Flow Limits How to Upgrade CPAP to Bilevel

[Deborah K.]

Thanks, Sleeprider.  We have great insurance with no copays on literally anything except prescriptions, so I'd like to go that way if I can.  So, please tell me if I have this right, as listed below.  Note:  The parenthetical stuff below is for you, not the doctor.  He's a doctor of internal medicine, and I don't know whether he would know the technical terms used by pap machines.  If he likely would know please tell me.

1. I should explain to my doctor that I am bumping up against the highest pressure provided by my machine (I am hitting 20 some nights), and need higher.

2.  I should tell him that the amount of air I take in with each individual inhalation is lower than it should be.  (Tidal volume)

3.  I should point out how higher pressure support results in greater comfort and efficacy in terms of flow limits and ventilation, and that a regular cpap machine does not provide high enough pressure support.  (EPR)

4.  I should tell him that higher pressure support is only available with a bilevel machine and that use of a bilevel will resolve these high flow limits which are disruptive to sleep and cause high levels of respiratory effort.

5   I should ask if he can set up a special sleep study to deal with these issues to help me get a bilevel.  (Can he do that?)

Also, could he prescribe me a bilevel even if the sleep study says that a regular cpap would work?

Thanks for any more advice you can offer on getting a bilevel. I really want one.

[AndyB]

Deborah,

My personal experience is almost identical to Sleeprider's suggested path. After being diagnosed with "severe" sleep apnea 8+ years ago, I was given a ResMed A10 AutoSet. I used it faithfully for several years and my AHI was consistently around 1.5-2.0. My sleep doctor said all was great. However, I usually had significant flow limitations even with EPR set to 3.0; I asked my doctor to prescribe a bilevel but he said my apnea was adequately treated with the A10 AutoSet.

So I chose to buy a low hours, good condition used ResMed AirCurve 10 VAuto and titrate myself by trial and error. I'm very glad I went that route -- AHI is now consistently under 0.5, flow limitations are few and usually inconsequential, and breath wave patterns are generally good.

If you can afford it, Sleeprider's suggestion to buy a used ResMed AirCurve 10 VAuto makes good sense.

Good luck,
AndyB

[Sleeprider]

You potentially need higher pressure that would justify bilevel which can provide up to 25 cm pressure, however, I 'm fairly certain that if you could use higher pressure support (the difference between IPAP and EPAP) that your maximum pressure needs would actually be reduced and comfort increased. We can't really treat the upper airway flow resistance with CPAP, so the need is to improve your comfort by using bilevel therapy. Your discomfort and lack of good sleep with CPAP remain your best argument to move to bilevel.

Your tidal volume is low and your minute vent is not too great either. Have you ever worn a pulse oximeter? We would really need to look at a zoomed chart (3-4 minute resolution) to see what these flow limited breaths really look like.

Pointing out the benefits of pressure support might be good, but instead, ask him his understanding of it. If your doctor doesn't get it, it should be pretty obvious from his answer.

True higher pressure is only available from bilevel, but what you need is pressure support during inspiration so you don't need to "suck" air and can let the machine do some of the work. This is why respiratory effort related arousals (RERA) happen. We can treat those with PS.

Ask what he can do to help get a bilevel trial that accommodates your need to sleep in your own bed. Rental, lease or just prescribe it. Your CPAP therapy effectively reduces apnea but your quality of life and sleep are not what they should be.

Maybe consider buying a used machine like the Aircurve 10 Vauto in Aurora, CO for $350? I don't know what part of the state you live in or I'd look for local results.

[Deborah K.]

 You have been so helpful.  I actually live in Aurora.  Where did you see the machine listed?  I don't know if we'll want to buy a machine, but it's worth looking into.  I have to run, but I'll carefully read your other advice and try to figure out what to do.

[Deborah K.]

I can't seem to get two attachments in one post, so I'll have to make a second post for the short view.
Here is Nov. 8, full night:  

   

[Deborah K.]

Here's the 4 minute view:

   

[Deborah K.]

Can my doctor prescribe me a bi-level machine if I explain what I need even if the sleep study does not clearly show that I need it?  He knows me pretty well and I think I could maybe convince him to prescribe one, but can he?

My husband has been on pap a few years longer than me, on bi-level.  He had a new sleep study and titration recently, and now they say he has an AHI of 27 and only needs a regular apap.  This makes no sense.  His sleep study and titration five or so years ago showed that his AHI was about 95 and that he needed a bi-level.  He hasn't lost weight or anything, so how can this be?  I don't think people get better from apnea.  Do they?  He cannot sleep without his machine, so I wonder if since he went directly from using his machine, then having his study/titration if that may have resulted in an incorrect diagnosis.  I have heard people say one should not use their machine for a while before testing.  Maybe he should schedule a new study and try to sleep in his recliner with no machine for a week before the study.  Or maybe, if I am able to get one through my doctor, we can ask his doctor to do the same for him, based on his obvious need for a bi-level.

What do you think?  I'm trying to get bi-levels for both of us, because we both need them, him more than me.

[Sleeprider]

Yes, your doctor can prescribe any PAP device he deems necessary or appropriate for your health and care. Similarly, your husband should never have consented to a new test. I keep my care completely with my primary doctor and last had a sleep test in 2008. I had to drop my last DME because they suspended my supplies and would not fill an order for a new bilevel without a new sleep test. I went to Rotech who used my doctor's prescription and old sleep study and got the new Vauto last June. There is never a need to see a "sleep specialist" (aka quack) once you have a diagnosis and have been using PAP therapy. I would need more information on your husband's case to figure out why anyone would conclude bilevel is not needed, when that has been used five years. Why did he take another test? What are his settings on the bilevel. Why are you guys still seeing sleep specialists? Move your care to your doctor.

[Deborah K.]

We both go through our regular doctors for sleep care.  We thought we had to have a new sleep study to get a new machine through insurance.  I'm delighted to hear we were wrong.   This gives me tremendous hope that if we can convince our doctors to prescribe us bi-levels, then we can have the folks here help us titrate based on what we show via Oscar and be happy, happy happy!

So this should really work?  (I need double reassurance.)

[Sleeprider]

A diagnosis of sleep apnea rarely changes or improves to the point CPAP would not be indicated. There is no mandate for re-testing when a replacement machine is acquired and the patient has been under the care of a physician, regularly discussed their CPAP therapy and indicated it is beneficial. The choice of a device to treat apnea is between the doctor and his patient and can be supported by a titration if the doctor deems it necessary, however; titration exams are never a requirement to obtain a PAP device. Medicare rules are typical. A patient qualifies for CPAP after an in-person clinical evaluation and a positive sleep test using PSG or type II, III or IV home sleep test. While the criteria for a positive sleep test is defined as greater than or equal to 15 events per hour, or 5 or more events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke. https://www.cms.gov/medicare-coverage-da...?ncdid=226

Once that examination and testing has been satisfied, there is no requirement for a patient to be re-tested, including when obtaining a replacement CPAP. Patients entering Medicare that have been tested before obtaining Medicare coverage will continue to qualify for supplies and equipment provided they have previously met the diagnostic criteria, and have continued to be under the care of a treating physician and demonstrate continued benefits of the use of CPAP. Patients can be considered for bilevel therapy if the treating physician (your doctor) makes the determinations described on this Medicare Policy summary by Resmed: https://document.resmed.com/en-us/docume...er_eng.pdf
Treating physician documented that both of the following issues were addressed prior to changing a patient from an E0601 to an E0470 device due to ineffective therapy:
a. An appropriate interface has been properly fitted and the beneficiary is using it without difficulty. The properly fitted interface will be used with the E0470 device; and
b. The current pressure setting of the E0601 prevents the beneficiary from tolerating the therapy, and lower pressure settings of the E0601 were tried but failed to:
1. Adequately control the symptoms of OSA; or
2. Improve sleep quality; or
3. Reduce the AHI/RDI to acceptable levels.

In your case, your doctor needs to make these findings using your feedback on the efficacy of your treatment, where CPAP has failed to adequately improve symptoms of OSA, or improve sleep quality, or reduce AHI/RDI. Your Oscar data, qualitative feedback and other information can be used to make these determinations. There is NO REQUIREMENT for a test. For your husband, the use of bilevel is not contingent upon a particular level of AHI in a diagnostic sleep test. The use of bilevel is indicated by his need for two-channel pressure to resolve sleep quality, RDI and the factors listed above. His prescription for bilevel can be made by his treating physician, which can overrule the "Recommendation" or conclusions of the sleep doctor. If you want discussion points for your treating physician, just have your husband try CPAP one night, and get his qualitative feedback. Why was he prescribed bilevel previously? How does a one-night sleep test overrule the basis for his original bilevel prescription? What are his current settings? Is he using pressure support?

Surround yourselves with a supportive medical team. Stay away from sleep specialists and clinics and DMEs who give you false information that you need more tests. Keep your original sleep tests and records and don't let anyone tell you to take another test. The purpose of a test is to extract money from you and your insurance and to make you a dependent on a quackery specialty. Stay with your treating physician and understand he has all the skill and power needed to support your sleep disordered breathing needs.