Replaced my ASV, not happy, need help

[bemused]

Is being 'normal' for someone my age good enough?  I personally suspect that if we are not in the upper half of the range of normal for SpO2 the answer is NO!   I have seen research that says even just in the short term (28 days or less) the brain shows signs of impact/injury from being repeatedly deprived of oxygen for periods of time at any SpO2 below 95%.   So I am concerned, I 'suspect,' the ranges for "Normal" SpO2  (above 88%, 92%, 93% .. )  too low to be helpful for long term treatment full success in the same way that this community accepts that an AHI of 5.0 or less is an inappropriately high measure to consider fully treated long term for Apnea.

I would for sure try to get your own copy of the night long report.  Average SpO2 for the night is less important than time below 'strong health" thresholds of 94-95%.   Hopefully you will be a report back that includes time below 92% and what I think are more valuable metrics for the tuning stages of treatment  "time below 94-95%".  I believe knowing the time you spend below 95% (and have seen research published on this) indicates that amount of time your brain did not get all the oxygen it really wants.  
 
When she reviews the results with you and they if are "normal" or within "normal ranges" but not high in the range might push a little further.     ~"Yes but will I be less tired if they are a little higher?  The on the Epworth Sleepiness Scale I am still tired in these ways."    http://healthysleep.med.harvard.edu/narc...ness-scale   Note: Like AHI, the Epworth Sleepiness Scale is a common diagnostic to determine if the patient is fully treated or additional treatment is warranted.

I'm back -- did the oximetry Monday night. It was kind of a rough night but I did have a four-hour stretch where I slept enough to get some numbers. The dr is having the full report sent in the mail so should have it by Monday. In the meantime she emailed and said that the average during those four hours was 92%. Average during the last part of the night (when I was awake much of the time) was 94%. All of which she interpreted as "good." Just as an aside, I noted during times I was awake that my pulse was very slow, low 50s, so will be interested to see what that part of the report shows (assuming it does). I had a heart monitor a while back for possible bradycardia but was told (with o details) that it was negative.

When I get the full report I'll post it along with corresponding screenshots. Meantime my question is -- should optimizing the therapy (getting the settings right) bring up the SpO2 to a better level? I would rather not deal with the hassle and expense of (attempting to) add oxygen if I don't need to -- and despite all the bumps, I am feeling better. Still tired, still sleepy, but better.

[SarcasticDave94]

It should/could bring your oxy level up. And I hear ya on the extra equipment to hook up, use, and care for.

I just did a 6 minute walk test yesterday to see how oxy was doing for my COPD and thinking I'd need a POC. I got about a 95%.

Glad to hear as well that your therapy is helping enough for you to recognize improvements.

[bemused]

Finally got the oximetry report, and it does seem like more desaturations than would be optimal, but not enough to trigger oxygen per Medicare:
   

I have a hard time correlating the desats with the Oscar graphs. This is the overview, plus a close-up of the longest desaturation per the report:
         

My dr doesn't seem concerned by the report at all, though she is open to discussing. Meanwhile I have gradually been raising the min EPAP per your recommendations. I have gotten it up to 6, though I am thinking I want to dial it back because of some aerophagia. The minute vent. is up some which seems like a good sign.

[bemused]

To tell the truth, though, I am more concerned/disturbed by the very irregular breathing patterns in the flow rate and my repeated awakenings, 4-6 a night. And I have been having a lot more trouble going to sleep and getting back to sleep after waking. I know some other posters have suggested PLM as a cause of the irregular pattern, but my last PSG showed 11 PLMs an hour with just 3 related arousals. This is last night, which is typical of the last week or so:

   

[sheepless]

I don't think it's possible to infer plm from more than about a 10 minute scale and I didn't re-read this thread to look for the now familiar plm pattern. however, for me, plm episodes can be quite variable from night to night. and while 3 arousals per hour isn't severe, it's less than ideal. a lot of things can disrupt sleep. if you're still feeling effects from fragmentation, this is one very possible cause you are aware of and can attempt to treat with meds and supplements, while continuing to look for other causes.

[JoeyWallaby]

slowriter, using EERS, had a higher SpO2 than without. Since it's only a one night vs one night comparison and he's using BiLevel while you're using ASV, I don't know if there is actually any significance.

http://www.apneaboard.com/forums/Thread-...#pid319281
http://www.apneaboard.com/forums/Thread-...#pid319477

First image no EERS, second image with EERS

[Sleeprider]

Medicare Part B coverage requirements: https://www.resmed.com/us/dam/documents/...er_eng.pdf
A test taken during sleep. If patient is tested during sleep, test must have at least two hours of recorded time. Test must indicate arterial oxygen desaturation to 88% or less for at least 5-minutes of tesing period. A patient tested during sleep will not qualify for portable oxygen.

You may also qualify with a oxygen desaturation at 89% and a secondary qualifying condition.

Your sleep test shows 13 minutes 12 seconds of desaturation less than 89% during sleep which is over twice the requirement to qualify for supplemental oxygen. Tests during sleep do not qualify for portable equipment, so you would receive a larger generator. I don't understand why you would be denied coverage with these clearly poor results.

CMS Reference: https://www.cms.gov/Outreach-and-Educati...t-Only.pdf
Home Oxygen Therapy MLN Booklet ICN 908804 October 2017 Page 4 of 35
Patient tested during sleep and if arterial PO2 is at or above 56 mm Hg or an arterial oxygen saturation is at or above 89 percent while awake, additional testing must show:▪Arterial PO2 is at or below 55 mm Hg or an arterial oxygen saturation is at or below 88 percent for at least 5 minutes taken during sleep or▪Decrease in arterial PO2 of more than 10 mm Hg or a decrease in arterial oxygen saturation more than 5 percent for at least 5 minutes associated with symptoms or signs more than 5 percent from baseline saturation for at least 5 minutes taken during sleep associated with symptoms or signs reasonably attributable to hypoxemia (some examples of symptomsare impairment of cognitive processes and nocturnal restlessness or insomnia and some examples of signs are cor pulmonale, “P” pulmonale on electrocardiogram [EKG], documented pulmonary hypertension, and erythrocytosis reasonably attributable to hypoxemia)

[bemused]

[quote pid='322344' dateline='1575484379']
You may also qualify with a oxygen desaturation at 89% and a secondary qualifying condition.

Your sleep test shows 13 minutes 12 seconds of desaturation less than 89% during sleep which is over twice the requirement to qualify for supplemental oxygen. Tests during sleep do not qualify for portable equipment, so you would receive a larger generator.  I don't understand why you would be denied coverage with these clearly poor results.

CMS Reference: https://www.cms.gov/Outreach-and-Educati...t-Only.pdf
Home Oxygen Therapy MLN Booklet ICN 908804 October 2017 Page 4 of 35
Patient tested during sleep and if arterial PO2 is at or above 56 mm Hg or an arterial oxygen saturation is at or above 89 percent while awake, additional testing must show:▪Arterial PO2 is at or below 55 mm Hg or an arterial oxygen saturation is at or below 88 percent for at least 5 minutes taken during sleep or▪Decrease in arterial PO2 of more than 10 mm Hg or a decrease in arterial oxygen saturation more than 5 percent for at least 5 minutes associated with symptoms or signs more than 5 percent from baseline saturation for at least 5 minutes taken during sleep associated with symptoms or signs reasonably attributable to hypoxemia (some examples of symptomsare impairment of cognitive processes and nocturnal restlessness or insomnia and some examples of signs are cor pulmonale, “P” pulmonale on electrocardiogram [EKG], documented pulmonary hypertension, and erythrocytosis reasonably attributable to hypoxemia)
[/quote]
So nocturnal restlessness and insomnia would be secondary qualifying conditions? Does that mean that adding oxygen could make me sleep better and be less tired/sleepy during the day? I don't have high blood pressure or hgb, and as far as I know my lungs are fine.

My sleep dr is not a pulmonolgist, maybe I should see one?

[Sleeprider]

You have significant oxygen desaturations in spite of efficacy with an advanced ASV. You have central or complex apnea. Yes you should see a qualified pulmonologist. You need a doctor to determine that it is medically necessary for you to have supplemental oxygen therapy, and I'm certain that it will be fairly easy to qualify under the condition of "hypoxia related symptoms or findings". You have described such symptoms on the forum many times. Any doctor that thinks an average SpO2 is just fine, with deep desaturation exceeding 5-minutes in a qualified test is clearly unqualified to treat your condition. You can take your medical history, sleep studies, ASV prescription and titration in addition to this study as evidence of a medical need. I'm appalled you need to do so, and makes me seriously question Kaiser a health provider. You understand, they have an inherent conflict of interest in that they provide your insurance, health care and supply DME?

[bemused]

Oh, I think I've given the wrong impression. In her and Kaiser's defense, she had in the past suggested oxygen might be an option, and that I might need to see a pulmonologist as that isn't her area of specialization. The misconception on the Medicare guidelines was mine, not hers, and I haven't yet requested or been turned down for oxygen. I've actually been very happy with her, she has shown repeatedly that she is on my side and will keep working as long as needed to get what I need--a big change from my previous sleep docs, who were in fact pulmonary specialists first and sleep doctors second. Her last email to me said we could talk more once I'd seen the whole study, which she had mailed at my request. I just sent her an email asking about oxygen and whether I should do a pulmonary appointment. One nice thing about Kaiser is that anyone I see there will have access to all of that info.

That being said, without this forum I may have just accepted her comment that the 92% average was fine and not pursued it further. So again, thanks!