How do I make the case for BPAP?

[SleepingFish]

I got treated by an at home sleep study, and assigned a CPAP machine (redmed 10) with APAP and a range of 4-16.  As CPAP pros, you know this isn't actually the right setup for really anyone.

Over the past year, I have tuned things on my own as far as I can tell. I had a respiratory therapist tell me off the cuff that I might need BPAP to fully treat my Sleep Apnea.

So I got a referral from my doctor to go get a proper titration study, which would hopefully tell me if I did indeed need BPAP and what kind of settings I would need. My insurance denied it as not medically necessary. So great- insurance thinks its important to pay for a possibly wrong machine, just no effort into how to set it up.

The cost out of pocket to get a titration study is insane. I may as well buy my own BPAP machine and start working on settings. So before I start down that path, I would ask the community if anyone knows of a way to show a medical need for a titration study - or similar. My AHI on CPAP with my own settings is < 5, so I am sure they consider me treated.  But I am not, still sleeping like poop. This is BCBS in USA if it matters.

[Sleepster]

I got treated by an at home sleep study, and assigned a CPAP machine (redmed 10) with APAP and a range of 4-16.  As CPAP pros, you know this isn't actually the right setup for really anyone.

Not pros, just experienced. In my opinion, I can see how this would be the right setup for some people. Although the pressure range is probably too high.

I think you're getting ahead of yourself. Post your OSCAR charts so we can have a look at your settings. It may be that they can be adjusted to suit you.

As far as getting a good night's sleep, well, that takes most people some time. You likely spent many years or perhaps decades with untreated sleep apnea. Your body learned how to sleep that way, and now it has to learn a new way. It takes time.

And the hose and the mask, and the air pressure are all a bother that can interfere with your sleep. But you get used to that and it stops being a bother. But it takes time and requires patience for most people. This is why so many people give up too early and put their CPAP machine in the closet.

If it looks like your current CPAP can't work for you, based on the data you post and the recommendations you get here, then you can approach your doctor with an informed discussion about getting a prescription for a BPAP.

[SleepingFish]

I think you're getting ahead of yourself. Post your OSCAR charts so we can have a look at your settings. It may be that they can be adjusted to suit you.

I posted a few a while back and stopped getting responses. Not sure if I am just too boring or what. But this is a free community, I can't expect people to volunteer their time right now to help me. I have money for this, and am happy to use it to pay for help from a dr. etc.  But not too impressed with my local doctors and their APAP prescriptions. 

I went on my own and hired a pulmiogolist, who looked at my OSCAR data and said that I might need to explore BPAP.  I have really tested every pressure from 6 -> 18, and EPR from 0 -> 3. Nothing has quite got me where I want to though.  It would be a pretty hefty lift to post all of my OSCAR data for all of my different settings, and I am pretty sure no one would respond to that post.

[Gideon]

Traditionally basic BiLevel would be for failing CPAP, or non-compliant OSA as listed below.  There is a ton more models of BiLevel, each with the intention of treating a different condition.  Which is appropriate for you we have no way of even guessing without data.



VAuto Automatically adjusts pressure in response to flow limitation, snore and obstructive apneas; Pressure Support (PS) is fixed throughout the night and can be set by the clinician. It Treats OSA, non-compliant OSA

S (Spontaneous) Senses when the patient is inhaling and exhaling, and supplies appropriate pressures accordingly. Both treatment pressures are preset: inspiration (IPAP) and expiration (EPAP). It treats Non-compliant OSA and COPD

You have tried BiLevel therapy, how was it?  and Why didn't it work to the point of asking here?

Typically a BiLevel Prescription would start with a PS=4.  You tried EPR of 3 and that is usually enough.

Show us your charts.  with EPR=3 (Closest to BiLevel) and include zoomed views (3-minutes) so we can evaluate your individual breaths.

[SleepingFish]

> You have tried BiLevel therapy, how was it?  and Why didn't it work to the point of asking here?

I have no access to a BPAP machine.  

Attached is 3 minutes of breaths with EPR=3, and a tighter zoom.

I can NOT get rid of my 99% flow limit no matter what I do. And based on what I saw here, my inhale vs exhale ratio is wrong.

Ignore the leaks here. This was back when I had a beard and was trying to tough it out. I have since shaved my beard and solved leaks.

[SleepingFish]

Tighter zoom if helpful

[Sleepster]

I posted a few a while back and stopped getting responses.

Not in this thread. That's why I didn't see them.

I went on my own and hired a pulmiogolist, who looked at my OSCAR data and said that I might need to explore BPAP.

Then get that pulmonologist to prescribe the ResMed AirCurve 10.

  I have really tested every pressure from 6 -> 18, and EPR from 0 -> 3. Nothing has quite got me where I want to though. 

You can't keep changing settings and expect that to work. You have to leave the settings alone for several days or longer to see the effects. You have to give your body time to adapt to the new settings. Plus, you don't want to just randomly change things. The changes need to be based on the data. This could very well be why you are not sleeping well.

By the way, congratulations on using your machine each night , all night. That is the first step towards success. The next is fixing any large leaks, and it looks like you've got that done, too. Now we need to work on tweaking your settings to optimize your therapy.

I can NOT get rid of my 99% flow limit no matter what I do.

That's probably why the pulmonologist recommended BPAP.

Ignore the leaks here. This was back when I had a beard and was trying to tough it out. I have since shaved my beard and solved leaks.

That won't work. We need recent data with EPR set to 3. Also, it looks like you had a fixed pressure of 18 when you collected that data, and not the pressure range of 6-16 you have listed in your profile.

[Gideon]

1. Forget the 99% FL as it is essentially meaningless. Look at your 95% number instead.

2. EPR =3 Fulltime IS BiLevel Therapy with a PS of 3. This 8s without question. The issue is do you need more pressure support than 3?

I question your pressure of 18.

You need to look at the detailed flow rate. Based only on these samples and assuming they are representative of your typical breathing you have fairly consistent flow limitations that at least sometimes (1st chart) may be disturbing your sleep. This also assumes you have no other underlying conditions.

You MAY, only may not will, benefit from a BiLevel machine with it's higher levels of PS.

[Sleeprider]

SleepingFish, getting approved for bilevel is not hard, but getting insurance to pay for it is another matter.  Your doctor can simply prescribe bilevel based on your conversation with your RT and and your own feedback. You have very high pressure for CPAP at 18 cm, and the EPR 3 i46Ls basically your "sample" of pressure support. If you turn off EPR I'm sure your 95% FL will go from 0.03 to over .10 pretty quickly.  Your chart shows some interesting anomalies.  There re several double peaks in inspiraiton and as we move beyond 22:46:20 breathing becomes seriously flow-limited. This is RERA or arousal territory.  Statistically, your inspiration time is considerably longer than expiration time, and this is a hallmark of flow limitation or flow resistance.  It is confirmed in your chart flow rate.  We see a relatively long inspiration, often marked with cardiac ballistic artifacts, followed by robust and rapid exhale.  I'm pretty sure on bilevel, we could increase pressure support to improve inspiration time and volume, giving more time for a normal exhale to occur, and we could do this at a much lower pressure. We could eliminate the leaks due to high pressure and the CA events would also be eliminated, by using a high trigger sensitivity for triggering IPAP. 

I got my first bilevel out-of-pocket fairly cheap. It was a used Philips System One 760 BiPAP Auto.  An awful machine, but a lot better than the Philips auto CPAP I was using.  The machine was able to produce data, which I discussed with my primary doctor, an internal medicine specialist with no specialty in sleep medicine. I was able to persuade him that my therapy was demonstrably better with bilevel/BiPAP than CPAP and that it made me feel better, more alert. I asked him to prescribe bilevel for me, and he did.  After an initial denial, and further support from my doctor my first Resmed Aircurve 10 Vatuo was approved through insurance.  No sleep study, no titration test, but I did have my original diagnostics test as well as the Oscar and Encore charts in my doctor's records to back it up.  That machine provided good service through last year, but the hours were piling up, and I needed my first machine through Medicare.  I contacted my DME, last year who responded by cutting me off from all CPAP supplies and said I needed to get a "sleep test" because my test was too old and Medicare might deny payment.  So I changed DMEs to Rotech, and we worked with my same doctor and obtained a new prescription and I got the new Aircurve 10 Vauto in late June, paid 100% by Medicare and my supplemental insurnace without a test.  

If you have the will, there is a way. Don't take no for an answer and don't trust that your best care would ever come from a specialist.

[SleepingFish]

Sleeprider:  So does the evidence posted so far lead you to believe that I should pursue BPAP? If so, would it be wiser to get a referral or just try some settings myself?  I can likely work the system and get what I want, it will just take a bit. I have the money for whatever, but of course no desire to just light dollar bills on fire.


As to changing my settings, I have had my current settings for 60 or 90 days. It's actually much lower and no EPR.  I give a "decent" AHI, but I am not sleeping right. Attached is a zoom of that.  I am at 12 fixed, no EPR. you can see my 95% flow is more like .18, which is poop.