Newly diagnosed severe CSA & OSA (AHI=108) seek advice

[Liteheart1]

Thanks in advance for cutting my learning curve. Any thoughts/recommendations appreciated and some specific ?s at end of my narrative. ASV treatment has been recommended for severe apnea with both Obstructive (17 events) Central (76) & Mixed apneas(4) with 7 hypopneas for AHI of 108.5/hour which is (very) severe. Arousal index of 103. Lowest SaO2 78% with avg. 89%. 2nd sleep study to determine titration (and CO2 levels) will be done soon, and expect to have ASV machine by end of Feb. CSA is non-Cheyne-Stokes type. My typical resting heart rate upon waking in the morning is about 50 with oxygen level of 92% based on finger tip monitor. While I am not an olympic athlete that would warrant having such a low resting heart rate, routine cardiologist is fine with the slow ticker and sees it as advantage.

75 year old male; even with very severe sleep apnea am relatively symptom free with no tiredness upon waking; do not wake up during the night; snoring is relatively minimal; some occasional tiredness in late afternoon. Epworth score of 8. I do not have any typical risk factors (over weight; opiate use; or heart disease – blood pressure is normal). Until 2 years ago my health was excellent but at that time diagnosed with Grave’s hyperthyroidism. Thyroid levels for last 16 months in normal range from very low dosage Rx.

Sleep doctor I am seeing is quite good. Has just ordered brain MRI to rule out physical abnormality to brain stem areas which would contribute to the CSA observed.

1) Any suggestions for upcoming 2nd sleep study (with CO2 monitoring) to get most useful info from it? {I understand that this forum's users will be better at suggesting tweaks to settings and therefore perhaps the sleep study while required by Medicare/insurance is somewhat of a formality.}
2) Am I correct that most forum users prefer ResMed ASV machine over Respironics? {I am leaning toward ResMed and might not have opportunity to try both.}
3) During recent sleep mask fitting appt. (including CPAP and ASV air flow which was fine but low pressure), I was fitted with Respironics Wisp nasal mask. During initial sleep study I had started out with nasal mask but due to some mouth breathing had been switched to full face mask which in that setting and dealing with the shock of sleep apnea diagnosis I found to be rather claustrophobic. Assuming that at home mouth breathing might be minimal is there any advantage for ASV treatment mode to use full face mask versus nasal mask?
4) Sleep Dr has already diagnosed and recommended ASV treatment. Is it likely I'll need to "fight" with Medicare to go straight to ASV even though initial sleep (split night) study already showed that the limited CPAP time had no improvement to CSA events. {Given the very high AHI, I am eager to begin effective treatment ASAP.}
Once I have actual data from sleep study and then home use will share that as well. Expect I will use OSCARS.
Thanks

[Sleeprider]

It sounds like you are in the hands of a good doctor that is providing access to ASV rather than diagnosing you incorrectly with obstructive sleep apnea and making you go through the trials and failures of CPAP and BPAP machines. The second sleep study is probably to evaluate the efficacy of ASV and will involve titration of pressure and monitoring of O2 and CO2 to verify ventilation is correct. ASV should generally provide for both spontaneous triggering of IPAP and non-spontaneous backup to maintain your normal ventilation.

We prefer the Resmed ASV based on its relative simplicity and the therapeutic results we have seen in members vs those using Philips SV. The Resmed Aircurve 10 ASV does a good job of maintaining minute vent and respiration rate based on the user's own normal respiration. It does this without any settings other than minimum EPAP pressure, minimum pressure support and maximum pressure support. Most users think it feels pretty natural and they adapt to the feel of ASV in a relatively short time. The initial experience can be kind of unsettling as it sometimes feels like the machine is taking control. User's advice to one another is to "blow-back" at the machine when it feels like it is not syncing correctly, and things will straighten out.

I would rather see a user start with nasal therapy and move to full face only if necessary after a reasonable trial. Nasal pillow masks are preferable to nasal masks because they are lighter, less chlostrophobic and easier to keep a good seal. My favorite is the Resmed Airfit p10. but you should try several and see what feels best. Most users can learn to prevent air from escaping through the mouth by using the back of tongue to block air form entering the mouth. Daria Vader used to use this as her signature:

Tongue Suck Technique for prevention of mouth breathing:
Place your tongue behind your front teeth on the roof of your mouth
let your tongue fill the space between the upper molars
gently suck to form a light vacuum
Practising during the day can help you to keep it at night

Medicare nearly always required a patient to try and fal CPAP before getting Bilevel, failing that and getting bilevel with backup. You might shortcut this by asking the doctor to demonstrate in the titration test taht CPAP and bilevel are ineffective. It should not take long to establish that central apnea persists with either of those therapies, and the machine used for titration tests is capable of all modes of therapy. Anyway, this is a concern to raise with your doctor. He has followed the correct procedure to date by using full PSG sleep study to document central sleep apnea or complex apnea, and has scheduled a titration test to demonstrate efficacy and benefit of ASV (HCPCS E0471 bilevel with backup rate)

Here is a link to the Medicare CMS checklist for dispensing ASV https://www.cgsmedicare.com/jc/mr/pdf/mr..._e0471.pdf
Here is the Resmed summary of how patients qualify for ASV (see section III) https://www.resmed.com/us/dam/documents/...elines.pdf

[Liteheart1]

User's advice to one another is to "blow-back" at the machine when it feels like it is not syncing correctly, and things will straighten out.  With nasal (or nasal pillow) is this then a "snort" blowing back, or more of a continual strong exhalation?

I would rather see a user start with nasal therapy and move to full face only if necessary after a reasonable trial. Nasal pillow masks are preferable to nasal masks because they are lighter, less chlostrophobic and easier to keep a good seal. My favorite is the Resmed Airfit p10. but you should try several and see what feels best.  Most users can learn to prevent air from escaping through the mouth by using the back of tongue to block air form entering the mouth.  Daria Vader used to use this as her signature:

Tongue Suck Technique for prevention of mouth breathing:
   Place your tongue behind your front teeth on the roof of your mouth
   let your tongue fill the space between the upper molars
   gently suck to form a light vacuum As in sucking through a straw so that cheeks also pull inward? 
Practising during the day can help you to keep it at night

Medicare nearly always required a patient to try and fal CPAP before getting Bilevel, failing that and getting bilevel with backup.  You might shortcut this by asking the doctor to demonstrate in the titration test taht CPAP and bilevel are ineffective. It should not take long to establish that central apnea persists with either of those therapies, and the machine used for titration tests is capable of all modes of therapy.  Anyway, this is a concern to raise with your doctor. He has followed the correct procedure to date by using full PSG sleep study to document central sleep apnea or complex apnea, and has scheduled a titration test to demonstrate efficacy and benefit of ASV (HCPCS E0471 bilevel with backup rate)

Here is a link to the Medicare CMS checklist for dispensing ASV link deleted
Here is the Resmed summary of how patients qualify for ASV (see section III) link deleted Thanks for Medicare guidelines/rules; I will pass to sleep Dr so that she can continue to expedite things.
You and this forum are great, thanks again.

[Sleeprider]

"blow-back" is described as an affirmative exhale. No need to mess up a clean mask, but let the machine "know" you are in control, and it will back off on triggered breaths and pressure fast.

Tongue suck is much like the suction on a straw. The vacuum keeps the tongue firmly in place. Many of us using nasal pillows learn to control the air to the point we can talk, sip drinks and open our mouth without losing pressure in the airway. It takes practice and the first attempts will likely be humorous or at least produce embarrassing noises. Therapy pressure is not unmanageable, and translates to fractions of one PSI. You can easily find cm H2O to psi converters. The highest pressure you will ever potentially see is 25 cm which is only 0.356 psi.

[SarcasticDave94]

I'd be a ResMed AirCurve ASV user that would advocate getting ResMed in your situation. I hope you can take shortcuts by avoiding the otherwise needed fails to get an ASV via a short path. I think it's possible if you and your doc can provide medical necessity that leaves no questions for them. My sincere best wishes to your success.

[Liteheart1]

Thanks again @sleeprider, explanation of "blow back" procedure makes more sense and I can now practice even before getting machine. As you know, having a knowledgeable and responsive user forum is a great adjunct to the professionals and often times better.

[70sSanO]

Your doctor has a lot of control in how he presents your case to Medicare.

I went from an APAP to an ASV titration and then an ASV machine based on his initial letter and a successful titration.

Truthfully, he took my word about my centrals, I did have Rescan data That showed the CAs, but this was my first meeting with him.

I did have a long history, unsupported by a DME or sleep doctor, with CPAP. If you have a good doctor that knows how to present it as medically necessary hopefully it will be accepted.

I would doubt he would order an ASV titration if he knew you would not be able to get an ASV machine.

John

[Liteheart1]

Thanks also to Dave and John for comments and input. The forum has already been an invaluable source of info and support, and I expect I will continue to read and participate as the journey continues. Have a great day!

[SarcasticDave94]

Please update us here when you get the ASV, and include OSCAR data when available. If you have any questions about ASV treatment, I'll answer as best as I can.



PS when you do get that ASV, it shouldn't take very long to get you running with the therapy this can give you.

[Liteheart1]

Thanks Dave ... will do. Given how severe CSA and OSA has been for unknown period of time and even though I am primarily symptom-free, I expect that with improved sleep efficiency which could happen fairly quickly that there will be a notable increase in quality of life so a lot to look forward to. I am reminded of what nature photographers often say: a life is not measured by the number of breaths, but the moments that take your breath away. Perhaps a good perspective for those with apnea!