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== Justifying ASV ==
 
== Justifying ASV ==
−
[[Central sleep apnea (CSA)|Central Sleep Apnea (CSA)]] is the cessation of respiratory effort result in a lack of respiratory movements. During sleep, your breathing is disrupted regularly because of how your brain functions, your brain simply doesn't tell your body to breathe, and therefore you don't try to breathe.
 
  
−
Apnea: 80% to 100% reduction in airflow for >= 10 seconds
+
'''Note:''' Much of the material in this article (especially in relation to Medicare requirements) is relevant to the United States only.
−
Hypopnea: 50% to 80% reduction in airflow for >= 10 seconds
 
−
Flow Limitation: <50% reduction in airflow for >= 10 seconds
 
  
−
=== Five types of Central Sleep Apnea ===
+
It is very likely that you are here because someone referred you here because after reviewing your [[OSCAR]] daily charts and/or your Sleep Studies they felt that you are a candidate for an Advanced PAP machine such as one of the Bi-Levels. There are two paths to treatment and the choice is yours.
−
per the Mayo Clinic
 
−
# Primary CSA, which is the same as idiopathic CSA–the patient has no known related diseases.
 
−
# Cheyne-Stokes breathing CSA, which may be a product of heart failure, stroke, or possible kidney failure.
 
−
# Non-CSB CSA associated with other medical conditions, including heart and kidney problems.
 
−
# High-altitude CSA, which often appears during sleep at altitudes above 15,000 feet, and induces a form of Cheyne-Stokes breathing with noticeably shorter cycles than classical CSB.
 
−
# CSA induced by the use of certain drugs, typically opiates.
 
  
−
=== Diagnosis of Central Apnea ===
+
'''Path 1:''' The path that you were thrown into whether you realize it or not.  That is to treat your apnea, whatever types of apnea that you have, with the machine they gave you, a CPAP, preferable an auto-CPAP either the ResMed or the Philips Respironics machines.  New members of the forum come here looking for help with intractable apnea and discomfort from these problems.  The forum members and "gurus" are very good at optimizing therapy to reduce these problems, and increase comfort with the therapy.
−
# Must have clinical symptoms to make the diagnosis - Sleepiness, insomnia, snoring, apneas, awakening with Shortness of Breath, A‐fib, CHF, or neurological disorder (such as stroke, MS)
 
−
# Central AHI >5
 
−
# Central apneas and Central hypopneas >50% of total AHI
 
−
# Not better explained by another sleep disorder
 
  
−
=== Hypopneas - Obstructive and Central ===
+
'''Path 2:''' Take the often difficult and lengthy journey to procure an advanced PAP machine. The new member that has been advised they have central or complex apnea needs to be aware that optimizing may provide significant immediate relief from symptoms and improve AHI, but improved therapy results can '''disqualify them from higher levels of therapy''' (ASV), that might be possible without this self-optimization.  Sometimes individuals resolve central and complex apnea with CPAP and find long-term comfort, however, if results are inconsistent, or produce good AHI but not comfort or relief from other symptoms, The forum optimization should be '''discontinued as soon as possible to avoid disqualification from higher levels of therapy.'''  This path frequently requires failing at CPAP, then failing at BiLevel E0470, before succeeding at ASV E0471
  
−
How can you tell the difference between obstructive and central hypopneas?
+
'''ASV or [[Adaptive servo-ventilation (ASV)]]'''
 +
The below is based on Medicare Requirements for procuring
 +
* E0470 - RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITHOUT BACKUP RATE FEATURE, USED WITH NONINVASIVE INTERFACE, E.G., NASAL OR FACIAL MASK (INTERMITTENT ASSIST DEVICE WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE) ''(Similar to '''ResMed Aircurve 10 VAuto''')''
 +
* E0471 - RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITH BACK-UP RATE FEATURE, USED WITH NONINVASIVE INTERFACE, E.G., NASAL OR FACIAL MASK (INTERMITTENT ASSIST DEVICE WITH CONTINUOUS POSITIVE AiRWAY PRESSURE DEVICE) ''(Similar to '''ResMed Aircurve 10 ASV or ResMed Aircurve 10 ST/A''')''
  
−
An obstructive hypopnea contains one or more of the following:
+
=== Complex Sleep Apnea ===
−
# An increase in PAP flow signal
+
For [[Complex sleep apnea|Complex Sleep Apnea]] the Medicare requirements for issuing an ASV machine.
−
# Snoring during the event
+
* Therapy Optimization should be discontinued and the original settings, from the doctor, restored.
−
# Paradoxical breathing
+
* Titrate to minimize OSA, that is the obstructive AHI to less than 5 per hour.  '''''This typically is raising EPAP or pressure until obstructive AHI is less than 5 per hour, we expect this to make the Central and Complex Apnea worse thus failing the current treatment'''''
 +
* Record the central apnea-central hypopnea index (CAHI) (looking for greater than or equal to 5 per hour and greater than 50% of total AHI)
 +
* Document the presence of at least one of the following symptoms: '''''These symptoms are specifically noted by Medicare. These are key symptoms that we look for by asking "How do you feel?". Do not limit your answers to the following and do not fabricate the answers.'''''
 +
#  Sleepiness, '''''"How do you feel?"'''''
 +
# Awakening short of breath,  '''''"How do you feel?"'''''
 +
# Difficulty initiating or maintaining sleep,  '''''"How do you feel?"'''''
 +
#  Frequent awakenings, or  '''''"How do you feel?"'''''
 +
#  Nonrestorative sleep,  '''''"How do you feel?" Nonrestorative sleep is defined as the subjective feeling that sleep has been insufficiently refreshing'''''
 +
#  Snoring, '''''Can be documented on OSCAR'''''
 +
# Witnessed apneas '''''Most of us have this one with our significant others''
 +
'''
  
−
A central hypopnea will have none of the above.  
+
=== For Central Sleep Apnea ===
 +
For [[Central sleep apnea (CSA)|Central Sleep Apnea]] the Medicare requirements for issuing an ASV machine.
 +
* Therapy Optimization should be discontinued and the original settings, from the doctor, restored.
 +
* Document a ''central apnea-central hypopnea index (CAHI) is greater than or equal to 5 per hour''' also apnea-hypopnea index '''(AHI) greater than 5'''
 +
* Document The sum total of '''central apneas plus central hypopneas is greater than 50% of the total apneas and hypopneas'''
 +
* Document the presence of at least one of the following symptoms: '''''These symptoms are specifically noted by Medicare. These are key symptoms that we look for by asking "How do you feel?". Do not limit your answers to the following and do not fabricate the answers.'''''
 +
#  Sleepiness, '''''"How do you feel?"'''''
 +
#  Awakening short of breath,  '''''"How do you feel?"'''''
 +
#  Difficulty initiating or maintaining sleep,  '''''"How do you feel?"'''''
 +
#  Frequent awakenings, or  '''''"How do you feel?"'''''
 +
#  Nonrestorative sleep,  '''''"How do you feel?" Nonrestorative sleep is defined as the subjective feeling that sleep has been insufficiently refreshing'''''
 +
#  Snoring, '''''Can be documented on OSCAR'''''
 +
#  Witnessed apneas '''''Most of us have this one with our significant others'''''
  
−
Central Hypopnea. Central hypopneas are associated with reductions of purely in-phase thoracic and abdominal effort or movement signals, followed by an increase in chest and belly movements at the end. There is no evidence of phase shifting or paradoxical breathing, no airflow flattening, and no snoring throughout the entire central hypopnea.
 
  
−
A Central AHI is composed of Central Apnea and Central Hypopnea.
 
−
The Central Apnea numbers are easily extracted from modern PAP machines which report detailed efficacy data. We need to concentrate on Central Hypopnea numbers to demonstrate a '''Central AHI >5''' and that '''Central apneas and Central hypopneas >50% of total AHI'''
 
  
 +
[[File:Respiratory-Assist-Device-Order-Template-Draft-20180412-R10b.pdf|thumb|center]]<br />
 +
[[File:Mr_checklist_rad_e0471.pdf|thumb|center]]
  
−
Central Hypopnea. Central hypopneas are associated with reductions of purely in-phase thoracic and abdominal effort or movement signals, followed by an increase in chest and belly movements at the end. There is no evidence of phase shifting or paradoxical breathing, no airflow flattening, and no snoring throughout the entire central hypopnea.
+
== Symptoms ==
−
=== Charts identifying Central Hypopneas ===
 
  
 +
Note that these are not all specific to Central/Mixed/Complex apnea. They are symptoms that impact our sleeping, arousals, and yes apnea too.  Think of these, but do not limit yourself to these when you are asked "How do you feel?"
 +
* Daytime hypersomnolence;
 +
* Excessive fatigue;
 +
* Morning headache;
 +
* Cognitive dysfunction;
 +
* Dyspnea, etc.;
 +
* Fatigue;
 +
* Insomnia;
 +
* Difficulty going to sleep;
 +
* Difficulty falling asleep;
 +
* Wakening during the night;
 +
* Daytime Sleepiness;
 +
* Excessive Daytime Sleepiness (EDS);
 +
* Poor concentration;
 +
* Difficulty with balance;
 +
* Shortness of breath;
 +
* Dry mouth;
 +
* Restless Sleep;
 +
* Non-Restorative Sleep;
 +
* Snoring;
 +
* Obstructive Sleep Apnea;
 +
* Restless Leg Syndrome;
 +
* Nocturnal Leg Cramps;
  
−
[http://www.apneaboard.com/CSA-and-ASV-Updated-Morgan.pdf CSA-and-ASV-Updated-Morgan.pdf]
+
 
 +
== Tips for getting an ASV machine ==
 +
I see 2 big steps.<br />
 +
 
 +
First, you need to change doctors to a doctor that treats Central Apnea.  By that, I mean one that actually prescribes ASV machines with some regularity.  Realize that all doctors 'treat' Central Apnea.  Also note that most doctors only treat OSA, even though they 'treat' Central Apnea.  Any doctor that routinely prescribes ASV machines is likely much more aware of what is required than other doctors, these doctors are the ones you want.<br />
 +
 
 +
Second, gather evidence with your current machine to justify an ASV machine
 +
third whenever you go in for a sleep study, if not a sole study of ASV request a split study that includes ASV,  If you have Central Apnea, an ASV titration has a very high probability of demonstrating success.  It is much easier to get an ASV if you have a titration demonstrating that it works for you.<br />
 +
 
 +
 
 +
Another possibility is to go "rouge", go without a medical team or insurance to back you up.
 +
# This method is not supported by everyone. You always treat yourself at your own risk.
 +
# Verify that you have a Central Apnea other than one based on CO2 in the blood such as [[Treatment-Emergent Central Apnea]] (Other much cheaper techniques can treat this)  There is no sense in getting an ASV if you don't need one.
 +
# Procure a used ASV on the secondary market. (Craigs List, e-bay, you got the idea,
 +
# Join a self-help forum, set up your own thread so you can maintain a history.  http://www.apneaboard.com/forums  is a good one with many ASV users contributing  This is a very important step because this is your support.
 +
 
 +
== Further reading ==
 +
[[Justifying ASV backup Info]]<br />
 +
 
 +
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7725531/
 +
----

Latest revision as of 15:21, 8 July 2021

Justifying ASV

Note: Much of the material in this article (especially in relation to Medicare requirements) is relevant to the United States only.

It is very likely that you are here because someone referred you here because after reviewing your OSCAR daily charts and/or your Sleep Studies they felt that you are a candidate for an Advanced PAP machine such as one of the Bi-Levels. There are two paths to treatment and the choice is yours.

Path 1: The path that you were thrown into whether you realize it or not. That is to treat your apnea, whatever types of apnea that you have, with the machine they gave you, a CPAP, preferable an auto-CPAP either the ResMed or the Philips Respironics machines. New members of the forum come here looking for help with intractable apnea and discomfort from these problems. The forum members and "gurus" are very good at optimizing therapy to reduce these problems, and increase comfort with the therapy.

Path 2: Take the often difficult and lengthy journey to procure an advanced PAP machine. The new member that has been advised they have central or complex apnea needs to be aware that optimizing may provide significant immediate relief from symptoms and improve AHI, but improved therapy results can disqualify them from higher levels of therapy (ASV), that might be possible without this self-optimization. Sometimes individuals resolve central and complex apnea with CPAP and find long-term comfort, however, if results are inconsistent, or produce good AHI but not comfort or relief from other symptoms, The forum optimization should be discontinued as soon as possible to avoid disqualification from higher levels of therapy. This path frequently requires failing at CPAP, then failing at BiLevel E0470, before succeeding at ASV E0471

ASV or Adaptive servo-ventilation (ASV) The below is based on Medicare Requirements for procuring

  • E0470 - RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITHOUT BACKUP RATE FEATURE, USED WITH NONINVASIVE INTERFACE, E.G., NASAL OR FACIAL MASK (INTERMITTENT ASSIST DEVICE WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE) (Similar to ResMed Aircurve 10 VAuto)
  • E0471 - RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITH BACK-UP RATE FEATURE, USED WITH NONINVASIVE INTERFACE, E.G., NASAL OR FACIAL MASK (INTERMITTENT ASSIST DEVICE WITH CONTINUOUS POSITIVE AiRWAY PRESSURE DEVICE) (Similar to ResMed Aircurve 10 ASV or ResMed Aircurve 10 ST/A)

Complex Sleep Apnea

For Complex Sleep Apnea the Medicare requirements for issuing an ASV machine.

  • Therapy Optimization should be discontinued and the original settings, from the doctor, restored.
  • Titrate to minimize OSA, that is the obstructive AHI to less than 5 per hour. This typically is raising EPAP or pressure until obstructive AHI is less than 5 per hour, we expect this to make the Central and Complex Apnea worse thus failing the current treatment
  • Record the central apnea-central hypopnea index (CAHI) (looking for greater than or equal to 5 per hour and greater than 50% of total AHI)
  • Document the presence of at least one of the following symptoms: These symptoms are specifically noted by Medicare. These are key symptoms that we look for by asking "How do you feel?". Do not limit your answers to the following and do not fabricate the answers.
  1. Sleepiness, "How do you feel?"
  2. Awakening short of breath, "How do you feel?"
  3. Difficulty initiating or maintaining sleep, "How do you feel?"
  4. Frequent awakenings, or "How do you feel?"
  5. Nonrestorative sleep, "How do you feel?" Nonrestorative sleep is defined as the subjective feeling that sleep has been insufficiently refreshing
  6. Snoring, Can be documented on OSCAR
  7. Witnessed apneas Most of us have this one with our significant others

For Central Sleep Apnea

For Central Sleep Apnea the Medicare requirements for issuing an ASV machine.

  • Therapy Optimization should be discontinued and the original settings, from the doctor, restored.
  • Document a central apnea-central hypopnea index (CAHI) is greater than or equal to 5 per hour also apnea-hypopnea index (AHI) greater than 5'
  • Document The sum total of central apneas plus central hypopneas is greater than 50% of the total apneas and hypopneas
  • Document the presence of at least one of the following symptoms: These symptoms are specifically noted by Medicare. These are key symptoms that we look for by asking "How do you feel?". Do not limit your answers to the following and do not fabricate the answers.
  1. Sleepiness, "How do you feel?"
  2. Awakening short of breath, "How do you feel?"
  3. Difficulty initiating or maintaining sleep, "How do you feel?"
  4. Frequent awakenings, or "How do you feel?"
  5. Nonrestorative sleep, "How do you feel?" Nonrestorative sleep is defined as the subjective feeling that sleep has been insufficiently refreshing
  6. Snoring, Can be documented on OSCAR
  7. Witnessed apneas Most of us have this one with our significant others


File:Respiratory-Assist-Device-Order-Template-Draft-20180412-R10b.pdf
File:Mr checklist rad e0471.pdf

Symptoms

Note that these are not all specific to Central/Mixed/Complex apnea. They are symptoms that impact our sleeping, arousals, and yes apnea too. Think of these, but do not limit yourself to these when you are asked "How do you feel?"

  • Daytime hypersomnolence;
  • Excessive fatigue;
  • Morning headache;
  • Cognitive dysfunction;
  • Dyspnea, etc.;
  • Fatigue;
  • Insomnia;
  • Difficulty going to sleep;
  • Difficulty falling asleep;
  • Wakening during the night;
  • Daytime Sleepiness;
  • Excessive Daytime Sleepiness (EDS);
  • Poor concentration;
  • Difficulty with balance;
  • Shortness of breath;
  • Dry mouth;
  • Restless Sleep;
  • Non-Restorative Sleep;
  • Snoring;
  • Obstructive Sleep Apnea;
  • Restless Leg Syndrome;
  • Nocturnal Leg Cramps;


Tips for getting an ASV machine

I see 2 big steps.

First, you need to change doctors to a doctor that treats Central Apnea. By that, I mean one that actually prescribes ASV machines with some regularity. Realize that all doctors 'treat' Central Apnea. Also note that most doctors only treat OSA, even though they 'treat' Central Apnea. Any doctor that routinely prescribes ASV machines is likely much more aware of what is required than other doctors, these doctors are the ones you want.

Second, gather evidence with your current machine to justify an ASV machine third whenever you go in for a sleep study, if not a sole study of ASV request a split study that includes ASV, If you have Central Apnea, an ASV titration has a very high probability of demonstrating success. It is much easier to get an ASV if you have a titration demonstrating that it works for you.


Another possibility is to go "rouge", go without a medical team or insurance to back you up.

  1. This method is not supported by everyone. You always treat yourself at your own risk.
  2. Verify that you have a Central Apnea other than one based on CO2 in the blood such as Treatment-Emergent Central Apnea (Other much cheaper techniques can treat this) There is no sense in getting an ASV if you don't need one.
  3. Procure a used ASV on the secondary market. (Craigs List, e-bay, you got the idea,
  4. Join a self-help forum, set up your own thread so you can maintain a history. http://www.apneaboard.com/forums is a good one with many ASV users contributing This is a very important step because this is your support.

Further reading

Justifying ASV backup Info

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7725531/




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