new DSX600, dramatic jump in AHI - ASV OMG!

[DrMike]

After first (do I need it) and second (let's try this) sleep studies in 2017, I was prescribed an F&P Icon+. Per SleepHead, AHIs swing nightly wildly between 4 and 40 with no apparent cause. Initial sleep doc in late 2018 basically said "Sorry, you can't get a new machine for another three+ years."

When the average nightly AHI readings began to average 30+ and I was again taking naps daily I hunted a new doc. He didn't say explicitly "Who was your previous clown?", but looked at my chart of nightly AHI readings and immediately ordered a new study.


The new Bi-Pap titration sleep study revealed Central Apneas were predominant; I now have a 6-day old Dreamstation DX600 and am running OSCAR

With E/Ipap set to 8/18, new machine shows a 6-day average AHI of    65+   with an   HI   of 3.65  and a Clear Airway Index of almost 61. Don't have follow-up appointment for several weeks yet.

Q 1: is my new machine likely telling the truth?

Q 2. Isn't the BiPap supposed to correct the Apneas, or does it just identify that they are occurring?

Q 3. If #2 doesn't correcting, what is the significance of high CAs?

Am attaching OSCAR  screen shots.

[Sleeprider]

Your BiPAP treats obstructive sleep apnea with pressure support that makes it more comfortable than CPAP, however it cannot treat central apnea.  The machine you need is indeed a bilevel, but one that detects when you stop breathing spontaneously  and applies adaptive pressure support to provide a breath when you don't take one.  The machines in that category are called Adaptive Servo Ventilators (ASV) and the main machines we see used for that are the Resmed Aircurve 10 ASV and Philips Respironics Dreamstation BiPAP SV Auto.

You will not resolve this problem with your fixed bilevel. however you will kill yourself with your current settings. Please return to CPAP mode using what previously worked best. your current pressure support of nearly 12 cm is washing out your CO2 and causing much higher central apnea. You cannot tolerate doing this, and I would prefer to see you not use any therapy rather than continue with these settings. Somehow your BiPAP pro seems to be in Auto mode, and is delivering an average 17/7 pressure (PS 10). You must reduce the pressure support on this machine. I strongly urge you to either stop using this machine, or implement your previous CPAP settings.

 If you have good insurance, you need to talk to your doctor about your URGENT need for ASV titration.  Since most sleep clinics are now closed due to the virus concerns, I recommend you contact your doctor for a prescription for ASV.  The machine you want is the Resmed Aircurve 10 ASV. You can buy them new or gently used with a warranty from Supplier #2 and Supplier #33.  The current price from Supplier #2 is $1319 to $2149.  You can use the same mask.  Insurance will take a longer time to get you appropriate treatment, and your problem is severe.  I hope you will chooe to invest in your health and just get reimbursement for out-of-network supplies.  If you get the Aircurve 10 ASV, the starting pressure prescription should be
Mode: ASVauto
EPAP min 5.0
EPAP max 15.0
PS min  3.0
PS max 15.0

The recommended ASV titration protocol is attached below, but these settings will immediately resolve your central apnea, and we can quickly optimize them using the machine data.  Please call your doctor's office. Tell them your current central apnea AHI and request that they authorize a prescription for ASV.  Then call SecondWindCPAP and order the device you can afford.  Please do not hesitate to ask any questions you may have about ASV, but this is your solution.

[SarcasticDave94]

Without as yet seeing those sleep studies, but you state the Central Apnea (CA) were predominant/pre-existing, this bi-level is not going to address it. You can see what your chart tells us, lots of CA flags. Only an ASV can help, and preference is strong on the ResMed AirCurve 10 ASV. I have this exact ASV myself, and it does its job of eliminating CA very well.

So, in order of your 3 questions, my answers below:

1. I'd believe your machine is accurate in reporting events. It just cannot address the CA.

2. A BPAP, bi-level, BiPAP can address Obstructional Apnea, Obstructional Hypopnea, and even Flow Limitations. It cannot address Central Apnea; in fact it makes the events increase as in my own case before ASV.

3. Sorry for some repetition. High CA is due to the wrong machine being issued to fix something it will never be able to do. A BPAP will not help the CA events. Only an ASV will.

You must call the doctor about this as soon as possible. You must be very pointed in stating the CA are uncontrolled. You are on the wrong machine.

[jaswilliams]

Can you post up your redacted copies of the sleep study and prescription either the wrong machine was issued and you should of got a machine with a backup rate or the settings are completely wrong. You need an ASV as others have said.

[DrMike]

Redacted original Rx is attached

   

[DrMike]

Sorry, do not have copy of sleep study; rushed out of Dr's office with copy of Rx to take to my DME supplier to expedite the order of the new machine.

[DeepBreathing]

DrMike, I've edited your file to make sure the redacted material was totally gone.

[jaswilliams]

Well the DME has provided what was on the prescription so it’s not a bad DME it’s the dr who has gone mad I suggest you go back to him if you can as your Central Apnoea is not treated with those settings

And as you say has got worse. It’s not surprising with the amount of PS recommended (The difference between EPAP and IPAP)

[Sleeprider]

Call you doctor and ask if he meant to write the script for ASV rather than auto BiPAP. Seriously, those settings (18/6) would cause me to have central apnea. Notice how the amount of Pressure Support is missing from the prescription? That field was critical to prevent the kinds of problems you are seeing. Most doctors would have specified PS 4.0 cm. If that was the case your pressure settings would be EPAP min 6.0, IPAP max 18.0, PS 4.0 resulting in a range from 10/6 to 18/14. Without a backup rate no one can tolerate 18/6.

Secondly, you have the Dreamstation BiPAP Pro Dx600. That is not an auto BiPAP, so the DME shares in this problem. That is a fixed BiPAP but it appears to have a learning mode I was not familiar with. The machine that should have been dispensed is a Dreamstation BiPAP Auto Dx700.

You need ASV. BiPAP without backup will not work. It is urgent that you get this corrected. The machine you should request is the Resmed Aircurve 10 ASV. The Philips Respironics Dreamstation BiPAP SV Auto(Dx900) is also an ASV, but we have seen our members do generally better with the Resmed. Either one will be a huge improvement over the machine that is currently trying to kill you.

[DrMike]

THANKS ALL!

Am in Dr's waiting room now.