[Diagnosis] CameronK- BiPAP ST Help

[CameronK]

Hello, I am right in the middle of my long sleep study journey with various results and treatments, and I was wondering if anyone would be willing to look over my info and give me their guidance or opinion.

In July 2020, I completed a sleep study and was diagnosed with mild to moderate obstructive sleep apnea and was prescribed a ProSomnus MAD device. Here are the results from that study:

Code:

https://docs.google.com/document/d/1e2_rYebh-rFtxZpo6S8j8ZgcMgBSZrjozc8jVWNNlt8

The MAD has helped me sleep a great deal with the side effect of negatively affecting my jaw positioning. I decided I wanted to either stop using the ProSomnus or use it as a back up method, so I asked my neurologist about the possibility of treating my sleep apnea with a CPAP. We did a home sleep study in late 2023 with these results: 

Code:

https://docs.google.com/document/d/18uCFMjFOTUB6bZc0OLnTMQ09md0vFj5ZETavGkQKGWs

After that study, I was prescribed an AirCurve 11 CPAP and was hoping my journey was over! But from the very beginning I could tell this may not be the right therapy for me. The CPAP pressure always seemed too strong to breath against as I exhaled and would cause me to swallow air. 

The discussion then switched to BIPAP therapy and we did another sleep study. Unfortunately I had a hard time sleeping during this study, but they were able to test CPAP therapy on me and determined that all of my apneas were Central in nature. Here is a link to that study:

Code:

https://docs.google.com/document/d/1z3wCjYAT7WP7SxfICT9pU-Mi8pPkM0EdNEE8vfyjg8c

This was surprising to me because neither the 2020 or 2023 study showed signs of Central apnea and lead me to question if the central apenas were caused by the CPAP therapy itself. This may be related, but I do have an issue where I cannot breath in if there is a pressure of air in my face. For example, if I were to stick my head out of a car window from a moving car, I can’t easily breath in and will inadvertently swallow instead of breathing.

To follow up on that study and to test out BIPAP therapy, we did another sleep study with these results:

Code:

https://docs.google.com/document/d/1rwPtn3hm_OZ-hxHM5ranRpcwBOERskB2DpVjE5qJrAg

During this study, I remember tolerating the therapy well, except for the Timed portion where I was awakened by it and basically waited for it to end so I could fall asleep again. I don't feel like I would tolerate that well if I had to deal with it every night.


Based on all of this, does it seem like a BIPAP ST machine is right for me?

I am concerned that I will attempt treatment with this machine, only to have to return it and move to ASV or similar and would I would like to get this right as much as possible. I am supposed to take home an AirCurve 10 ST on Monday and wanted to talk this through before I do so. Thank you big time for anyone that would like to look this over  

[PeaceLoveAndPizza]

It seems to me you lucked out with a good PSG tech. They did a thorough analysis and made what seem to be sound recommendations. I do not see anything that would suggest questioning their judgement. 

Whether it will work or not you will not know until you try it. According to the study it worked well, so I would expect it to do the same when you have it at home. It is worth a go.

Try it as they configure it and post some OSCAR charts. Folks here can help from there if needed.

[SarcasticDave94]

If all you're trying to treat is Central Apnea, then ST is not correct. This is the old school treatment for CA, which had been replaced by ASV. So now ASV is the best answer for CA treatment.

ST always has been for patients with lung disease, but some with CA might be treated acceptably but not great.

So to answer the question, the better Central Apnea treatment is ResMed AirCurve 10 ASV not ST. Same medical codes apply for both machines, maybe it'll just need a discussion with the doctor to edit the script to ASV.

[CameronK]

I'm a little over 2 weeks into using a Bi-level machine, and I am looking for some advice. While I was initially diagnosed with moderate obstructive sleep apnea in 2020, subsequent sleep studies have shown central apneas. I have one other post in this forum with all of my sleep studies attached there if that helps.

I was prescribed an AirCurve ST. After reading some threads here, I am unsure if this is the appropriate machine for me as I have no pulmonary conditions. The sleep technician simply used ST therapy on me, it worked, and therefore is the machine insurance will cover. 

But before I invest in this or another machine, I really want to make sure it is the best one to treat me. An extra gripe I have is my DME gave me a machine with 1,300 hours after I was told it was new.

I am contemplating just paying out of pocket if that is what it takes to get an appropriate therapy without having to do another tritiation study, which would likely take months. 

Thanks for any advice and help. I attached screenshots of OSCAR data from the last few nights.

I also attached one screenshot where I tried S mode one of the nights. 

Please let me know if I need to expand on any of the data and I will reply with it here.


               

[Crimson Nape]

CameronK - Your 2 threads were related to your therapy. For this reason, I have merged them. This provides the reader a history of your past settings and results. Having the ability to see past attempts and their results will help to form better recommendations. Please use this thread for all your therapy related posts. I have changed the thread title to, "CameronK- BiPAP ST Help" to be more inclusive.
- Red

[SarcasticDave94]

While the numbers look OK, ST is still not the correct choice as a Central Apnea treatment machine. You're already not happy about being given a machine with 1,300 hours on it, you should also be upset the medical team that's supposed to be supporting you want to treat Central Apnea with an old, dumb technology when better and newer is available for the same script codes.

The 2 reasons I know why ST can even seem to give therapy for CA, 1) backup rates, 2) timing. ASV will do similar but you can't program most things manually, however ASV has a backup rate

Tell your doctor you don't want a device that treats pulmonary disease you don't have. Demand the ResMed AirCurve 10 ASV. ResMed states this ASV is the Central Apnea treatment device, period full stop.

Tell this doctor to get with the 21st century and get the ASV.

This quote is from ResMed

"AirCurve 10 ASV
Leveraging adaptive servo-ventilation (ASV) to target a patient’s recent minute ventilation, the AirCurve™ 10 ASV offers truly personalized therapy for obstructive sleep apnea (OSA), central and/or mixed apneas and periodic breathing. Auto-adjusting pressure support is designed to treat central breathing disorders, while auto-adjusting EPAP is suitable for upper airway obstruction."

[CameronK]

Thank you for your replies. I am still dealing with this. The process of working with the sleep clinic and neurology department has been brutal and the worst experience top to bottom I have had in dealing with any type of professional facility.

I'd plead my case through their portal to no avail, only nurses reply there with quick messages pushing me off saying it would require another study, etc, but luckily I had a telemedicine appointment with the PA I am assigned to (we never actually see, speak to, or communicate in any way with the actual MD). Otherwise it may have been months to get any type of appointment that would allow me to communicate with them (this appointment was created in April). Overall the PA is helpful and at the end of our conversation agreed he could see a possibility that ASV would work for me and he understood that I was ok to pay out of pocket to make this happen. At the end, he also recommended I first try upping my backup rate from 9 to 10 and also try setting the machine to S therapy.

So far the biggest downside of the ST is fixed backup rate waking me up. The best I've been able to sleep on it is about 6 hours or less, BUT my AHI comes under 1.0 most of the time, sometimes around 0.5. I tried his suggestion to adjust the backup rate from 9 to 10 but it is a no go and it makes it worse than before. Any cadence over 9 is just too much for it to be comfortable for me.

The other idea of trying S therapy is interesting in that when I have tried it, my AHI will come in higher around 3, BUT the benefit with this method is I can actually sleep all night. I tried S only last night and slept a full 8 hours, which is the longest I've had on the machine.

But I'm concerned if this is the right therapy for me overall due to this in my last sleep study:

"Patient was started on Bilevel S pressures; pressure was started at 8/4 cm cm and titrated as high as 14/10 cm. Unfortunately, ongoing apnea seen at all pressures utilized, and 100% of the residual events were purely central in nature.
Bilevel ST was subsequently utilized. The best Bilevel pressure was 14/10 cm, with a residual AHl of <2/hr or less at this setting, stage REM sleep at this most effective pressure."

The PA noted that the MD would have to sign off and give ASV settings if we were to go that route. I already came up with settings myself to try to speed this along. 

Right now my current ST settings are:

IPAP: 11 cm H₂O
EPAP: 7 cm H₂O
Backup Rate: 9
Ti Max: 2.8 seconds
Ti Min: 0.5 seconds

And I came up with these possibly ASV settings to start with:

EPAP Min: 7 cm H₂O
EPAP Max: 9 cm H₂O
PS Min: 4 cm H₂O
PS Max: 10 cm H₂O

I formerly asked for a prescription for the ASV machine, but I am in message portal hell with no direct responses. I feel like I have no other option but to continually pester them every couple of days which I will start to do on Monday.

But I also have a couple of days this weekend to keep trying S, and almost wonder if this is good enough.

Here are three OSCAR reports in reverse order. The S therapy one is first and dated Aug 1.

   
   
   

[SarcasticDave94]

Calling, whining, complaining daily was how I got my ASV so "fast" in 2017, thinking it took 2 months after the order began.

S mode is likely less disruptive because T for timed isn't on. This means timing isn't set ideally I'm thinking.

Note that as you get progress to get ASV on script, keep on their case that backup rate and timing is Auto configured on this so any number they script will be fine. Some say that they won't script ASV because they can't program this because of that timing setting aspect. It's there but not manually setup.

[CameronK]

Thank you. Just so I understand correctly, are you saying to remind them the backup rate is auto set so they don't get hung up on it? But we'd still need them to script the other settings like EPAP Min/Max?

Also I would think the timing being auto set would be a huge selling point for me being prescribed the ASV since fixed timing seems to be an issue for me at some point in the night's sleep.

[SarcasticDave94]

You got it.

Personally between you and me, they can order default ASV or with specific numbers. We can reset it to whatever is needed in about 2 minutes.

My RT from Apria at the time I got mine had to guess because she didn't have clues like even Sherlock's sidekick Watson had.

ResMed AirCurve 10 ASV settings besides common humidifier, heated hose, Ramp, Smart start and stop, same clinician key as other 10 series too.

Mode:
CPAP static single pressure

ASV single static EPAP, PS range of at least spread of 5, IPAP range which isn't directly configurable but is a sum of EPAP plus PS

ASV Auto adds EPAP as range, PS identical to ASV mode, IPAP still range of EPAP plus PS

No manual timing, period, all algorithm configured, breath rate etc via a rolling 3 minute window, you'll want to breathe regularly, if you go into ASV with fast rates it'll try to pace it, go slower before masking and it'll pace more normal rates