ResMed AirCurve 10 VAuto vs ASV to Treat Central Apnea

[Sleeprider]

Good stuff Paul and nice to hear quality of life is high with this addition. If your wife is prescribed O2 it is pretty easy to get an oxygen bleed adapter for any PAP machine including ASV. I wrote a wiki article on oxygen bleed.

[waldo1945]

Read your O2 article Tom.  Glad you covered the two ways to bleed oxygen into the CPAP hose.  The hoses with the Climate heated element throughout the hose can come with a built in oxygen connection at the CPAP machine end (they are a little more expensive than the "normal" Climateline).  This allows the full length of the hose for the oxygen to blend with the air output of the CPAP to the mask.  There is also an optional "T" that connects to the mask end of the Climate heated hose.  This tee cannot be used at the CPAP machine end because it will not allow the needed electrical connection to be made for the Climate hose heating element.  This tee can be used at either end of a CPAP hose that does not have the built in heated coil element.  We prefer the connection at the CPAP machine end such that the extra oxygen line is connected at the CPAP machine rather than at the mask end.  It is just one less hassle at the mask end of the CPAP hose and it allows the full length of the CPAP hose to blend the oxygen.

My wife is prescribed Oxygen 24/7 so we have an oxygen concentrator that continuously feeds oxygen through a small diameter tube to the CPAP end of Climateline hose that has the oxygen connector at the CPAP machine end.  We are prescribed an oxygen setting of "3" in an arbitrary manner in my opinion.  I am in the process of having my wife wear a finger oximeter at night for recording so we can determine an oxygen setting that will keep her blood oxygen concentration between 95% and 98%.  It may turn out to be a setting of "3" but I just want to make sure.  

I have not been prescribed oxygen for my sleep apnea.  The new ASV machine has eliminated all of my apneas.  But I have noticed by recording my blood oxygen concentration with a finger oximeter while sleeping that my average is 92%.  So I have used my wife's oxygen concentrator and found that a setting of "2" gets my blood oxygen concentration to between 95% and 98% while sleeping.  I will discuss adding oxygen to my regime the next time I visit our pulmonary specialist.  From a medicare and insurance perspective, I believe they want the blood oxygen saturation to be 88% and below before prescribing and paying for oxygen.  Time will tell.

[Sleeprider]

I don't know the rules for approving O2 generators, but I think you are at least partially right that you need to show an oxygen minimum of 88%, but only for a small fraction of the time. I think you have improved your odds of avoiding that with the therapy you have now, but I wouldn't have bet that before ASV.

If you see anything that would be useful to add to the wiki, please don't hesitate to make suggestions.

[SarcasticDave94]

FWIW Medicare criteria for supplemental oxygen while asleep is 88% (or less) arterial oxygen desaturation for 5 or more recorded sleeping minutes.

[waldo1945]

You are correct Tom and Dave.  I researched the insurance oxygen requirements and there are two to choose from.  Either one will qualify for an oxygen prescription.  One is measuring the blood oxygenation percentage while sleeping.  The sleeping period needs to last at least two hours during which time at least five minutes of 88% or below blood oxygen saturation level needs to be accumulated.  The five minutes does not need to be continuous.  Just add up all the seconds where the blood oxygenation level was 88% or below and accumulate at least 300 seconds or five minutes during a two hour or longer time period.  The longer the sleeping period the better the chances of accumulating the five minutes. 

My wife took a different test.  This is six minute walking test preferably done while one is awake.  My wife walked the hall in the doctor's office accompanied by an office assistant.  The office assistant was pulling a cart with an oxygen tank which had a cannula connected under my wife's nose.  The oxygen flow was turned off when the test started.  As the pair started walking, my wifes blood oxygen percentage started to decrease from 96%.  At around the two minute mark, wy wifes blood oxygen level had dropped to 88%.  The pair then stopped walking.  The office assistance turned on the oxygen flow and they then started walking again.  The oxygen flow was slowly increased while walking until my wife's blood oxygenation was back up to 96% while still walking within a six minute continuous period.  The oxygen flow required was three liters per minute.  That's how setting my wife's oxygen concentrator to "3" liters per minute was determined.  My concern is that this setting, while essentially exercising, is different than what is necessary while sleeping.  I understand that either too much or too little oxygen flow should be avoided.  The amount necessary to get between 95% and 98% is desired.

[Sleeprider]

Using a recording oximeter, or simply lying still with a real-time oximeter, it should be fairly easy to self-titrate the nocturnal oxygen requirement while on CPAP/ASV. As you note, as long as the oxygen remains in the target range it is correct. If if moves out of the target range then adding or subtracting is a fairly simple adjustment. This "titration" can be done as often as necessary if you own a simple recording oximeter. I think a lot of members have had good luck using Supplier #19. This would at least give you something quantitative to discuss with the doctor if adjustments are needed.

[waldo1945]

This is an update on my wife's Resmed Aircurve 10 ASV machine.  Recall I decided to buy one on Craigslist to avoid the normal three month time period to get one through our insurance company and we were able to buy one new for $450 including the mask.  I also bypassed our doctors and did this on my own based on my experience with needing an ASV machine to control my central apneas. My wife has been using the ASV daily for about a month with no central apneas.  Almost two weeks ago we informed our General Practitioner doctor of our decision.  While he had no problem with the decision, he asked that we talk it over with our Pulmonary Specialist with whom we had an appointment this past Monday (yesterday).

We brought the ASV machine to our pulmonary doctor and he reviewed the stored data on the screen.  He noticed it was an ASV machine and not my wife's normal CPAP and asked what was happening.  I told him that I had loaned my wife my ASV machine because it was eliminating her central apneas and I thought it more important with her pulmonary fibrosis for her to use the ASV machine.  He said he would need more data before he could agree with me.  So I showed him the three previously posted Sleepyhead charts with which he readily agreed as long as my wife had no history of heart disease which she does not. (ie ejection fraction greater than 45%).

So he wrote a prescription for an ASV Titration Sleep Study as it is a necessary step for our insurance company to pay for most of the ASV machine cost.  (Plus he owns the sleep study clinic and wants the additional business.)  I let him do all of this because it is his normal procedure and so that he would note his agreement for an ASV machine in his notes for future reference.  I plan to let the pulmonary doctor know next week that we purchased an ASV on Craigslist and we do not need our insurance company to share the cost or the sleep study.  (Our insurance just shared the cost for my wife's new CPAP machine three months ago which one of our teenage grandsons is now using to help us with his diagnosis.  He has Attention Deficit Disorder and so far he has not had any central apneas)

My wife's sleep study five months ago only showed two central apneas and it was decided by the doctor to try the less expensive CPAP machine.  These overnight studies are really hit and miss when diagnosing intermittent problems like complex apneas.

[SarcasticDave94]

Congrats on your success with your docs, creating the proof of need medical trail, and for getting an ASV in hand.

[waldo1945]

Appreciate your continued encouragement Dave.  I took some time to search for many of your posts and was impressed.  Not very many people would share the intimacies of their lives with so many people as you have done on this site.  It makes your comments more heartfelt and meaningful for which I wanted to thank you again.

A new challenge for Tom if he will accept.  Attached Sleepyhead thumbnails are for our 43 year old son who is going through a 90 day trial with a CPAP machine.  I don't know what suggestions to provide with all the hyponias of unknown origin. I have provided his numerical history table, a chart with an average day and another chart with one of his worst days.  To be sure, his trend is a lot better now than when he started but it is hard to believe he is still getting quality sleep even though the average AHI is under 5 and hour.  Any suggestions for improving his situation?

[Sleeprider]

Paul, I think the approach with your wife on ASV and getting the study done is a good move for the long-term. I'm curious if her results with few centrals was on CPAP or based on an untreated diagnostic study. As you know, her central events were a hit or miss affair, and she could go hours, or even a few nights with very few centrals, then suddenly have large clusters of persistent CA.

Sleep apnea challenges must run in the family, because your son shows pretty strong signs of UARS along with some obstructive apnea. Most of his events are hypopnea, and most of the RERA and hypopnea arise out of flow limitation. I do think UARS should be treated, and there is a pretty good article in our wiki here: http://www.apneaboard.com/wiki/index.php..._and_BiPAP

The take-away from the article, and most titration protocol are that CPAP has a limited capacity for treatment of issues like hypopnea and flow limitation given that the only tool is pressure. In the case of the Airsense 10, you also have limited pressure support as EPR. With the auto CPAP, the pressure will rise to the maximum allowed setting given the presence of abundant flow limitation, so in this case we see you are using a fixed pressure of 9.0 with EPR 2 and pressure is stable. I don't know what other pressures you have tried. It appears from the summary chart you have tried 9-cm fixed with EPR 2 for 28 days with an average AHI of 2.96, so the August 18 result is probably not typical, and is worst case. I don't think we should base decisions on the exceptionally bad result. If September 5 is more typical, then I'd try to optimize treatment of flow limitation and RERA by increasing EPR to 3. It may be worth keeping pressure at 9.0 and only target FL and H, however if OA increases, then change pressure to 10.0. Keep an eye on CA activity with the increase in EPR. It is worth noting the trends are in the right direction except for RERA which is certainly related to FL. The high flow limitation and likely OA and H without treatment is something that is probably worth discussing and diagnosing more formally.