ResMed AirCurve 10 VAuto vs ASV to Treat Central Apnea

[waldo1945]

Excellent JesseLee.  I have downloaded your form.  It has everything that is on my General Practitioners prescription form.  I see my pulmonary specialist the 14th of this month and hope to get a prescription from him for the ASV machine.  I will fill out your form to show him what I want including specifying the Resmed 10 ASV machine.  If not, I will try to get the ASV prescription from my GP.  I am also looking into getting oxygen supplied at night if I can't get rid of the cluster central apneas.  My oxygen concentration dips below the magic 88% threshold during these clusters (78-85%) .  Medicare guidelines say that they only have to be below the magic 88% for five non consecutive minutes in a two or three hour sleep period.  I meet those requirements during the cluster central apneas.  I am not a medicare patient but most doctors follow the medicare guidelines for such things.  Thank you again :-)

[waldo1945]

Attached is my wife's latest screenshot for her Resmed 10 Auto Set For Her machine.  Recall that we are seeing if adding back an EPR of 2 is better than none.  The results have been similar for the last two days with fewer central apneas than without EPR.  My wife usually does not match conventional wisdom so it is not a surprise that we are having better results with EPR restored. Remember her prescription after the sleep study was for CPAP 8.  The attached shows that the For Her algorithm prefers a higher pressure to try and keep the obstructive apneas under control.  She still had two obstructives at the higher pressure on the attached.  As Sleeprider has indicated, it looks like she also would benefit from an ASV machine since most of her apneas are now centrals.  We are willing to make additional setting changes on my wife's machine as directed by Sleeprider.

There is one topic mentioned in other threads that I would like to mention here.  Since we want to try to get our insurance company to help pay for an ASV machine (maybe one for each of us), we may need a new sleep study.  Others have mentioned that they had to spend another night in a sleep lab actually using an ASV machine (to make sure it eliminates the central apneas) before the insurance company would help pay for the machine. Since our pulmonary doctor also operates a sleep lab, it is more likely than not that he would want a new sleep study using an ASV machine before providing the prescription.  Time will tell.

As for me,  I am still using my Aircurve 10 Vauto with a prescription setting of BPAP (the S setting) 11 to 15 and EPR of 4.  I am trying to collect simultaneous oxygenation levels when the cluster central apneas randomly occur while sleeping.  I only have one set of simultaneous screenshots so far where the cluster apneas were so frequent (and one right after the other) that caused my oxygenation level to be between 78 and 85%.  The desired oxygenation level is above 94% with 88% being the level where some insurance companies may authorize some financial assistance. I have screen shots of many more cluster central apneas during the past year but I did not have a finger oxygenation meter that would record at that time.  My next doctor appointment is on June 14th so I have a few more days to try and get additional screen shots shots of clustered central apneas and simultaneous blood oxygenation level.

My wife was just prescribed oxygen while sleeping so we are looking into getting a used Invacare Perfecto 2V which provides the continuous oxygen enriched flow required by a PAP machine. It is good that the Resmed provides an optional heated PAP hose with an oxygen input for another $12 in cost that our insurance will cover with us sharing 15% of the cost.  I hope that this post has not been too confusing with so many topics covered.

[Sleeprider]

Waldo, I think by any measure, this is a better result than the previous graphs.  Let's go ahead an line them up and then we can talk about it.







Okay, here is what we have learned so far.  Your wife has far better results with EPR 2 than EPR OFF. The reason is that there is far less obstructive activity or at least hypopnea. I think the next step is to narrow down the variable pressure with EPR to get good results. If she has residual CA at a level of concern, she may join you in the ASV club.    I agree that we usually reduce EPR or pressure support to try to reduce centrals, but I think in this case, she is relying on the pressure support to make it easier to breathe.  One lesson I have learned in looking at hundreds of charts is that there are only individuals, no rules.  Everyone of us seems to have our unique quirks in how we respond to the therapy and its variables.

Based on the most recent results, a pressure range of 8 to 12 with EPR 2 looks pretty good.  I think if you cut EPR to 1 or off you will see hypopnea or OA replace centrals.   One consideration we should make is whether those central apnea are fairly brief (10-15 seconds), or longer and of greater concern.  Also, have her start keeping a brief diary of how she feels after arising in the morning. She can do this with her morning coffee routine, but make it before looking at the AHI results or Sleepyhead.  You can actually enter that information in notes in Sleepyhead.

[waldo1945]

Attached is my wife's most recent screenshot.  She had 17 central apneas: six at 10 seconds duration, five at 11 seconds, three at 12 seconds, two at 13 seconds and one at 14 seconds duration.  None were clustered one right after the other like mine.  The closest was 10 minutes apart.  The next closest was 27 minutes apart.  She also had three hypopneas: the closest was 17 minutes apart from any other event. The doctor wants her on three liter per minute of oxygen day and night for therapy rather than based on any nighly evidence of going below 88% blood oxygen saturation while sleeping.  I have asked her to keep a log of how she feels after sleeping.  When asked this question by her doctor last week, the answer was "still tired".  We start the oxygen therapy today to determine if that will help minimize the feeling of being tired all the time. 

We purchased the used oxygen concentrator that we wanted yesterday.  We paid $200 for an Invacare Perfecto 2V machine with 12 hours of running time.  It was used in a beauty shop to spray paint cosmetics and facial therapy.  This is like new since they are designed to last at least 20,000 hours.  This particular machine was also a little overkill for a beauty shop since it has the oxygen purity sensor which is still showing 96% purity.  Thank you again for your continued advice.

[Sleeprider]

Waldo, the use of supplemental oxygen on CPAP therapy is a well-known mitigation for the kinds of issues we see here. A recording oximeter is a pretty inexpensive investment that can monitor the effectiveness of the therapy. Supplier #19 has a number of models that are compatible with Sleepyhead.

If you want to understand the dilution effects of CPAP on oxygen therapy, I wrote a Wiki you might want to read http://www.apneaboard.com/wiki/index.php..._with_CPAP Basically this can give you the calculations needed to determine the final concentration of oxygen at the mask for varying O2 feed rates and concentrations.

[waldo1945]

Thank you for the oxygen article. I recently purchased a finger blood oxygenation meter compatible with sleepyhead. I am currently hogging its use so my wife cannot use it. My future plan is to sneak up on my wife while she is sleeping, and while we are titrating the oxygen into her PAP, to put the blood oxygenation meter on her finger. Then I will be adjusting the oxygen flow to achieve the desired above 94% blood oxygenation level starting with the 3 liter/Min rate recommended by our pulmonary doctor. While I am an engineer, trying to calculate the correct oxygen flow setting has more variables than I care to take into consideration.

Is it important to note that fewer (none) apneas occurred while her PAP algorithm was keeping her at higher pressure levels during my last post? I just adjusted her lower setting from 8 to 10 so that the machine will not spend as much time at the lower settings. Just curious to see what happens. Will post her results. So her PAP is now set 10 to 15 with an EPR of 2 using the "For Her" algorithm. No oxygen machine connected yet.

[Sleeprider]

Higher pressure may be better for your wife, if it does not adversely affect comfort or result in more events.  Do an internet search on the term: "Positive End Expiratory Pressure PEEP".  Basic ventilation principle is that higher expiratory end pressure (aka EPAP) results in improved oxygenation, while pressure support or the analogous EPR is for ventilation and reduction of CO2.   Your wife would ideally use no pressure support or EPR and maintain a higher EPAP pressure to improve oxygenation and potentially reduce CA events.  At least that's the theory.

[waldo1945]

Attached is my wife's current sleepyhead screen shot after making the machine setting adjustments that we previously discussed.  The attached actually shows two different adjustments.  The one on the left is the first adjustment to raise the "For Her" algorithm minimum pressure up from 8 to 10.  It did not make that much difference (my opinion) in the number of central sleep apneas as the algorithm seems to be designed to seek a lower pressure when possible.  So the centrals began again with more frequency as the algorithm adjusted the pressure down.  

The adjustment to the settings on the right is going back to CPAP mode where I could keep the pressures from self adjusting.  Remember her original prescription was for CPAP 8 with an EPR of 2.  I adjusted the settings to CPAP 11 with an EPR of 2.  It resulted in one obstructive apnea with all the others being centrals the longest of which was 14 seconds. These seems to be a reasonable setting as the centrals are less frequent with this higher pressure setting.  My wife did not complain about this higher setting so I am going to assume it can be tolerated.

I now plan to add her oxygen prescription at the prescribed 3 L/Min through the Resmed CliimateLineAir Oxy heated tube that our insurance company just purchased for us.  I am hoping she will start feeling less tired with this new setup.  But the bottom line is that the centrals are not going to go away unless we can get an ASV machine for her.  So we are now going to pursue getting ASV machines through our pulmonary doctor for both of us.  You may not get further posts from us until after our appointment with our pulmonary doctor  June 14th.

[Sleeprider]

the fixed pressure trial resulted in nearly twice the AHI as the variable at higher pressure. Interesting result that I would not expect.

I think the first time I saw your wife's chart I commented that perhaps both of you should be on ASV. I agree with your efforts and approach.

[waldo1945]

This post is back to the main topic of my periodic cluster central apneas.  Recall that about the third of the days in a month I get a cluster of central apneas one right after the other.  My blood oxygen level drops down into the 77%-85% range until I finally awaken gasping for air.  I visited my pulmonary doctor today well armed with information and left with a prescription for an overnight ASV titration study which will hopefully lead to a prescription for an ASV machine to eliminate my central apneas.  I have attached two of the documents that helped communicate the problem to my doctor.  Now the story.

I knew I was in trouble when all my pulmonary doctor wanted me to bring to the office visit today was my BPAP machine.  The statistics available on the BPAP display screen are averages.  (the details are only available on the machines memory card) Since my central apnea clusters only occur about a third of the time, their existence were buried in the shown averages.  My machine was saying that I was below the magic five apneas per hour no matter the time frame selected so all was OK.  The only good thing that the machine showed was that 95% of my apneas were central apneas.  I needed to bring the attachments to describe the problem.  The attached sleepyhead screenshot showing 158 central apneas one right after the other before I awakened on two separate occasions was very convincing. I used a finger oximeter to record the blood oxygenation percentage while sleeping. I also have a FITBIT watch that showed my erratic sleep schedule an not getting into REM sleep very often.  This board's recommendation to go into a doctors appointment well armed with information was crucial to my success thus far. My doctor said I made his job easy by providing the detailed information. Now we need to wait for the results of the ASV overnight titration study. I will let you know when the ASV titration study gets scheduled.