Why no Titration? - Follow up on Wednesday

[DariaVader]

Hi Don. It sounds like your insurance company doesn't want to pay for titration tests except in exceptional circumstances. Although this is contrary to what I understand is the American way of doing things, I wouldn't worry about it too much. If you have simple obstructive apnea, your Autoset is capable of giving all the data necessary for a skilled technician (or skilled patient) to home in on an optimum treatment. That's the way many (most?) practitioners work here in Australia.

Actually, More and more Insurance companies in the US are going this route according to my sleep doc (who endorses it)

[Tacoma Droner]

. . . The denial from my insurance was worded as such:
We could not approve the next test because......
Your doctor ordered this test because you have a known blockage of the upper airway during sleep that causes pauses in breathing. This test is used to adjust your treatment. This test is needed if you have chronic lung disease or chronic heart failure. We have not been told that you have these problems. For these reasons, this study is not medically necessary for you.

If it's true that more and more insurance carriers are headed in this direction, my interpretation is that the insurance carriers are saying basically what a lot of us believe anyway. Which is, that the PAP settings recommended in a sleep study don't hold up once we go home and start using our own machines. I know that I was motivated to find out how to get into the clinician's menu on my first machine because therapy wasn't working! Once I learned how to adjust my own settings, my PAP therapy suddenly got good!

It also suggests that the insurance companies are finally realizing that many of the APAP machines currently on the market can do as good a job (if not better) of determining optimal pressure levels. Today's machines are a huge improvement over what was around 10 years ago.

[DonC]

Hi,

Thanks for your input everybody.

I spent a pretty good hour with the doctor yesterday. I think I have a good one so we will move forward from here. He didn't look at the pile of info I had with me as thoroughly as I expected but seemed to rely on the report he got from the machine through the Supplier. I couldn't see the format so couldn't tell if it is easier to read than Sleepyhead but, anyway, the info was the same.

The doctor immediately said that I needed Titration and implied that I might need a BiPAP machine. I was surprised when he said that he thought the machine I have (ResMed AirSense 10 Autoset) would provide BiPAP service. I didn't think that it would. He said that if I needed anything different I may need a new machine which I agreed with.

He gave me a copy of my Sleep Study and whilst there are a ton of numbers I picked out the following:
Slept for 253 minutes
In bed for 442.5 minutes
Sleep Efficiency 57.2% (Norm 90%)
Time in Deep Sleep - 9.3% (Norm 20-25%)
Time in REM - 10.3% (Norm 20-25%)
Total Apneas - 72.8 per hour (22% H / 35% OA / 43% CA) - pretty much the same as now.
REM AHI 55.4
NREM AHI 74.8
Oxygen Low 75%
Oxygen Avg 90%
Time Oxygen below 88% - 36.4%

It also talked about arousals but I am not sure I want to get into that But, if there is anything else I should be taking note of let me know.

Overall I am pretty happy and hope that the Titration happens quickly (I am going to Florida soon to talk at the American Society of Hematologists convention about the Clinical Trial I am on for treating Multiple Myeloma - 5 years and going strong) and would like to have it sorted by then.

Please give your input in numbers, machines, doctors and arousals.

Thanks in advance,
Don

[DonC]

Just a quick addition - On BiPAP would I have to go to a FFM rather than the nasal pillow I am getting used to or is that just with VPAP?
Thanks,
Don

[DariaVader]

you can use the same mask - but you need to have the titration be for bipap OR asv, IMO

[Mosquitobait]

I also want to talk to him about masks as I have quite a collection of them to say I have only been at this for 30 plus days. And, it is only going to get bigger as I like the look of the DreamWear and can't wait to see the one that SuperSleeper said is in the pipeline. How many masks do you guys have in the drawer next to the bed?
By he way SuperSleeper can we do the same on chin straps. There has to be a better design. Your chin is either pulled backwards (which has to be counter-productive) or your head is wrapped if fabric (I get terrible chin strap hair).
Wish me luck.
Don

This made me laugh. I too kept acquiring masks and have actually switched back to the first one. I have an Airfit P10, Wisp, Sleepweaver advance and a Sleepweaver Elan. All but the P10 I bought on my own. None are perfect, but the leak rate is low with all of them under most circumstances. I'd like to try a nasal mask, but can't seem to coordinate with the DME on days that they do mask fittings. I returned to the Wisp. This was my favorite, but I need to work out a way to keep the bottom strap from sliding up on my head at night.

As to a chin strap, I'm making an adapted one to work with my brother's beard. I'm using fleece with pajama elastic on the inside. This will be custom fit to my brother's mask so that it is around the port, but remains above the air vent. Hope it works.

[Tacoma Droner]

Don, your Swift FX is fine with the BiPAP.

I don't think you've posted what settings you are using for your machine. If you click on this link here - LINK - you can see how to get into the Clinician's menu and read your settings.

Once you post up that info, we might be able to make some suggestions that will give you better results from now until the titration date.

[DeepBreathing]

Hi Don. The arousals they're talking about aren't as much fun as the ones you're thinking about This is the definition from our wiki:

Arousal - An abrupt change from sleep to wakefulness, or from a "deeper" stage of non-REM sleep to a "lighter" stage.

Regarding your numbers and machines. Your Autoset isn't a bipap. It will not treat central apneas - in fact its algorithm specifically does not attempt to treat them because you need a different type of machine to do that. You had a central apnea rate of 43% out of a total AHI of 72.8. This means your central apnea index is 31.1. In other words, just your centrals alone rate as severe apnea. As one who's been down this particular path, I can tell you and your doctor right now that you need an adaptive servo-ventilator (ASV). Not a bipap or bipap auto - ASV. You have severe central apnea and it won't be fixed by anything else IMHO.

Having tried both the Philips Respironics and Resmed ASV machines (albeit the now superseded models) I strongly recommend you try both before you make a final choice. The Philips has a lot of adjustable parameters which in theory means you can optimise your treatment better. The Resmed does everything by software and makes all the adjustments automatically. I couldn't live with the Philips but I love the Resmed. Others have the contrary experience.

[DonC]

Hello All,
DB, I think I will try to move towards the ResMed if ASV is the way to go. I think I will have to change masks in the end DV but thanks for the info.
A couple of you have asked me to put up my "Clinical Settings" so, TD, here they are. I do understand that these may be changed after the Titration or the machine changed altogether.

Here are the clinical settings on the Autoset:
THERAPY
Mode - Autoset
Max Pressure - 18
Min Pressure - 8
Mask - Pillows
COMFORT
Ramp Time - 5 Mins
Start Pressure - 4
EPR - Off
Climate Control - Manual
Tube Temp - 80 F
Humidity - 4
ACCESSORIES
AB Filter - No
OPTIONS
Essentials - On
Smart Start - Off
Reminders - All Off

As for the chin strap Mosquitobait, I too am in the middle of making my own. I will use bits of the three I have purchased. The wife is not too happy, but she panics when she sees me with a power tool in my hand.
Thanks again for all the great support.
Don

[Sleeprider]

Don, your pressure in APAP is similar to what mine are in bilevel. Where pressure frequently exceeds 14 cmH2O a bilevel is often used to offer better exhalation relief. The Autoset does that on a limited basis up to -3 cm of pressure relief, while bilevel offers more difference between IPAP and EPAP, and is expressed as pressure support (PS). Modern APAP has come a long way in being more comfortable, and I think BPAP is becoming less common as a result. Bilevel can use the same mask or nasal pillows as any other CPAP, although there are a lot of people who 'think' pillows are not suitable for higher pressure.