how to have CA added to OSCARS "Events Flag" Graph

[Jay51]

I agree with Red's (Crimson Nape's) assessment above.  The ST machine is for lung disease, restrictive disorders, neurological, etc.  In the S mode (Spontaneous breathing), they probably assume the person would have a good enough spontaneous respiratory rate that no CA's would ever happen (or at least any significant ones).  


In T mode (Timed back up breathing rate), it is a timed back up rate.  A timed back up rate would prevent all CA's (because a CA has to last at least 10 seconds; and the back up rate would trigger before then to cause a breath).  

Flow limitations are the least of the machines worries as its algorithm is made for more complicated and serious things such as pulmonary disorders, COPD, restrictive lung disorders, and neurological disorders affecting breathing.  

Just my assessment.

[Wm kintz]

If you are experiencing CAs, then the ASV model would be more appropriate.  Of course, that is if you do not have left ventricular ejection fraction (LVEF) below 45%.
- Red

I'm pretty sure that that is the ResMed model I started with, but my Sleep Dr said I needed a different machine to fix my Central Apneas.  And that is how I ended up on the ResMed ST.  I, in browsing the forum, saw somewhere that the ST model could be set to deliver a breath if I didn't take one.  I'm not sure that mine is set for that at present.  If I don't take a breath when it thinks I should, it gives me a pressure "bump", a "nudge," a brief "puff" to remind me to take a breath but it doesn't deliver a tidal volume if I don't take a breath.  I can't quote you my EF, but I had an echo recently and it was well above that.  I need to get those records just to have them but I'm sure I'm well above that.  I will get more information on what my Sleep Dr. thinks of my PulseOx issues soon, and will bring up with my Sleep Dr that the machine like reminds me to breath with a pressure "bump" but it doesn't insist. It may be that the DME folks didn't set the machine right.  If, while exhaling longer than the machine thinks is good, because it thinks it is time for an inhale, I take the smallest inhale, it's happy and lets me continue to exhale then.  I'm taking in 5 nights of  samples of my PulseOx's being low (<88 %) for 15 min to more than 30 min (I'd have to look to be sure, maybe an hour or more) in spite of my AHI being 1.5 this am (new personal record).  The OSA is cured.  The hypopneas, not so much.  I'll get to posting on the main forum after I get my next visit done.  I just don't want to ask for help on the therapy side until I give my Dr a chance to make his suggestion first.  I'm petty sure if my machine did more than it's "nudge" and insisted I take a breath, that I'd learn to do that so it would stop trying to help out.  This looked like treatment emergent Central SA in the beginning though I had some centrals I was able to document on my Garmin Watch before I ever had my sleep study, so there is that.  In any event, I do appreciate your suggestions.  I'll get my echo report to confirm my recall, and to have a copy.  Thanks again.
Wm kintz

[Wm kintz]

WisNaeMe,
Thanks for the "Good Luck".  You said:" They tend to revert to only using 'authorised' resources, where the data provided unfortunately seems to be fairly basic and poorly presented. For some reason they rarely seem to look at the graphs - where the real action is...! and become more fixated on indices such as AHI."  Yea, they do. It is a lot quicker to look at AHI than to analyze the graphs, just not as informative.  I'm pretty sure the DME data doesn't have graphs to look at, certainly not to expand. I think it is usually a matter of time.  I am hoping because my Doc used to run a sleep lab, he will be open to data analysis, and I'll be taking him data with my Laptop Oscar.  Then there is the problem of looking at new software.  If he asks, I can tell him how to expand the graph.  But learning to use a new software is always a time proposition.  Time again.  I have every intention of getting a copy of ResScan and installing it on my Laptop to be able to do just what you suggested:  "Look at what ResMed makes available thru the DME supplier to the Dr.

Thanks again.
Wm Kintz

[Wm kintz]

Jay51,

In my reply to Crimson Nape I said: "I'm pretty sure that that is the ResMed model I started with (the ASV model), but my Sleep Dr said I needed a different machine to fix my Central Apneas.  And that is how I ended up on the ResMed ST.  I, in browsing the forum, saw somewhere that the ST model could be set to deliver a breath if I didn't take one.  I'm not sure that mine is set for that at present.  If I don't take a breath when it thinks I should, it gives me a pressure "bump", a "nudge," a brief "puff" to remind me to take a breath but it doesn't deliver a tidal volume if I don't take a breath."

You said: "I agree with Red's (Crimson Nape's) assessment above.  The ST machine is for lung disease, restrictive disorders, neurological, etc.  In the S mode (Spontaneous breathing), they probably assume the person would have a good enough spontaneous respiratory rate that no CA's would ever happen (or at least any significant ones).  

In T mode (Timed back up breathing rate), it is a timed back up rate.  A timed back up rate would prevent all CA's (because a CA has to last at least 10 seconds; and the back up rate would trigger before then to cause a breath)." 

That seems to be the explanation for what I was trying to describe above:  I get a "puff" if my exhalation is greater than some set rate, but it doesn't deliver a breath"  I may be wrong about what happens while I'm asleep but I've never caught the machine trying to deliver a "breath" If the ST in T Mode is "sufficient," then why is Medicare OK with prescribing Oxygen if you are below SpO2 of 88% for 5 min ?

Anyway, I suspect I'm in the S mode and not the T mode.  That is important information to ask about.  Thanks for providing me the words to inquire with.
Wm kintz

[Jay51]

Great questions and great job being proactive with your therapy.  

In "S" mode it allows for spontaneous breathing rate.  It will not "nudge" you to breathe at all.  It will only provide some pressure support once you initiate the breath yourself.  

In "T" mode, if the back up rate is set to say, 15; then the machine will force you to breath every 4 seconds by giving pressure support whether you are ready for it or not.  It does not matter where you are in your breathing cycle, every 4 seconds the pressure support would trigger (increase your IPAP).  It can be effective in preventing CA's, but ST can be hard to tolerate by some; and there are better ways to treat CA's than the ST machine.  

Great thinking by you.  Ask your Dr. all of this stuff.  You can post here again for more info or support.  

Regarding supplemental oxygen, if you sleep study showed that you spent a cumulative 5 total minutes or more below 88% SPO2, then by Medicare's definition, you qualify for supplemental oxygen at night.

[Wm kintz]

Reply to Jay51,

on Wed Nov 15, 2023, I recorded a drop to 84% SpO2 concurrent with a drop to 9 breaths per minute (my sleep study for Dx was in December 2023 so this breaths per minute was from a spontaneous breathing, with 2 drops to 12, none but the nine were lower than 12 and the duration matched the duration of the SpO2's being lower than the rest of the night.  I captioned the photorecord: "Evidence that at least part of the issue is Central Sleep Apnea"  My last appointment with my sleep Dr. was a month ago and I took in some printouts of my Garmin PulseOx while asleep showing multiple episodes of SpO2 less than 88, some of roughly 30 min duration.  

So, to recap, I think I was on ASV when I first saw the Dr.  He decided I probably had CSA and changed the machine to a ResMed ST.  My OSA is cured, gone, at least with the BiPap I'm on.  When I was at my Sleep Dr's office last month he changed my fallback rate to 14 from 12 if I remember right.  In many ways, things are better at the fallback rate of 14, in other ways NOT.  On 7/21/24 my OA was 0.00%, my Unclassified Apena 0.00%, my Hypopnea 0.50%. On 7/27/24 OA 0.00% (always is), UA 0.00%, Hypopnea 0.91%, On 8/1/24 my UA 0.00 %, my Hypopneas 0.61%.  What is not to like: the increase in rate appears to be compromising my Overnight Heart Rate Variability which used to be in the range of mid 50ms's and is now dragging along at low 40 ms's.  Garmin uses HRV in it's algorithm to make exercise recommendations and it appears to be completely messing up that process, I've been in "recovery mode" for about 2 weeks now, but it started declining when my fallback Respiratory Rate was increased.  I think it is doing this because the increase in rate decreases the time for expiration where most of the HRV occurs physiologically.  Not Strictly a BiPap issue but not sure how to fix it.  

Plenty of studies show the health effects of improving HRV; NONE exist looking at this tiny slice of the pie where BiPap decreases HRV while sleeping.  Secondly, and this could impact the HRV issue: supplemental O2.  I really like my Dr.  He seemed to think that the hypoxias (low SpO2's) needed to be addressed so he brought me back in 1 month instead of the 3 months previously.  He said that he thought he needed a pulmonary function test so we could find some reason to put me on nocturnal O2. 

You said: "Regarding supplemental oxygen, if you sleep study showed that you spent a cumulative 5 total minutes or more below 88% SPO2, then by Medicare's definition, you qualify for supplemental oxygen at night. "  My Sleep study didn't apparently show that but then it showed OSA and didn't show the CSA that I now have.  My Garmin is clearly documenting periods of SpO2 down:  Last night I had 33 minutes with SpO2 of 88% or less, down to 82% at one point, with my Average SpO2 while asleep 94%.  I don't know if my sleep Dr. knows that more than 5 minutes of 88% qualifies me for supplemental oxygen.  My sleep Dr. seems to think he needs a diagnosis of COPD or something that a Pulmonary Function Test might yield to prescribe O2.  You wouldn't have a ICD10 code that I could show him to support that just having a low SpO2 88 >5 minutes is sufficient to prescribe O2 thru Medicare?  Somethng quoting 88% would be MOST HELPFUL. It is NOT every night, and I have no clue why it happens the nights it does, but it happens often enough I am concerned.  

I am not even sure how to go about finding the reference he apparently needs.  I know you would think I would not have to provide the reference but I think maybe I do.  I found ICD-10-CM Code "G47.34 Idiopathic sleep related nonobstructive alveolar hypoventilation" that looks like it applies but I haven't found a specification for SpO2.  Maybe he just wants to be sure that I don't have COPD or something else that he ought to know about.  One night last week I had an Overnight Average of 97% and a low of 90%.  So I don't think I have COPD based on that alone.  I just want to have whatever he needs to have to go ahead and prescribe O2 as a trial, if that worked, that might let my fall back rate go back to 12 and my HRV back to the 50's.  When I'm asleep I guess I don't care much what the machine is asking of me, but a rate of 14 as a fallback, while I am semiconscious it leaves me "feeling" out of breath trying to breath that fast.  I know this is not a software related question but thought you might see it here since you were the last one to comment on my thread and specifically mentioned the "5 min at 88%".  I'll move to the regular CPAP pages after I see what my Dr. says when I see him this MONDAY.   I just didn't want to invite a lot of suggestions and reply "well, my Dr is doing something else, once I see how that turns out, I'll try your suggestions. 
Wm kintz

[SarcasticDave94]

To diagnose COPD, you'll need to take a Pulmonary Function Test (PFT).

If as you say, you don't have lung disease, the ST is the wrong device, or not as good as the ASV since it came along. ResMed AirCurve 10 ASV is specifically for treatment of Central Apnea. ST used to be the choice, due to the timed breath function.

I think neither ASV or ST flag CA specifically, but are lumped into Unclassified.

If you're wanting supplemental oxygen, there's a few tests to consider. One is a 6 minute walk test where you can guess walk for 6 minutes then they check your SpO2 for less than 89%. Also there's another test overnight, Cap Ox, or also known as a VPOD CapOx test, is a combination of oximetry and capnography that measures blood oxygen and carbon dioxide levels.

[Wm kintz]

Reply to SarcasticDave94:
I won't have a problem with doing a PFT (except I'm not wild about Arterial Blood Gas's), but don't expect I'll have a problem with the expiratory phase of the flow volume loop; haven't tried to blow out any candles recently, but can run 6 miles (elliptical: bad knees) and exceed my American Heart Association age predicted max HR by almost 20 bpm.  My Dr's been doing this for quite a while, used to do the sleep lab in town for some years, so he may be falling back on the ST for CSA based on his past experience.  I'm not doubting that ASV might be optimal, if newer. 

The machine I had before this ST had a mode called VAuto and was a ResMed Machine so may have been that very machine, but I may not have kept the data on the machine name, because I was on it such a short time before I was changed to the ResMed ST.  I can certainly do a 6 minute walk test where you can walk for 6 minutes then they check your SpO2 for less than 89% because I have my own finger tip pulseox by Nonin (reliable).  The "overnight, Cap Ox, or also known as a VPOD CapOx test, is a combination of oximetry and capnography that measures blood oxygen and carbon dioxide levels" was one my Dr mentioned, the problem is that the times I have low SpO2 is not regular.  I had the 33 min I mentioned last night 88% and below (to 82%) but I also had a night last week that my SpO2 Average over the night was 97% and the lowest SpO2 was 90%. 

 It's not so much I want Oxygen as I want to fix the 33 minutes of less than 88% when they occur.  If Oxygen would let me decrease my "fallback" rate of 14 back to 12, that might fix my Heart Rate Variability Overnight Averages and lose the feeling, half conscious as I go to sleep, that I have to put up with the feeling that I'm out of breath to have to breath that frequently, once I'm asleep, I may or may not have that feeling, but I am not aware of it.  I really appreciate everyone's observations and recommendations, because there appears to be nothing very simple about my issues.  Except the OSA is gone with the pressure.  That was the original DX before it became more complicated.

Thanks again,

Wm kintz

[SarcasticDave94]

Understood. Note that with ASV you're going to have all Apnea treated. As ASV treats CA, it'll cover the treatment for all Obstructive and Hypopnea. However as a byproduct of the CA treatment, the flow limits chart will probably look a bit busy. But in that case, it shouldn't affect you while ASV does its job well.

[Jay51]

Thank you so much Dave for answering all of Wm kintz's questions.  I got the PM last night, but am just able to respond now.  Here is some information I found on both qualifying for supplemental oxygen and an ICD- 10 code for it.  Usually, the PSG sleep study documents greater than 5 minutes under 88% - and that secures the supplemental oxygen.  For sure, show your Dr. tomorrow your own SPO2 readings (especially 33 minutes below 88% SPO2).  This is concrete, numeric information to support your case.  Any other concrete data (Dr.'s usually like summary data, so the more days the better) take it to the appointment also.  I hope your appointment goes well tomorrow.  


List of Qualifying Diagnosis for Oxygen Under Medicare (newmedicare.com)


ICD-10-CM Diagnosis Code Z99.81 - Dependence on supplemental oxygen (icdlist.com)