[Treatment] Noob; wondering about equipment, info dump below

[ZPrime]

Hello Apnea Board!

I'm 38, weigh about 290lbs, 6'3". I've got a beer gut, definitely not a small person.
My wife complains about my snoring and breath cessation followed by choking/gasping in the middle of the night.
I'm always tired, no matter how long I sleep. I can sleep 12+ hours and still feel tired afterwards. I'm an IT guy and have often had to work weird hours in the past, but my body also seems to prefer late hours. I'd consider myself an extreme night owl. If left to my own devices, I usually don't get tired until 3-4AM and wake up at 12-1pm. This makes normal life pretty difficult, especially when whatever sleep I do get, sucks.

Typically a stomach sleeper, sometimes side. Don't like to sleep on my back but do on rare occasions.
Definitely a mouth-breather at night; I often feel like I can't get enough air through my nose - sometimes because of congestion, other times I just don't like the whistling sensations I get from my nostrils.

Went to my GP, they ordered an in-home test (they call it "HSAT").

Here are the direct results from the MD that reviewed it... the in-home test made it hard to sleep on my stomach due to all of the garbage attached to me. I also woke up and used the bathroom at one point in the middle, which wasn't obvious to them during review (I left the equipment all hooked up).

RESPIRATORY DATA:
The study started at 22:47:26 and ended at 07:37:50 and the total recording
time was 530 minutes. By convention, sleep is assumed for the whole
recording. Snoring was noted. There was a total of 671 respiratory events. Of
these events, the total number of apneas was 479 (281 obstructive, 49 mixed,
and 149 central) and 192 hypopneas. The respiratory event index (REI) was
75.9 events per hour of study time. The mean oxygen saturation during the
study was 92.0%, with a minimum oxygen saturation of 63.0%. The patient spent
102.1 minutes at oxygen saturation measured less than 90% (19.2% of recording
time) and 69.0 minutes at oxygen saturation measured at or less than 88%
(13.0% of recording time).

Time REI/AHI
Supine 338.5 min 82.8
Off-Supine 192.0 min 63.8
Total 530.5 min 75.9

ECG DATA:
The average heart rate was 54 bpm with a range of 39 bpm to 108 bpm.

ICSD DIAGNOSIS:
Obstructive Sleep Apnea Syndrome [G47.33]

IMPRESSION/RECOMMENDATIONS:
1. This study confirms a diagnosis of severe sleep apnea. Many of the events appeared central in nature.
2. The results of this study may represent an underestimation of the degree of obstructive sleep apnea, especially hypopneas, because of the known limitations of HSAT, such as inability to record arousals because EEG is not recorded.
3. Untreated sleep apnea is associated with a variety of consequences including but not limited to hypertension, heart disease, stroke, obesity and daytime sleepiness that can affect normal daytime functioning.
4. PAP therapy is the usual first line therapy. Recommend an in-laboratory PAP titration study to ensure that central events resolve with PAP therapy. Other treatment options for OSA may include weight loss, positional therapy, oral appliance, upper airway surgery, upper airway stimulation, treatment of allergies and avoidance of alcohol and sedating medications (such as opioids, benzodiazepines, and muscle relaxers) that can cause respiratory depression.

After the HSAT results came back, a nurse practitioner with my MD's office prescribed a "PAP Titration" PSG. I've never had a "normal" PSG, but from what I gather a "normal" one skips the mask until partway through the test?
My titration didn't; they put a mask on me from the get-go, and then told me to try to fall asleep in a crappy hotel bed with 20+ wires coming off of me...  

Here are the (sleep MD interpreted) results from the lab PSG:

SLEEP ARCHITECTURE:
The study started at 22:41:41 and ended at 05:03:39. Total sleep time (TST)
was 144 minutes resulting in a sleep efficiency of 38.3% (total recording
time (TRT) = 376 m). There were 16 awakenings with a total time awake after
sleep onset of 150.5 minutes. The sleep latency was 80.0 minutes and the REM
latency was 236 minutes. The patient spent 63.5% of sleep time in the supine
position. The sleep stage percentages were 11.5% stage N1, 68.4% stage N2,
7.3% stage N3 and 12.8% REM sleep. There were 52 arousals, resulting in an
arousal index of 21.7. There were 58 stage shifts.

POSITIVE AIRWAY PRESSURE DATA:
CPAP was initiated at 5 cmH2O. Snoring was eliminated at a CPAP setting of 5
cmH2O. There were 108 respiratory events consisting of 86 apneas [0
obstructive (0%), 1 mixed (1%), and 85 central (99%)], 22 hypopneas and 0
RERAs. The mean oxygen saturation during the study was 95%, with a minimum
oxygen saturation of 73%. The patient spent 8.1% (11.7 min) of sleep time
with an oxygen saturation below 90% and 6.8% (9.8 min) of sleep time with an
oxygen saturation at or below 88%. Periodic Breathing was present.
Supplemental oxygen was not administered. A large Amara view full face mask
without strap was used. The mask leak at the most effective pressure was
within normal limits.

[table of pressure data omitted here because the formatting was trash...]

MOVEMENT DATA:
No abnormal behavior was noted. There were 0 periodic limb movements during
sleep, resulting in a PLM-index of 0.0. Of these, 0 movements were associated
with arousals, resulting in a PLM-arousal index of 0.0.

ECG DATA:
The average heart rate during sleep was 69 beats per minute, with a range of
53 to 84. During wake, the heart rate ranged from 57 to 113 beats per minute.
No arrhythmias were noted.

OTHER NOTABLE FINDINGS:
Experience to PAP therapy as stated by the patient on the morning after sleep
questionnaire: felt benefit from PAP therapy; more alert, energetic and
refreshed. PAP therapy was easy to use but not comfortable due ot mask being
too tight, mild leak, pressure feeling too strong.

ICSD DIAGNOSIS:
Obstructive Sleep Apnea Syndrome [G47.33]
Treatment emergent central apnea [G47.39]

IMPRESSION:

1. CPAP and Bilevel PAP both were tested. CPAP was transitioned to Bilevel
PAP due to central apneas.
2. Central apneas were noted at many CPAP and two bilevel PAP settings. Some
respiratory events that were scored as central events in this in-lab PAP
titration appear to be related to obstruction in nature when looking at the
respiratory flow shape. This is further supported by improvement on bilevel
PAP and ultimate resolution at higher pressure settings.
3. Although no REM sleep was observed at a bilateral PAP setting of 21/17
cmH2O, no respiratory events observed at this setting in supine position and
oxygen saturation maintained above 94%. At bilevel PAP setting 19/15 cmH2O
AHI remained elevated in presence of REM sleep.


RECOMMENDATIONS:
Recommend to acclimatize patient with Bilevel PAP 19/15 cmH2O for 8-10 weeks
followed by a repeat PAP titration startind [sic] at that setting is recommended.

Sooo... given all of this. Do I have any choice in what machine I get? I was surprised that they'd suggest a BiPAP without any "auto" functionality, and irritated at the suggestion of an additional PAP titration in another 8-10 weeks. Why not just prescribe an Auto BiPAP?? Is my health provider just trying to line their pockets with another PAP titration?

Since the last order was written by a NP and not an MD, she was willing to write the prescription for what the sleep analysis doctor "recommended," but was not willing to be more specific and recommend an Auto BiPap or anything like that. When I pushed, she said that I would need a direct consult with a sleep doctor for something like that, and put that into my chart and gave me a number to call... and then coronavirus hit and I haven't tried to call yet.

I'm also concerned about costs at this point... I was laid off in January, when I was at the beginning of trying to figure all of this out (because it was affecting my job... and then got canned).  I then had to go through the process of getting on my wife's insurance, which took forever, and then convincing my giant hospital system that I actually was on her insurance. And now, we have yet to actually see a bill / copay or any other information from her insurance, which has me even more worried about money. I got a very generous severance when I was laid off, but finding a job in the middle of this crisis is a daunting prospect... plus I wanted to get the sleep problems fixed before I went hunting, partially because if I was asked to have a phone interview at 9AM tomorrow, there's no way in hell I'd be able to get up for that.

So yeah, sorry this is super long but I wanted to be thorough.

TL;DR version: after a PSG suggested BiPap with relatively high pressures (and I was uncomfortable during the PSG due to the high pressure), should I be asking for an automatically adjusting machine? Is it "archaic" to prescribe a fixed-pressure device when all of the auto-learning stuff exists?

[jaswilliams]

You have mixed apnoea a Bipap was tried as you still had Central apnoea’s these were still there it is likely you will need an ASV but there was no time to do an ASV titration at the same time so you have been prescribed a Bipap without a backup rate. I recommend if you can getting a prescription for a Resmed VAuto as this is the most flexible machine in its class but if as suspected a ASV type machine will be needed at a later date. Stick with the Resmed brand

[DeepBreathing]

G'day ZPrime, welcome to Apnea Board.

I agree with Jaswilliams - you have mixed apnea and should probably be looking at a Resmed Aircurve 10 ASV machine.

Unfortunately your diagnosis is wrong:

ICSD DIAGNOSIS:
Obstructive Sleep Apnea Syndrome [G47.33]
Treatment emergent central apnea [G47.39]

The fact is you had a shedload of central apneas in your first test, so they'e not treatment emergent but endogenous. You can play around with bilevel machines till the cows come home, but you won't get proper consistent treatment of your central apnea. You need an ASV. Note that word consistent - treating centrals with the wrong type of machine will often show excellent results for a night or two, but then it will just go bad again. The ASV is designed specifically for this condition and is what you should be using.

Now, there is one caution: A recent large study showed that people with severe congestive heart failure (left ejection fraction <35%) died at a higher rate when on ASV. However the study has been pretty much rejected and a new study with better controls and protocols seems to be indicating the opposite. However the guidelines limiting ASV for people with congestive heart failure are in place for the time being.

[SarcasticDave94]

I too think that you're going to need the ASV, specifically the ResMed AirCurve 10 ASV. This is what I still have currently, and it will give great results for you. As is, you would need to get a passing grade on the echocardiogram test, an ultrasound audio/visual of your heart. A cardiac doctor will review and issue a write-up with an LVEF grade as a percentage. You will need a 45% or higher to pass. No worries on this, as if you'd not be likely to pass this, you'd know you're in bad shape from heart issues.

Be proactive in this as the doctor and others will go blind and not see central and mixed apnea as reasons for treatment with a specialized device like ASV. They also will not see the CA and mixed events. Only obstructive apnea counts to most of these doctors, you will actively make them look at these.

[ZPrime]

Other than a relatively high resting heartrate (because I'm fat and out of shape), I have no known cardiac issues. My BP is just slightly high but not bad enough that my GP thought it was a concern.

Why all the love for ResMed? Are the equivalent machines from Philips somehow lacking? Philips has a fairly large corporate presence near me which is the only (tiny) reason I'd maybe have a preference for them.

[Gideon]

Welcome to the forum.

Your problems start because of your "Official" diagnosis of OSA.  It is EXTREMELY IMPORTANT that your home study contained a significant amount of central apnea.  You need to continuously bring this up because this was without CPAP and therefore cannot be treatment-emergent sleep apnea.  More on this later.  Since I was reading this in the summary I thought you were heading down the correct road then I read the incorrect diagnosis of OSA meaning NO central apnea.

Your Titration study, which was the correct type of study, was performed with the incorrect knowledge that you had no history of Central Apnea because your diagnosis was OSA thus the conclusion that your central apnea is treatment-emergent.

It is not uncommon for a patient with treatment-emergent central apnea to be given a CPAP or BiLevel machine since this form of apnea goes away within 2-3 months as your body adapts.  Again, you DO NOT have Treatment-Emergent Central APnea!!!  

With a CPAP or BiLevel device, (You need an ASV) treatment of the centrals is accomplished by avoiding the centrals.  Treatment of Centrals with their proposed device, even the VAuto will be to decrease pressure support and pressure, which will increase obstructive events frequently resulting in a simple fixed CPAP pressure.  In other words, the treatment that they are proposing is doomed for failure.  Rest assured that we will work with whatever device you get to make the best of it.

Talks with your doc have to like. "I understand how you got here, it started with HSAT that, I believe, incorrectly diagnosed no central apnea even though they found significant sleep apnea.  Then the titration test HAD to incorrectly diagnose Treatment-Emergent Central Apnea because per diagnosis I had (incorrectly) no central apnea.  Can you change that diagnosis after review? 
I understand that an ASV will treat all of my apnea, both the obstructive and central, HOW DO WE GET THERE?"

Any talk with your doc has to be about how to get to ASV.  Very likely this will require another overnight to trial an ASV.  This is what you want.  A PSG without an ASV is worthless to you.  You will also need to clear your heart for your LVEF thanks to an earlier study suggesting that low values would be problematic.

[ZPrime]

Here's the data from the lab PSG, unfortunately I'm not sure of a way to format it more nicely (it shows up in the Epic "MyChart" system as lines of space-separated text so not exactly simple to make into a real table)

Code:

PAP BUR O2 TST %Sup SupAHI REM RAHI CAI AHI ArIdx Nadir AvgSaO2
05 0 0 13.5m 100% 115.6 0.0m 0.0 93.3 115.6 66.7 90% 94%
06 0 0 10.0m 65% 120.0 0.0m 0.0 72.0 102.0 72.0 91% 96%
08 0 0 24.0m 0% 0.0 0.0m 0.0 0.0 0.0 0.0 93% 94%
10 0 0 25.0m 0% 0.0 0.0m 0.0 12.0 16.8 12.0 94% 96%
11 0 0 6.0m 100% 130.0 0.0m 0.0 130.0 130.0 60.0 87% 96%
13 0 0 2.0m 100% 90.0 0.0m 0.0 90.0 90.0 90.0 76% 98%
17 / 13 0 0 21.5m 100% 97.7 16.0m 101.3 75.3 97.7 8.4 73% 87%
19 / 15 0 0 21.5m 100% 19.5 2.5m 0.0 11.2 19.5 0.0 91% 93%
21 / 17 0 0 20.5m 100% 0.0 0.0m 0.0 0.0 0.0 0.0 94% 95%
......
PAP BUR O2 TST %Sup SupRDI REM RRDI HI RDI ArIdx Nadir AvgSaO2
05 0 0 13.5m 100% 115.6 0.0m 0.0 17.8 115.6 66.7 90% 94%
06 0 0 10.0m 65% 120.0 0.0m 0.0 30.0 102.0 72.0 91% 96%
08 0 0 24.0m 0% 0.0 0.0m 0.0 0.0 0.0 0.0 93% 94%
10 0 0 25.0m 0% 0.0 0.0m 0.0 4.8 16.8 12.0 94% 96%
11 0 0 6.0m 100% 130.0 0.0m 0.0 0.0 130.0 60.0 87% 96%
13 0 0 2.0m 100% 90.0 0.0m 0.0 0.0 90.0 90.0 76% 98%
17 / 13 0 0 21.5m 100% 97.7 16.0m 101.3 22.3 97.7 8.4 73% 87%
19 / 15 0 0 21.5m 100% 19.5 2.5m 0.0 8.4 19.5 0.0 91% 93%
21 / 17 0 0 20.5m 100% 0.0 0.0m 0.0 0.0 0.0 0.0 94% 95%

Moderator note: Here is the data tabulated in a spreadsheet.

   

[Gideon]

ResMed hands down.
Why ResMed?

1. Faster algorithmic response to events than PR.

2. Lower average pressure

3. Better to avoid Aerophagia.

4. EPR provides for better treatment of hypopneas, RERAs, Flow Limits, UARS, and snores

5. EPR acts like a BiLevel up to a limit of 3cmw and a max pressure of 20 cmw

6. EPR follows your breathing where as Flex predicts it with a feeling of fighting to get a breath when it predicts incorrectly

7. More flexibility in treating a greater variety of Apneas and respiratory events.

8. In general provides better therapy.

I have frequently told many DreamStation users that they need to get either the ReaMed AutoSet or. BiLevel to get better therapy. 

Respironics costs less

[Gideon]

For the PSG, best to copy, remove personal info, and post the resulting image. Scan then edit to accomplish that, take a pic with your phone as a last resort.
There isn't really a cost difference between a simple BiLevel and a VAuto, like the others above I have a preference for the AutoSet in a CPAP and the VAuto as the base level BiLevel, but YOU need the ASV.

PR vs ResMed ASV, many users here have used both and nearly all prefer the ResMed.

[ZPrime]

Also - I truly and deeply appreciate all of the replies here so far, because I'd be totally clueless without all of your help! Very happy I started posting here before moving forward with a sleep MD consult - now I am better armed to have a useful discussion.

One of the things mentioned in the info for the HSAT is that it can underestimate obstructive apneas. Would this mean they are then interpreted as central instead, possibly causing my centrals to read higher than they actually were?

There was also this line from the lab PSG: "Some respiratory events that were scored as central events in this in-lab PAP titration appear to be related to obstruction in nature when looking at the respiratory flow shape." Is this just the interpreting MD not wanting to believe I'm having that many centrals even on PAP support?