Sierra

I see the use of CPAP, APAP, BiPAP, and ASV's a bit differently. Yes, the ASVs are the only ones that monitor each individual breath and provide pressure support on a breath by breath basis. There are some BiPAPs that detect absence of regular breaths, and provide longer term pressure support, and may do a timed backup pressure support mode (VAuto ResMed?). And not all CPAPS and APAPs can distinguish between central apnea events and take the appropriate action. CPAPs take no action on either type of event, and that is the correct action in the case of a central event. The ResMed and Phillips DreamStation APAPs can distinguish between CA and OA events and basically use the same method to do it. And, they both respond appropriately in most cases which is no pressure increase in response to a CA event. One issue with them is that they don't distinguish between central based hypopnea events and obstructive based hypopnea events. If one is having central based hypopnea and the machine responds with more pressure then the treatment induced type of central apnea is aggravated instead of corrected. BiPAP machines try to use more pressure support and that also can aggravate central apnea. For these reasons pressure induced central apnea may be best treated with a simple CPAP or APAP in fixed pressure CPAP mode.

There are some machines out there, and the F&P SleepStyle may still be one of them that do not have the capability to distinguish between the obstructive and central events. They are the worst machines of all to treat complex apnea with central apnea. They actually increase pressure in response to CA events and that is the worst possible thing to do. I dodged a bullet when I got my sleep study done. The clinic I used would only offer a SleepStyle and not a ResMed or DreamStation. That machine would not have worked for me in Auto mode, but it may have in CPAP mode. And to your original point of this post it makes you wonder why they would only offer one brand of machine. This same sleep clinic only offered my wife the ResMed S9 a couple of years earlier. What changed? More of a "kickback" on the F&P SleepStyle?

The article at this link gives a deep dive look at the technical differences between the popular machines. It is a bit dated but does include the ResMed A10 and For Her versions, so is not that old. The Respironics machine included is the System One Remstar Auto, which I believe now is the DreamStation Auto.

Treatment of sleep-disordered breathing with positive airway pressure devices: technology update

My only experience with Ontario comes from helping people out there through the forum, and both my wife's and my machine came from on line companies in Ontario. From what I understand there are two slightly different types of stores there. Some are qualified to OHIP standards and some are not. You may have to be a bricks and mortar store to qualify as a supplier of the OHIP paid machines. OHIP sets the price they will pay, so that kind of puts a ceiling on the prices charged in Ontario, which is a good thing. Some stores provide follow up assistance with the machine. Where my son got his machine in Ontario which I think was the same place my wife got hers does provide some follow up. Or, at least they promise it. I have checked my son's machine and they have never changed anything on it. The only changes are the ones I have made for him. I bought my machine at a different place that was on line only and they do not do follow up. They may in fact have the same owners as the storefront operation qualified to OHIP. They will do an initial set up based on your sleep study report, but that is it. I asked for my machines to be left as configured in the factory.

My only experience with the US DMEs is in helping people on the forum. It really does not sound like a good system at all, although I guess like Ontario it does provide machines without cost. These DME outlets seem to force patients to follow their procedures for machines depending on their assessed needs. In the worst case it seems one would have to be prescribed a fixed CPAP first along with the mandatory in lab titration study to set the pressure, then if that does not work, an Auto version, and if that does not work, then a BiPAP, and when that does not work on central apnea finally an ASV. And this is done despite the fact that the last time I checked an APAP machine is only $80 more expensive than a basic CPAP. And, there is no data to support that a BiPAP is more effective in treating central or mixed apnea than an APAP. It may in most cases be worse. Seems like a horrible waste of time and money.

There are some that advocate using home sleep studies, and immediately prescribing an APAP with no in lab testing or titration. This eliminates a lot of the expense. This is the way the system is going in Alberta. I know many people that get an APAP, and none of them actually go the route of an in lab sleep test, and just use a home test kit, no titration test, and then use an APAP in Auto. There are still in lab test facilities but they are suffering big time, and are not impressed with all the home study private companies that have popped up in Alberta. They are almost as many of them here now as there are pot retail shops! Perhaps that is because they pocket the $1900 profit on each machine they can get customers or the insurance company to pay for.

And then if APAP does not work as well as it should then there is the option to switch it into fixed CPAP mode and set the pressure at the 90% pressure level based on the experience in Auto mode. Some even advocate that as the best final solution especially for those that have central or complex apnea. That is where I am.

There are also now on line stores for CPAP machines and supplies in Alberta. I get some of my supplies there now as the delivery can be better, and prices sometimes are lower. One is a company called Sleep Yeti. I may buy my wife's replacement machine there if they ever get some stock... Right now like others they have nothing.

I don't think we have anything like the DME in Alberta. These sleep clinics are privately owned, and do the sleep testing and then sell you a machine. You are free to go to any one of them if your doctor gives you a referral.

There is something very fishy in the Canadian sleep clinic business at least in Alberta. Each province may be different. The standard practice here is for a clinic to offer a "free" sleep test, and if it indicates a need for a CPAP device they give you one on trial, again for free. But, when it comes time to get the machine, the cost is $2400 (prices from 3 years ago or so). However if you go to an on line supplier, the price for the same machine and mask etc is $800 with free shipping. So what does the full CPAP setup really cost? 500$? don't know, but it has to be around there. So this begs the question as to where the $1900 difference between the cost of the machine and the sleep clinic goes? Private insurance companies cover this $2400. What is even more puzzling is that my son had his insurance company agree to the $2400 for the sleep clinic package. Then when he found out from me that he could buy the ResMed AirSense 10 AutoSet machine full package for $800 plus $1200 for a second portable (Z1 Auto) machine, the insurance company agreed to pay for them both. That would suggest they are not getting a kickback from the sleep clinic or from ResMed. So perhaps it is really the Sleep Clinic that is making totally exorbitant profit of $1900 from each customer. And this is not just ResMed. I was offered a F&P SleepStyle machine (which I disliked) for the same $2400, and I know of others who got a DreamStation for the same $2400. Kind of puzzling...

What it makes me think is that the private insurance thing is a rip off. You are better just paying for your own machine and not paying for insurance at all. That is what my wife and I did. No coverage for CPAP so we bought our own for the $800 or so each price.

You may find this article in the blog section at MyApnea of interest. It is written by Robert Thomas, M.D., Associate Professor of Neurology, Harvard Medical School and Beth Israel Deaconess Medical Center. From this article and others, it seems that the body mainly uses CO2 in the blood not O2 to control breathing. Probably CO2 is more sensitive than O2 in determining whether we are breathing to fast or too slow. My theory in this whole issue of central and complex sleep apnea is that there may be a number of different root causes, like heart failure, drugs (opioids or similar), and altitude, but the problem manifests itself in a control system instability or failure. In the case of low blood circulation the system gets out of sync with breathing rate and CO2. Then it becomes like a poorly performing cruise control in a car. You hit a bit of a hill, the car slows down, and the cruise after a delay give the engine more gas. If this delay is too long then, you may be going down the other side of the hill by the time it gives more gas, and then the speed goes too high, starting the cycle all over again. I see this effect quite clearly in my SleepyHead graphs. An obstructive apnea event happens spontaneously, and like the hill in the cruise control analogy that starts an unstable control system response which then results in one or more central apnea events.

I have not heard of apnea during the day to be an issue, but a number have reported sleep onset apnea. But, I have never seen it documented on a SleepyHead or OSCAR graph. In your case I would be worried about apnea during sleep as I suspect during the day it may be unpleasant but is self correcting at some point. In any case here is a link to the article.

Complex Sleep Apnea - A Patient’s Introduction

All I can say is that everyone is welcome to their own opinions. I like my AirSense 10 and that is what we plan to buy when my wife's S9 gives out. Would not consider a DreamStation unless I was forced too. A while back the DreamStation's were so cheap that they are hard to resist, but I would spend the extra for a ResMed. The DreamStation 2 still seems to be about 30% cheaper than the AirSense 10, but regardless nothing in stock of either brand where we buy. I hope my wife's S9 is like the energizer bunny and just keeps going and going...

I have not used an ASV and really cannot comment on how the ResMed ASV compares to the Phillips ASV. I have personal experience with a ResMed S9 Auto and AirSense 10 AutoSet. And, have helped numerous people set up adjust their DreamStation APAPs. I have no concerns that the ResMed is ignoring apnea events, and from what I have seen it seems to quite accurately identify them, what type they are, and how long they last. I very occasionally get unidentified events where the machine flags them but does not classify them. It seems to happen when the leak rate is high but not over the leak rate redline. When the leak rate does go over the redline the machine stops reporting all events and when in Auto does not take any pressure action. ResMed claims this is to avoid inappropriate action due to misclassification. Here is an expanded screenshot of a couple of events in succession. The first one lasts about 8 seconds and is not flagged as an event. You can see that after about 4 second the machine starts the pressure pulses to detect the type of apnea it is. Higher amplitude pulses indicate an obstructive event, while lower amplitude indicates CA events. By my eye this one is an obstructive event, but it does not last long enough to get flagged and classified. It has to go over 10 seconds. The second one proceeds the same but lasts longer. Pressure pulse starts at 4 seconds and the total length is about 17 seconds. It gets flagged as a OA event. By my eye the pulse amplitude starts out high but reduces as the event goes on. It in fact may have progressed from an obstructive event to a central during the apnea.

As far as the APAP machines compare I like the ResMed one better because of a few differences:

1. The DreamStation uses what some describe as a "hunt and peck" method of determining what pressure to use. If given a high range between minimum and maximum pressure, it seems to respond more slowly to apnea events but does bring the pressure up. Then when it gets higher it quite quickly starts testing to see if events come back when pressure is lowered. If no immediate events come in, then it keeps pressure down. And when one does it starts this routine all over again. I can immediately distinguish between a DreamStation OSCAR graph and a ResMed graph because on the Dreamstation the pressure will keep going up and down all night long. I don't think that does anything for the quality of sleep and for the frequency of events required to keep bringing the pressure back up again. It essentially ask for them.
2. The ResMed on the other hand brings up pressure in response to an event quicker, and then is slow to reduce the pressure. It does not do this hunt and peck game. Overall I believe that results in fewer events over the night, and a more uniform pressure that is less disturbing to sleep quality. Just my opinion.
3. The ResMed has a nice AutoRamp feature for starting the night out. It does not really ramp the pressure up. It just holds it at a selected pressure comfortable for going to sleep. When it detects you are asleep it ramps the pressure up to minimum.
4. The ResMed allows you to set the EPR (expiry pressure relief) to function full time, or not at all, or only during the ramp period. For some that do not benefit from EPR during sleep, as it may cause the IPAP to be higher, it can be nice to have EPR on during the ramp but off during sleep. The DreamStation does not do that.
5. I believe the EPR is more effective than the FLEX options offered by the DreamStation, as they give you the full selected pressure relief of 1, 2, or 3 cm. FLEX functions to more smooth the transition from IPAP to EPAP and than to provide the full selected pressure relief.
6. The ResMed machine calculates and displays the mask pressure which can be graphed in OSCAR. There is no pressure sensor in the mask, so it has to calculate this value. The DreamStation does not attempt to do that, so all you see is set pressure, not actual pressure. The Mask Pressure lets you see that EPR is working and how quickly the machine is responding to flow demands and how well it actually maintains pressure.
7. ResMed have an AirSense 10 machine that is called the For Her version. It has an extra For Her mode built in for optional use. It raises pressure more quickly in response to flow limitations and holds the pressure longer. It may be more suitable for people with lower levels of apnea. It does not go above 12 cm of pressure. I always suggest that anyone getting an AirSense 10 to get the For Her version. In the new AirSense 11 machine this feature is built into them all. There is no separate For Her version. Not sure if the DreamStation has anything like this.

In any case these are some of the reasons why I recommend a ResMed over a DreamStation for an APAP when I am asked. The DreamStation is still a good machine and I would use one if I had to, but in my opinion it is not as refined a product as the ResMed. And for an ASV things may be totally different. I just have no experience other than reading the Clinical manual for the ResMed model.

The OP indicated this in a second post.

"My titration study showed virtually no central apneas."

It looks like it is treatment emergent central apnea, and an ASV would not have been indicated as a result of the lab titration. However, one may be needed at some point, if other changes cannot bring it into control. At one point I was convinced I needed an ASV, but that has not turned out to be the case. The right settings in a simple CPAP fixed pressure mode has worked for me.

Here is an example of the trouble I was in back in 2018 in Auto mode of my machine with EPR (like pressure support) at 3cm.

And here is my report from last night. This in fixed pressure CPAP mode with EPR at 2 cm. It is not always this good, but I do now average 0.83 for AHI over quite a long time.

"It looks like the OSAs are very minimal, but the central apneas are now very high (30-60 AHI). My titration study showed virtually no central apneas."

It looks like you may have treatment emergent central apnea. This is when the pressure used to reduce obstructive sleep apnea causes an increased number of central events. I had something similar happen to me. In some cases this type of central apnea can go away after 6-8 weeks or so. In my case it did not go away. I have made some changes to limit the pressure the machine uses and have been able to average about 0.8 for AHI, but it still goes much higher on certain nights when central events happen.

If you could post a full screenshot of the Daily Report it would be helpful to see where you are at. The events bar, pressure graphs, and flow graphs are the most important and should be at the top From what you have posted it looks like you may be getting into Cheyne Stokes respiration (CSR) or if you have a DreamStation machine they call it periodic breathing (PB). A starting point to look at is to determine when central events are occurring. Then you can see if higher pressure is related to when they occur. If that is the case then you look for opportunities to reduce the pressure. In my case I believe my machine (ResMed AirSense 10) was seeing Hypopnea events and responding with increased pressure. Hypopnea can be central in nature or obstructive. If they are central then increasing pressure is not the correct response for the machine. I addressed that by limiting the pressure it could automatically go to.

Do you know why they selected a BiPAP machine? It may not be the best solution for you. I have an Auto machine but I now run it in simple CPAP mode with a fixed pressure, and do not allow the machine to automatically increase pressure. I set that fixed pressure based on what I saw when it was in Auto mode and then with just trial and error to see how low I could reduce the pressure before obstructive events started to occur.

In any case if you post a full screen it would help a lot to understand what is going on in your particular case. Where you are now with those regular CA events running up your AHI is not a good place to be.