ResMed AirCurve 10 VAuto vs ASV to Treat Central Apnea

[Sleeprider]

To the best of my recollection, the Airsense 10 and the Philips CPAP and BiPAP all have similar RERA detection that is based on an increasing flow limitation followed by increased flow rate. Flow limits and flow rates are typically inversely related anyway, but the assumption is is that the flow rate increases as a function of arousal, thus the RERA (respiratory event related arousal) is flagged. In clinical sleep studies, RERA is documented by in increasing airflow restriction or flow limitation, that is interrupted by a change in sleep stage on the EEG trace, or an arousal.

The CPAP sensors have no means by which to measure actual arousal, but we often see flow limitation or hypopnea terminate with recovery breathing, and that becomes the substitute for the EEG arousal. Resmed may include RERA detection in future VPAP machines, but as of now, they don't. I don't personally try to go back through the data to find potential RERA, but I know if I slept well or not. We use the pressure support on the Vauto and other VPAP machines (including ASV) to specifically target flow limitation and hypopnea. These are the main precursor events. I'm not particularly interested in RERA, but I think some of the user defined events in Sleepyhead might be useful in flagging suspect RERA, but I'm not sure how to go about defining it.

If you go through those RERA on the Airsense 10 and closely observe the flow rate preceding a RERA flag, I think you will see a definite pattern. There appear to be similar patterns on the VPAP chart from 10/28 at about 05:10 and on 10/29 at 2:45. Take a look.

[waldo1945]

Sleeprider, I have reviewed the flow restriction graphs looking for the patterns that suggests that the BPAP may not be eliminating all the RERA’s.  I believe the one you found on the Sept 28th graph is the only one that day.  I also believe I found two others in addition to the one you found on the Sept 29th graph.  These occurred during a six hour and then a seven hour sleep session respectively.  So the rate per hour is much lower than the over three RERA events per hour with the CPAP machine.  We therefore would prefer to use the BPAP machine for our son instead of a CPAP
 
I tried attaching our son’s baseline sleep study summary and CPAP titration summary as background but it was too large even one page at a time.  His baseline AHI was 23 with central and obstructive apneas as well as hypopneas.  No mixed apneas were reported. We already know from experimentation that he can tolerate a BPAP and/or ASV machine by loaning him mine to use instead of his current Auto CPAP.  He feels more rested after using either the BPAP or ASV.  I have shared the Sleepyhead results attached to my recent posts.  We are working on our primary care doctor to try to get him to at least recommend a BPAP machine which is the most our sons Medical Insurance may cover at this time. This attempt with our doctor is to also get the BPAP and ASV results scanned into my sons medical records. 
 
We are providing this information to our doctor because we found a Medicare provision that seems to indicate that he can switch from a CPAP to a BPAP during the 90 day trial period if the following conditions are met:
 
Documentation that supports the patient meets all the criteria for an E0601 device and the following: An E0601 has been tried and proven ineffective based on a therapeutic trial either during a facility-based titration or in a home setting National Government Services, Inc. Page: 2 of 4 There must be documentation in the patient’s medical record that both of the following issues were addressed: Interface fit and comfort. Beneficiary is using current interface without difficulty and it will be used with the E0470 device. E0601 pressure settings. The current pressure setting of the E0601 prevents the beneficiary from tolerating the therapy and lower pressure setting of the E0601 were tried but failed to adequately control the symptoms of OSA, improve sleep quality, or reduce the AHI/RDI to acceptable levels.
 
The E0601 device is a CPAP and an E0470 device is a BPAP. So hopefully we can get our doctors to ask the DME provider to switch from a CPAP to a BPAP for the last portion of the trial and at least determine the DME response that we can report to this forum.  The DME did tell my son at the beginning of the trial that any changes during the 90 day trial needed to be initiated by our doctor so we are hopeful at this time.

[Sleeprider]

Good luck with the move to BPAP. I experienced an improvement on bilevel similar to what you're talking about and persuaded my doctor to prescribe bilevel on the same basis you are advocating. I was not having to counter Medicare at that time, and I hope that my next machine will not be too much of a hassle when I start Medicare later this year. You have certainly become knowledgeable on many aspects of xPAP therapy and the CMS approval process. You might find you're in the position of instructing or informing your doctor.

[waldo1945]

We booked the last appointment of the day with our General Practitioner (GP) so we had all the time we needed to teach him about our son's CPAP experience.  The GP’s medical assistant had also already given us a copy of the first 30 day DME progress report so we could show our GP of 25 years (and now a friend) how to relate the DME information to the three colored Sleepyhead charts we had laid out to cover the exam room table.  The GP walked into the exam room and immediately asked us about the colored charts. 
 
We had arranged the charts from CPAP to BPAP to ASV so he could see all three simultaneously and explained each chart to him starting with the CPAP.  By the time we had gotten to the ASV chart he said “Oh look, it is adjusting the pressures and EPR from breathe to breathe!” At that point I knew we had transferred the desired knowledge to him.  We also showed that when he added the number of RERA’s per hour to the AHI on the 30 day DME report, it added up to all the disturbances flagged on the CPAP Sleepyhead chart so that he could relate the two.  I think our GP then understood why a BPAP would be a better choice for our son.
 
Our GP asked if he could have the charts and the Excel table of our sons day by day AHI and RDI including weekly and monthly averages that I have previously posted.  We of course said yes because he wanted to review them further and scan them into our son’s medical records.  So this step of our plan was accomplished. 
 
We adjusted the CPAP EPR from 2 to 3 as requested by Sleepyhead for the second thirty day data collection.  The idea was to change the CPAP setting to lower the exhale pressure and reduce the RERA’s.  We have now collected that data which shows some improvement but the RDI is still above 5 (see attached).  This EPR adjustment is as far as we can adjust with a CPAP so we want our GP to request a change to a BPAP machine for another 30 days of data collection.
 
We have again made another end of the day appointment with our GP for Oct 24, 2018.  We will bring two colored Sleepyhead charts to show and the attached Excel data for the 2nd 30 days data collection.  One Sleepyhead chart will be the same as the previous appointment where the EPR was 2.  The other Sleepyhead chart will be during the 2nd 30 day collection where the EPR was set to 3.  They show a decrease in RERA’s but not below the desired RDI of 5 disturbance events per hour (see attached).  We hope that during the past three weeks our GP has thought about our situation and is willing to order a change from a CPAP to a BPAP for another 30 days data collection.  We will let this forum know the outcome.  In the meantime, our son is going to contact his health insurance carrier to make sure they agree with our approach and will support another 30 days of testing but with a BPAP.  We hope our son’s health insurance uses the following MediCal process with which we are trying to comply:
 
If an E0601 device is tried and found ineffective during the initial facility-based titration or home trial, substitution of an E0470 does not change the length of the trial unless there is less than 30 days remaining in the trial period. If more than 30 days remain in the trial period, the clinical re-evaluation would still occur between the 31st and 91st day following the initiation of an E0601 and objective documentation of adherence on the E0470 would need to occur prior to the 91st day following initiation of the E0601. If less than 30 days remain in the trial period, the clinical re-evaluation and objective documentation of adherence must occur before the 120th day following the initiation of the E0601.
 
If an E0601 device was used for more than 3 months and the beneficiary was then switched to an E0470, the clinical re-evaluation must occur between the 31st and 91st day following the initiation of the E0470. There would also need to be documentation of adherence to therapy during the 3 month trial with the E0470.
 
CPAP is E0601 and BPAP is E0470.  The re-evaluation was the EPR change from 2 to 3 made during the 2nd 30 day collection period ie between the 31st and 91st day following the initiation of an E0601.

[OpalRose]

Kahri,
A new thread has been started for you here:
http://www.apneaboard.com/forums/Thread-...re-Support

[waldo1945]

I can't believe it has been almost eight months since my last post.  Here is a brief update.  I had open heart surgery to repair a leaky mitral valve.  Apparently it was quite a severe strain on my 73 year old body.  I am still trying to increase my ability to breath four months after the surgery.  I wish somebody would have warned me that I would need to build back up my breathing endurance after the surgery.

Despite my best efforts, I could not get my son's insurance to cover an ASV machine.  However he does seem content to use his current machine which keeps his apneas at about two per hour average.

My wife and I had appointments with our pulmonary specialist this month.  He seems very pleased that our ASV machines have virtually eliminated all apneas for both of us.  Recall that it was your recommendation to get the sleep study that confirmed our need for ASV machines. The pulmonary specialist does not recall that it was our use of Sleepyhead data and your recommendations to switch to the ASV machine rather than his idea.  Thank you and this forum for your continued support for all of us dealing with sleep apnea.  Paul T.

[SarcasticDave94]

Best to you on the recovery process Paul.

[Sleeprider]

Thanks for checking in Paul. Sounds like a tough stretch with the heart surgery and recovery, but thankfully your breathing is assured at night. We're okay with the Pulmonary thinking ASV was his idea. Maybe he will extend that insight to other patients in the future, so no need to remind him of his original resistance to the idea.