ResMed AirCurve 10 VAuto vs ASV to Treat Central Apnea

[mhehe]

Sleeprider, 
I was just showing Ron how you can use Vauto to reduce centrals. That was my last day on a 10 vauto. I am using the ASV now and here is a representation of what I usually get:

[Ron AKA]

Attached is a session using the 10 vauto. Note the ahi is 2.92 that can be acceptable. There is only 1 episode of osa and few csa. Remaining are hi that I could live with as my SpO2 did not go below 90%. My priorities were to kill osa, minimize csa then deal with hi but with the proviso that my tidal volume was within range. The trick was to go into S mode with the EPAP value I found to kill osa and IPAP to deal with hi AND set the trigger level to ultra sensitive to try to force a breath. My breathing rate median is usually 15-16 bpm and so the 2 ms time interval was fine for a nominal 15 bpm and as you can see my tidal volume is right.

Thank you that is very informative. Do you have any theories on why obstructive apena was so well controlled, but hypopnea was not so much?

[mhehe]

Ron, I had just started adjusting the 10 vauto and my main concern was osa and csa. Over time I probably would have found some way to reduce the ha. Sleeprider just posted a way to start seeing how to do it. There's no secret that hi can be reduced by higher IPAP. So as he suggested to try raising the ps by 0.2 cm and run it for a few nights. The elephant in the room, however, is that that may increase csa. In time it would be possible to consistently get lower total ahi. We are already close to 2.0. However, in my case that could not have worked. You can see that in my posting of the chart with 0 ahi the IPAP goes very high, over 2o cm quite regularly. The reason I worked hard to make my treatment work with the 10 vauto was that I had signed a piece of paper saying that I was responsible for paying for it and I wasn't sure if my medical provider was going to approve the ASV machine. As it is I had barely started on getting the most out of the vauto when the approval came through.

[Hojo]

Allow me my 2 cents worth; I found that I came down with OA with the use of the full face mask (mouth breather) and or sleeping on my back, which is what I need to be able to stand up straight in the morning.  I tried a cervical collar (not a large one) and bingo, all my OA events disappeared and allowed me to fine tune my ASV settings to just what was needed to eliminate CA and H events.

My EPAP is set to the absolute min the machine will allow (4) and I could probably handle a PS of 3 but when I want a big breath, the tubing is too restrictive sometimes so I've gone up to 3.8.

With the ASV I have finally able to sleep, get a good AHI, blood pressure dropped, and I feel so much better.  Sorry, no help on your BIPAP question though.

[Sleeprider]

Sleeprider, 
I was just showing Ron how you can use Vauto to reduce centrals. That was my last day on a 10 vauto. I am using the ASV now and here is a representation of what I usually get:

I thought that was the case, but apparently I'm not keeping up yet after vacation.  Amazing results with ASV.

[Spy Car]

An obvious problem, from my perspective, is that if one can potentially tweak the settings on a VAuto to get just under 5, while potentially still feeling lousy, one would pretty much eliminate the chances of being approved for ASV.

Bill

[mhehe]

Canadian Insurance practices vary by province. It is almost impossible to get an asv pap through insurance. I know that asv is best for csa but I believe I could do with the 10 bipap vauto in a pinch and get better ahi as well as sleep. A lightly used 10 vauto is a lot cheaper and more available than the asv. My brother who lives in BC was approved for an asv pap by his doctor but was denied by the province health insurance.

[Reznik]

Generally speaking, a bilevel without backup rate results in a worsening of central and complex apnea results, forcing the use of BPAP with a backup rate (i.e. ASV).  Almost invariably, members that present with complex apnea or predominately central apnea on the forum, do best with relatively low fixed pressure with no Flex or EPR.  When these individuals are challenged with varying pressures and especially with EPR, the central apnea and hypopnea go through the roof.

We have become accustomed to this absurd irony being a part of the process of approving adaptive servo ventilation, and it is a consequence of Medicare approval guidelines that specifically require a patient to not tolerate CPAP, and the next promotion is to Bilevel which generally worsens results.  It is only until these people move to bilevel with a backup IPAP rate that they begin to show improvement.  Keep in mind the current Medicare approval guidelines were developed before modern auto ASV machines were available.  They are the epitome of ignorance.  No knowledgeable physician would actually use these standards, but the amazing thing is most practicing physicians follow those guidelines and sacrifice their patients's health and comfort to follow them.

Just a point of clarification:  The reason for these absurd guidelines is Resmed's absurd pricing.  All of Resmed's machines are the same on the inside.  The only real difference is software.  Yet, an ASV machine costs 8x the cost of a CPAP machine.  If Resmed wanted to, they could release a single model that had all modes at a reasonable price, and people who needed ASV could get it on day one. 

In 20 years, it is very likely that ASV will be a standard mode in every machine, and the only people who won't use it are people who cannot tolerate the varying pressure (and people who have CHF with left ejection fraction over a certain amount).

The same thing happened with APAP machines.  They were originally more expensive than CPAP machines, and thus you had to fail on CPAP before APAP would be authorized.  Now, APAP machines cost the same price as CPAP and include both APAP and CPAP modes, and most people get APAP machines even if they're just set to CPAP mode.  They even use APAP in lieu of a titration sleep study.

[svitori]

I agree going through this process now. I have complex apnea but ended up needing higher pressures and CPAP did not effectively treat my condition even with fixed lower pressures and based on the test my doctor placed me on bi-pap.  He encouraged me to try and meet compliance for my insurance in 30 days so he could see quicker if he needed to switch me to bi level with a back up rate or ASV.  First appointment after the 30 days he told me he wanted to put me on ASV but because of my insurance it required another titration test.

[SarcasticDave94]

When I was on my journey to get ASV, my stop over at DreamStation Auto BPAP lasted a week. It was trainwreck times 100. I was polite and respectful, but I conveyed to the sleep doctor that it was needing to improve greatly to be called terrible.

As I said I used BPAP without backup for 1 work week, Monday-Friday. I called every day to tell them it's seriously bad. Friday I made a 7 AM urgent respiratory visit to show the lead nurse and on call physician the diagnostic report with 124 CA to 24 OA, with 1 event being 90 seconds. During that visit I'd asked why I wasn't on ASV.

They both agreed it was a necessity and it only took 6 more months to get ASV. I had to do the following: talk with PCP about echocardiogram, get echocardiogram, wait on results which was LVEF 55%, wait on an ASV titration, then insurance approval, and finally DME shipping.

Dave called the doctor, DME, or insurance daily after ASV was ordered until I knew a real ETA.