CPAP vs BIPAP vs APAP

[Sleeprider]

Reading this thread brings to mind a machine type question I've been thinking about. It is slightly off the OP's question, but I'd like to ask anyway. 
What seems to be the best machine type for someone like me who's successfully using an APAP for OSA (centrals not an issue) but pressures often bump up against the 20 max. available on the machine?
Many (most?) Bilevels go up to 25, but their exhale relief isn't really needed, I don't think.
Is my impression correct that to switch from an APAP to something like a bilevel would require a new sleep center titration to prove the need and get the script?

David

David, it really depends on why your machine is near the maximum pressure.  There are some individuals that have a fairly low event rate, but have flow limits that push the pressure up to the limit.  The high pressure does not necessarily provide an increased benefit because their events are treated at much lower pressures.  I have often recommended to some of them that they limit the maximum pressure for comfort to a level that stops most events to an acceptable level.  Another case is the person that continues to obstructive apnea at high levels right up to the 16-20 cm range.  These people almost always find better comfort and efficacy using BPAP.  Keep in mind it is the EPAP pressure that controls OA, so with BiPAP, we can take the EPAP pressure to higher pressures, and still use IPAP for hypopnea, flow limitation, snoring and comfort therapy.

[Dawei]

Not as simple as I had guessed. Didn't know it's EPAP that controls OA and IPAP for hypopneas & flow control. This sends me back to examining some of my recent detailed graphs.
I do recall that my hypopneas have never been as many as apneas during a night's sleep (half or less as many, I'd say).
Can you suggest a number relationship (apneas, hypopneas, flow limitations) to help me determine which type of high pressure guy I am--in need of a bilevel or just higher pressure than 20cm?

[Sleeprider]

Dave, take a look at Resmed's recommended Titration Protocol guideline https://www.resmed.com/us/dam/documents/...er_eng.pdf  Note that Resmed's titration guideline recommends Bilevel if CPAP pressure exceeds 15 cm for effective treatment (page 22).  You can then read the Bilevel titration protocol (page 26).  There is excellent information throughout this reference.

This reference shows how a technician should conduct a study and control events, and you will see how the standard approach is to use EPAP to first control OA, then IPAP is adjusted for other events, if the default 4 cm pressure support is not enough.  Bilevel is more comfortable than CPAP at higher pressure, and if your normal pressure range is over 16 cm most of the time, it's certainly worth considering.  It really depends on your tolerance to the pressure and efficacy.  Obviously if you need higher pressure than what CPAP can provide, you automatically move to bilevel.  You can read the CMS Medicare guidelines for approving bilevel. Start on Page 4 Table 1 https://www.cms.gov/Outreach-and-Educati...905064.pdf

[Dawei]

Tons of great info--many thanks, Sleeprider!
 I know my APAP pressure is in the 18-20cm category (somewhere around 19cm for 95th percentile) is my recollection right at the moment without data in front of me). So, it seems I am a candidate for bilevel.
I have figured out that E0601 is Medicare talk for CPAP (and APAP) machines, and E0470 is their coding for bi-level machines.
As you wrote, the ResMed titration document does provide some excellent info on the subject.
Although the Medicare document makes reference to titrating for bi-level in a lab or in home, in practice it sounds like a sleep lab is needed to follow the protocol that leads to a doc's script.

[Sleeprider]

I originally purchased a used PRS1 BiPAP Auto (DS760) on my own dime for $350 and demonstrated efficacy to my doctor using Encore Data. So I never did the sleep test. Between us, we concocted the prescription and rationale that met the insurance criteria, and that is how I have the machine I have today. In your case, your damn pressure is so high you automatically qualify for the bilevel, but YOU have to complain the pressure is "intolerable". That meets the insurance criteria and titration criteria. The rest depends on how good or understanding your doctor is.

This whole universe of getting the "best" treatment is a game. You have to play by the rules, but manipulate the system to your advantage by knowing the rules. Rules are a nothing more than a guideline for strategy; they can work against you or for you. It's easy to win this game, but most people don't educate themselves with even the basics of how to win. You only need to know the criteria, and what you can and cannot say. Everything will work with bureaucratic efficiency to carry out the intention of the rules. It is up to you how your case is defined as qualified or not. The alternative is just paying, in which case the rules do not apply. Good luck.

[Mosquitobait]

If you keep hitting the 20, I would plan on setting aside money so that your next machine is a Bipap.   Unless weight is a major indicator in your situation, your pressure will likely need a slight rise over time as you age.  There is no reason to switch machines now unless you are exhausted or it keeps hitting 20 all night.  I mention weight only because many cpapers find that they can lower their pressure if they lose weight.  Most other causes aren't something we can actively do anything about.

[Dawei]

Thanks, Mosquitobait. For me, weight isn't an issue. As far as hitting 20cm, I have a good batting average. ResScan shows me that pressure over the past two months, 95th percentile, was 19.8! (Max was 19.9; Median 16.2). Does that qualify as hitting 20cm all night?
Meanwhile, leaks, 95th, were zero.
I do need to read up about understanding Flow Limit graphs; mine look like a rusty saw blade with long teeth every night. Speaking of Flow, my AI for the 2 mo. period was 1.4; Hyp Index, 1.3; AHI, 2.7.
Thanks, again, Sleeprider for the bad news about how one gets a BPAP script.
Am going to visit a new sleep doc here in my new home state and get a tea leaf reading from him/her (friendly? Cooperative? Willing to help out an old guy on Medicare?)

David

[Crimson Nape]

My S9 would always go to .2 below the maximum set pressure.  I noticed that my Flow Limitation was high enough for the algorithm to trigger a higher pressure.  I tried setting the EPR to 3. This setting reduced my flow limit and the pressure leveled out at around 14cm.   If your Flow limit is above .33 you might be experiencing the same thing.