5.0 regarded as the upper limits of normal. I think this is an incidental finding that requires no attention. I'm inclined to ignore the respiratory therapist's comment.

I think the ResMed AirCurve 10 vAuto sounds like the best choice, since with OSCAR and your cumulative wisdom we can optimize the settings, if necessary even making the unit function as a CPAP if that proves the best choice for minimizing AHI of all etiologies.

As part of my due diligence, may I ask further if there might be a benefit to selecting instead the Philips Respironics Dreamstation Auto BiPAP? Like the AirCurve 10 vAuto, it has its share of sexy refinements.

[Sleeprider]

Look around and compare resuls between the BiPAP Auto and the Aircurve 10 Vauto.  I can save you some time and say I hav eused both and  the trigger sensitivity on the Vauto made all the difference for me.  In general, you will have lower AHI on Resmed. That may be due to a different scoring algorithm for hypopnea, but let me turn you on to "Easybreathe™".  Look at the shape cresting wave shape of the mask pressure wave. You won't find that on a Philips.

[SarcasticDave94]

I've never used one, but almost every bit of feedback says ResMed's VAuto is better by comments from actual users. If it were me, I'd stack the odds in my favor and go ResMed.

Nothing against a Respironics, it's just that I'd choose best available as my first choice.

[Nohbotal]

Sleeprider: Easybreath—That’s fascinating.  Looks like the very instant I  begin to exhale, the pressure plummets. Then the machine waits until I begin to inhale before more gradually increasing the pressure to IPAP. I call the shots.

[Sleeprider]

The sync on a Resmed with Easybreathe is much better than Philips with BiFlex, and your description is correct. The Resmed follows your lead every time, even when breathing is not as regular as in that example. With the Vauto, it can't trigger a breath, but it can support it, and make exhale much easier and more comfortable.