CyrusManz

This takes us back to my other posts here, regarding Resmed's algorithm reporting incorrect AHI numbers. Also the Resmed Airsense 10 Autoset does nothing for CA events so I am not sure how it provided any therapy. This is a quote directly by Resmed themselves:

"......*It can be challenging to treat patients with central SDB. Continuous positive airway pressure or automatic positive airway pressure (CPAP/APAP) therapy is often used as the treatment of first intention, but experience shows that CPAP/APAP does not consistently control apneas or improve symptoms*.........."

[https://me.resmed.com/healthcare-professionals/diagnosis-and-treatment/sleep-disordered-breathing/treatment-options-for-csa/]

Great. Pls provide a link so I can look at it.

Yes, there has been some spotty work to get conventional CPAPS to work for CSA or complex situations. Most were done before ASV was developed (its a relatively new technology). Some of thoese studies actually helped the development of ASVs.

Most respiratory therapists tend to shy away from prescribing ASVs , mainly because to get a ASV machine you must undergo testing for LVEF % and be found to have a more than 45% flow pressure in your heart's left ventricle first because back in 2008 there was a study on ASVs when some patients with this heart issue, died and they are a bit wary of prescribing ASVs for everyone now. But essentially there is no highly effective PAP therapy for CSA/ Complex disorders, other than ASV therapy.

I hear you, but that's not true. The reason ASV's were developed was because conventional CPAP therapy does not work on CSA.

As a long time ASV user I can assure you that your basic assumptions are incorrect. ASVs are designed to "take action" on detection of a potential CA event (remember that CLEAR AIRWAY is what the ASV detects as it has no other way to detect a Central event). A clear airway event signals that even though the airway is open, there is no flow when there is supposed to have been a "spontaneous breath". The ASV then intervenes by issuing a machine breath and looks for flow If no flow is registered on issuance of a machine breath, it is registered as a CA event however the machine continues to issue breaths at an elevated pressure each time up to maximum IPAP, as long as flow remains open (ie. patient's own spontaneous breathing has not resumed). ASV machines act like mini Ventilators to this regard, whereas regular CPAPS, BiPAPS et al act as positive air pressure sources, only which makes them good enough for OAS therapy.

Mind you, ASV therapy also takes care of OAS events through the same algorithm except that instead of supplying breatchs to break up an OAS event, it elevates EPAP pressure instead, thus helping keep the upper airways open and it does this breath by breath, also.

So ASV machines DO take action in a CA event (otherwise what's the point?) however Non-ASV and BiPAPS don't. Just clarifying here.

ASV algo does all this while at the same time setting a target for minute ventilation and then self adjust to keep MV constant AVAPS do the same except they keep TIDAL VOLUME constant so patients with other issues like COPD can benefit from therapy.

Now, when it comes to machines ability to distinguish between different events, the algorithm has to be high resolution (be able to monitor the characteristics of each breath), however even ASV or AVAPS machines are limited with what they can correctly detect since they can only monitor flow rate and mask pressure. To monitor anything else they need external sensors that can be attached to patients, for better feedback but then we are talking clinical type ventilators, a different ball game altogether.

For apnea events however you really only need the machine to recognize :

1-Clear Airway (CA this could also be Central because Central is when airways are open without diaphragm action).

2-Periodic Breathing (PB)

3-Hypopnea (H)

4-Obstruted Airway. (OA)

ASV machines actually do a great job of recognizing the above, except that in my experience, having owned both machines, Philips does a much more admirable job than Resmed.

Yes, so just to let you know there are no import duties to be paid to Government of Canada on CPAP/BiPAP , ASV etc, should you ever decide to purchase your equipment from a US supplier.

They all fall under "medical equipment" with distinct tariffs exemption codes which your US supplier must include in their Commercial Invoice so your equipment won't get held up at customs.

In regards to Central Apnea therapy, there is really no machine other than ASV machines which were specifically developed to treat Central Apnea.

Fact is that for a machine to be able to distinguish Central Apnea events from Obstructive events, it must be able to provide a breath when one is missing and to do that, the machine software needs to be able to monitor each breath, continually.

Regular APAPs and BiPAPS are simply not designed for treatment of Central apnea therefore they are not capable of recognizing a single missing breath and then act like a ventilator and provide a breath to compensate. Only ASV machines can do that.

Regular APAPS and BiPAPS are ONLY designed to treat Obstructive Apnea by providing EPAP pressure (this is the pressure you feel when you EXHALE). This way EPAP keeps the upper airway open.

Regular non-ASVachines cannot provide single Breaths to compensate for missing breaths that Central Apnea patients experience.

Now, there are only 2 companies that make ASV machines. One is Resmed (Resmed Aircurve 10 ASV) and Philips-Respironics (Dreamstation BiPAP Auto SV).

Problem is that philips recall has made it difficult to find Philips products online even though there are still some US suppliers who sell them at heavily discounted prices. This leaves Resmed for an entire ASV market and as I have argued in my other post, Reamed ASV algorithm does not work too well.

So in that case you are able to get a prescription for the "type" of machine you need and then shop for it online because Alberta government doesn't cover the cost but your own private insurance does. I hear there are a lot of DMEs in Ontario (Durable Medical Equipment suppliers), depending on where you live and how populated the area is. These outfits usually have a licenced specialist on site who helps you with the setup. These outfits also have to be registered with the Ontario government so they can claim the cost of the equipment on your behalf, but from what I know through friends in Ontario, their prices are much higher than what you can get online, except that the government coverage does not extend to personal online purchases. You have to buy from a registered DME, if you are going to use the government coverage. In the US it is pretty much the same if you are a on medicare or medicaid. If you have a private plan, depending on the type of plane you have, you get varying degrees of autonomy of on you choice of DMEs. Some people choose to pay out of pocket because they don't want to be bound by their insurance "compliance" rules. This way they just report to their own doctor by giving hi/her a copy of their memory card every month. I they decide to go with insurance coverage, then the insurance company gets access to their therapy data that the machine cellular modem uploads every day...I don't like this part personally,which is why I just buy my own machines and deactivate the modem.

Bear in mind that if you buy a machine in the US, then the cellular modem on it will only work with US cell providers, so it will not connect in Canada, which I presume you don't care, anyway.

I am not sure how Sleep Apnea is covered in the province of Alberta, Canada but in Ontario where I have a great number of friends and family, CPAP machines are covered by Provincial government healthcare , so the sleep clinic gives youa prescription for a machine with certain capabilities (BiPAP, Auto Pap etc ) and you take the prescription to a DME of your choice and they offer you different choices of brands. You end up paying a co-pay of about 10% under Ontario plan and get a new machine every 5 years . High end machines like ASV and AVAPS or S/T and travel PAPS are not covered.

This is however pretty much standard all over North America, whether or not there is a government program available, with the exception that private insurance can pay for higher end machines like ASVs and AVAPS.

Of course if you pay out of pocket like I do, you can purchase anything you want and given your experience in Alberta, it appears that the DMEs make a lot of money there with prescriptions, presumably because when they accept a prescribed sale, they will also have to undertake a lot of warranty liability...or they just enjoy gouging people because they can.

This being said, in most USA jurisdictions the insurance company would want to see your therapy compliance every month in order to continue coverage where as in Ontario this is very sporadic and rather laxed when it comes to checking your compliance.

The lawsuit above pertains to Resmed paying kickbacks to DMEs who pushed Resmed brands over others to patients who came to them for a newly prescribed machine.

This is evidently against the law in United States:-)

Ps,

In United States it is against the law to sell a PAP machine to a US resident without a valid prescription, whereas orders from outside of US can be filled without a prescription. So if you reside in Canada, there is a huge selection for you to choose from, if you are paying out of pocket and if you can negotiate with your insurance company and they do not require a running compliance report, then even better.

This is over a year old, but still very relevant.

".......Resmed Corp. to Pay the United States $37.5 Million for Allegedly Causing False Claims Related to the Sale of Equipment for Sleep Apnea and Other Sleep-Related Disorders ResMed Corp., a manufacturer of durable medical equipment (DME) based in San Diego, California, has agreed to pay more than $37.5 million to resolve alleged False Claims Act violations for paying kickbacks to DME suppliers, sleep labs and other health care providers, the Department of Justice announced today.

“Paying any type of illegal remuneration to induce patient referrals undermines the integrity of our nation’s health care system,” said Assistant Attorney General Jody Hunt of the Department of Justice’s Civil Division. “When a patient receives a prescription for a device to treat a health care condition, the patient deserves to know that the device was selected based on quality of care considerations and not on unlawful payments from equipment manufacturers.”

The Anti-Kickback Statute prohibits the knowing and willful payment of any remuneration to induce the referral of services or items that are paid for by a federal healthcare program, such as Medicare, Medicaid or TRICARE. Claims submitted to these programs in violation of the Anti-Kickback Statute give rise to liability under the False Claims Act.

The settlement resolves allegations that ResMed (a) provided DME companies with free telephone call center services and other free patient outreach services that enabled these companies to order resupplies for their patients with sleep apnea, (b) provided sleep labs with free and below-cost positive airway pressure masks and diagnostic machines, as well as free installation of these machines, (c) arranged for, and fully guaranteed the payments due on, interest-free loans that DME supplies acquired from third-party financial institutions for the purchase of ResMed equipment, and (d) provided non-sleep specialist physicians free home sleep testing devices referred to as “ApneaLink............” .

[https://www.justice.gov/opa/pr/resmed-corp-pay-united-states-375-million-allegedly-causing-false-claims-related-sale]

Of course I must post an example of how my Philips Respironics Dreamstation handles an apnea event and how it catches absolutely all suspect events. Below is a 22 seconds slice of a 5 hour sleep session which should a cessation in flow rate (breathing stop). Graph shows the machine issuing a breath however flow does not change significantly. The machine issues another breath and registers a Hypopnea event shortly after. My Dreamstation does this all night. In fact I cannot find a single event that has been missed by the missine, throughout.