Newbie just had my CPAP Titration done, need insight/advice!

Hello everyone,

I'm currently 23 years old, and over the past 6-7 years I have been steadily gaining weight. I went from about 165 lbs in sophomore year of highschool (2008) to 234 lbs currently (mostly centered around my gut/belly). I had always wondered what was going on and causing the weight gain. Sure I had decreased my level of physical activity over the years, leading a more sedentary life as a premed student in college, maybe eating less-healthier as well, but no big change from high school. I remember in high school i would always wake up extremely tired and be dozing off in the shower. I'd constantly be fatigued throughout the day, and this fatigue and sleepiness has gradually increased ever since. I had to quit my part time job because I'd always come in extremely tired, and barely be able to work at the pace that I needed to work at, and also lack the focus that I needed. I've known that I snore, but for some reason I never really brought it up with my doctor. I will be starting medical school soon, and I am currently in a gap year where I have had a lot of free time. I researched the issues and spoke with my doctor, and had a sleep study done earlier this month. It was determined that I do indeed have Obstructive Sleep Apnea, and my overall AHI was 17.6, with an AHI of 60 during REM sleep.

Today I had my cpap titration done, and the technician determined the best pressure for me was approximately 13 cm. Now here's where I need the advice and insight: I was connected to a plain old respironics cpap machine (I do not know the specific model, i apologize). I was started off with a nasal mask, but i had difficulty breathing with it. I think the pressure made it difficult for me to exhale through my nose and also caused my nose to get very stuffy with all of the air. So I requested that I try the full face mask, which made it less difficult for me to breath, and enabled me to fall asleep eventually (although i did wake up a few times throughout the night). My mouth got extremely dry and i had to request some water at one point in the night. Also during a few points in the night, i woke up having to make a huge gasp for air because i had stopped breathing. This happened at least twice. I switched positions a few times from sleeping on my back to sleeping on my side. Sleeping on my side resulted in leaking through the mask, and made it difficult to breath, therefore i had to continuously adjust my mask when i felt/heard the leaking.

My question now is, what happens next? My results will be scored and reviewed and made available to my reviewing physician, who will then recommend the treatment option. I've been reading up on the different types of machines such as cpap, bipap, apap, and aSV. I have a superficial idea of the differences, but nothing really in depth. But I do think that I will not be able to sleep comfortably with a CPAP machine, and will likely require one of the latter types of machines. But who will have the say in the decision? Does the doctor prescribe the specific type of machine (cpap, bipap, apap, etc.)? I dont want to have to first try the CPAP, and then go back to get a study done and then switch to a bipap or apap and then have another study done to titrate that. I just want to have the most streamlined path towards getting the right machine for me.

I would greatly appreciate any input that any members on this forum may have to offer me!
Tl;dr
Have OSA
Used FFM for cpap titration
Had difficulty exhaling and inhaling at times
stopped breathing a few times and woke up gasping for air, also with extremely dry mouth
Do I get to decide which type of machine I get to use for treatment?

I am insured by United HealthCare with full coverage if that helps

Thanks!

Welcome to the forum.
I find my apap with exhale pressure relief quite comfortable,
but it took awhile to get used to it--as it does everyone.
Not everyone needs a bilevel, and it is harder to get--possibly because it is more expensive.

Do NOT accept a Resmed Airsense "CPAP" it is the dumb, little or no data model.
All of the other Airsense models are excellent machines.
Be sure to read, nay print the maskarrayed blog for an excellent summary of other machines
--with respect to DATA. DATA is the most important feature to look for, that and the right MASK.
Get a list of the DME's in network for your insurance, and get the prescription
IN YOUR HAND so you can find which will sell you a FULL DATA machine. Good luck!

1.) Relax
2.) Rest assured they did not connect you to a 'dumb' plain cpap for a titration study. You were hooked up to a lab-grade xPAP machine that can emulate almost every mode of operation under the sun, emulating bipap or whatnot.
3.) Bipap is not 'better' than cpap. A servo-ventilator is not 'better' than bipap. These machines are just different, based on a patient's medical needs. More elaborate and costly, but not 'better'. If they say you only need cpap, then you only need cpap.
4.) Within classes of machines, yes, there are better ones and lesser ones. ALL models, even the very cheapest base models, WILL work and will likely help you just fine. However there are differences.

If possible, make sure to demand (all these specific things below MUST be on the written Rx for the machine!!!):
a. A machine model (even if a CPAP-type) that is 'fully data capable' so that you and your MD can see your full data and data trends, not just hours of usage. The basic, cheapest 'brick' machines don't record full data so if you ever need pressure changes, you will need further titration studies to determine them. Not easy or the best way to go.
b. If told you need a CPAP, request a data-capable "AUTO-CPAP" or "APAP" machine. These can adjust up and down each night based on needs, whereas a plain CPAP is fixed (an APAP can always be put into fixed CPAP mode if desired).
c. Almost all modern CPAP/APAPs have "Exhalation Pressure Relief" settings that drop pressure on exhalation, similar to a BIPAP machine, to make breathing more comfortable.
d. Request adding the 'heated tube' option, which can improve humidification, and decrease risk of condensation in the hose.

Keep in mind, the insurance will pay the DME the exact same amount for the cheapest, base model 'brick' CPAP as for the most advanced APAP version with all the bells and whistles. They have the same billing code. So it is to your advantage to demand the best model you can get. (Unless you yourself pay the whole thing out of pocket....)

The current "Cadillac" machines are the Respironics "System One" series, and the ResMed 10 "Air" series.

Once you research or do a hands on try of the machine, be sure to include the EXACT MODEL of the one you (and your MD) want on the RX! Otherwise the DME can pick any machine of that class (CPAP, BIPAP, APAP....) to give you. The model name and number and options (heated hose, mask) must be on the Rx to be assure you get the exact one desired.

The slightly lesser (but still good) machines out there are the DeVilbiss Intellipap models and the Fisher Paykel Icon models. There are even some less costly, Chinese-made models of which not many folks on here have a lot of experience. Mostly all Respironics and Resmed in the US.

The mask choice is also very, very important but that's a different discussion.

Finally, do lose weight it will help your apnea.

Good luck!

Your pressure need of 13 cm is probably starting to push the lower edge where a bilevel machine might be useful because it offers a wider range of pressure support (difference between inhale and exhale) and it's that difference that offers the relief at those higher pressures. Some people need bilevel at even lower levels but in general I think pressures in the teens is where bilevel might start to become more useful depending on the person. There are people though who can handle straight cpap at 20 cm and not need any relief...and there are people who need relief at 10 cm...so it is highly individualized.

It's usually the doctor that makes the decision on cpap/apap vs bilevel because the billing codes for those 2 types of machines are different.
If you haven't read this...read it as it explains how the process starts
https://maskarrayed.wordpress.com/what- ... me-part-i/

Brand is usually left up to the DME unless a doctor has specific requests and if that happens it needs to be written on the RX.

In your case...based on what you have said about your pressure needs and the already perceived exhale issue
and what I know about how the exhale relief function works with both the ResMed machines and the Respironics machine..
I would suggest targeting the ResMed brand because the exhale relief offered is more like a bilevel device even in cpap/apap mode.
The available exhale relief is a little more with ResMed and the timing is a little different than the Respironics relief so when in doubt...get the ResMed as it offers what is most like a bilevel device in terms of what it offers and how it feels.
I have used both...and I am speaking from experience. Maybe you would do okay with Respronics type of relief (it is really nice) but maybe you would do better with ResMed. ResMed exhale relief is more "dramatic" and for people with pressures in the teens and trouble exhaling I think that Resmed offers a greater chance for simulating bilevel pressures when using cpap/apap machines.

Since your pressure needs are in the teens then having a machine that could do auto adjusting of the pressures during the night might be of extra benefit...just in case you might need higher pressures for only part of the night and not necessarily all the night.
Auto adjusting machines (called APAP machines) always have fixed cpap mode available but fixed cpap only machines don't have APAP mode available.....so get the model that has APAP mode available if at all possible. You may or may not need it but it is nice to have just in case you do need it. It's always better to have something and not need it than need it and not have it.

In the ResMed line the APAP machine would be the ResMed AirSense 10 AutoSet or the AirSense 10 AutoSet for Her.
The "for Her" model actually has 2 apap modes available along with its cpap mode. The second apap mode on the for Her machine offer a slightly different algorithm as well as additional data collected. It might come in useful in both men and women as I don't really think that only women could maybe need that special mode. It was targeted for women but I know of men who could maybe benefit...so I actually suggest that even men get that "for Her" machine if at all possible.

You can talk to your doctor about bilevel which is a separate model machine...the AutoSet exhale relief is limited to 3 cm reduction and bilevel machines have higher than 3 cm available which can be really important to some people but 3 cm feels pretty darn good so it might be enough to make you happy.

You've received excellent advice/insights already but I want to add one additional point.

You commented that you woke up because you weren't breathing a couple of times. It seems this was a point of concern for you. Remember, however, that you were undergoing a titration. It is very likely (you might be able to confirm this when you receive your study results) that this occurred when the tech was still increasing your pressure. IOW, at the time you woke up the pressure might have only been at 7, say, or 8, because the protocol is to start low and increase the pressure by increments until your airway is splinted open sufficiently to prevent further apneas.

Thank you so much, everybody! I will schedule an appointment with my primary care physician and do my research on the various different machines and masks. My sleep technician told me that I could go to my home health provider to try on different masks (and also try different machines?). I do not know exactly what he meant. What type of providers are these? What would be an example of a place i could go to try different masks and/or machines?

Just a word to the wise. The weight gain you experienced isn't "just" because of apnea. Sleep
Apnea and the elevated stress hormones from apnea mess with your metabolic hormones--INSULIN, leptin, ghrelin, and thyroid. So you need a thorough endocrinology work up to look for metabolic syndrome, adrenal dysfunction, and hypothyroidism (remember what you learned in biochem?). I highly recommend you see a functional or integrative MD for a good evaluation. Otherwise you will be at a serious physical disadvantage to your led school peers.

My daughter is about to enter her "gap year" while applying to med school. From the tours we've taken it looks like med school is both a marathon and a sprint, so you want to optimize your health BEFORE you get there.

Janknitz wrote:Just a word to the wise. The weight gain you experienced isn't "just" because of apnea. Sleep
Apnea and the elevated stress hormones from apnea mess with your metabolic hormones--INSULIN, leptin, ghrelin, and thyroid. So you need a thorough endocrinology work up to look for metabolic syndrome, adrenal dysfunction, and hypothyroidism (remember what you learned in biochem?). I highly recommend you see a functional or integrative MD for a good evaluation. Otherwise you will be at a serious physical disadvantage to your led school peers.

My daughter is about to enter her "gap year" while applying to med school. From the tours we've taken it looks like med school is both a marathon and a sprint, so you want to optimize your health BEFORE you get there.

That's exactly what i'm trying to do! Trying not to be my own enemy with these health issues. I have read up on the leptin and ghrelin negative and positive feedback loops (respectively) in relation to sleep apnea, as well as the buildup of insulin resistance as a result of sleep apnea (which is what I believe to be going on with my mother). I will request my primary care physician draw samples for a full metabolic panel.

So my referring/primary care physician is the one who will be writing the Rx for the treatment, correct?

Read the Useful Links in my signature line at the bottom of this post for some hints on how to not get screwed in the process and get the right machine.

BullsFan91 wrote:Thank you so much, everybody! I will schedule an appointment with my primary care physician and do my research on the various different machines and masks. My sleep technician told me that I could go to my home health provider to try on different masks (and also try different machines?). I do not know exactly what he meant. What type of providers are these? What would be an example of a place i could go to try different masks and/or machines?

I hate to say it but it's not easy. The Durable Medical Equipment people that supply CPAP equipment, etc., to patients, all vary -- some have offices you can go to and try on masks, while others come to your home with supplies and fit you for masks. But in each case I have seen, including recently, it can really be catch as catch can. They may have only a handful of masks to try. So in the real world, I strongly recommend doing as much research as possible to find a mask that you find attractive and would be comfortable using, and that gets good reviews. Then, specifically ask that that mask(s) be brought to test, in addition to any others the DME can recommend. I saw this happen this past week -- one nasal mask (Wisp) was brought, one pillows mask (P10), and one FFM (QFX). That's all the DME tech had. Not really much of a comparison at all.

IMHO the best reviews come from the online vendors like cpap.com etc., but also the many videos and mask reviews from lankylefty27 on youtube. He's awesome and has reviewed dozens and dozens of masks. Definitely check him out for info.

You're probably looking for a mask as small and discreet as possible, like the P10 or the Swift FX or Swift FX Nano, or the F10, or the Nuance.

Good luck!

ANY doctor can write the RX for your equipment, although the sleep medicine specialist will probably roccommend the RX (CPAP or APAP set at xx,, with heated hose and humidifier, x type mask". If your primary care doctor is willing, you can request that the RX specify the make and model of machine YOU WANT and "mask of patient's choice. Be aware you will not get a bipap covered by insurance unless you meet your insurer's "qualifications" for the more expensive machine.

hyperlexis wrote:
I hate to say it but it's not easy. The Durable Medical Equipment people that supply CPAP equipment, etc., to patients, all vary -- some have offices you can go to and try on masks, while others come to your home with supplies and fit you for masks. But in each case I have seen,

Janknitz wrote:ANY doctor can write the RX for your equipment, although the sleep medicine specialist will probably roccommend the RX (CPAP or APAP set at xx,, with heated hose and humidifier, x type mask". If your primary care doctor is willing, you can request that the RX specify the make and model of machine YOU WANT and "mask of patient's choice. Be aware you will not get a bipap covered by insurance unless you meet your insurer's "qualifications" for the more expensive machine.

including recently, it can really be catch as catch can. They may have only a handful of masks to try. So in the real world, I strongly recommend doing as much research as possible to find a mask that you find attractive and would be comfortable using, and that gets good reviews. Then, specifically ask that that mask(s) be brought to test, in addition to any others the DME can recommend. I saw this happen this past week -- one nasal mask (Wisp) was brought, one pillows mask (P10), and one FFM (QFX). That's all the DME tech had. Not really much of a comparison at all.

IMHO the best reviews come from the online vendors like cpap.com etc., but also the many videos and mask reviews from lankylefty27 on youtube. He's awesome and has reviewed dozens and dozens of masks. Definitely check him out for info.

You're probably looking for a mask as small and discreet as possible, like the P10 or the Swift FX or Swift FX Nano, or the F10, or the Nuance.

Good luck!

Thank you so much for the mask recommendations, i'll be sure to check out the reviews for these, as well as watch lankylefty27's videos!

Janknitz wrote:ANY doctor can write the RX for your equipment, although the sleep medicine specialist will probably roccommend the RX (CPAP or APAP set at xx,, with heated hose and humidifier, x type mask". If your primary care doctor is willing, you can request that the RX specify the make and model of machine YOU WANT and "mask of patient's choice. Be aware you will not get a bipap covered by insurance unless you meet your insurer's "qualifications" for the more expensive machine.

Excellent, thank you for the clarification! I'll only opt for the bipap if that is what the interpreting physician finds is necessary. Regardless, I'll definitely ensure that my doctor and I work together to ensure that I get the machine that is most comfortable to ensure the most compliance.

Hello everyone,

So my report from my cpap titration has still not been finished and sent to my physician. I've seen from the pundits of this forum that it's best to take your therapy into your own hands once you have the necessary knowledge (and with the help of the experienced and knowledgable members of this forum).

I found a very lightly used (less than 2 months) ResMed S9 Autoset with the slimline tubing + H5i Humidifier for $400. I will likely be buying it today as I cannot tolerate this OSA anymore! The past few days/nights have been bad. My therapeutic pressure determined at the sleep study was 13 cm H2O. Given this, what range should I initially set the machine's pressure range to? I know this range is subject to change according to the sleepyhead reports that are generated, but would something like 9cm H2O - 13cm H2O be a good start?

Thanks!

If 13 was what was advised....I usually like to start apap mode maybe 2 cm below titrated pressure recommendation and maybe use 2 to 4 above it for the range maximum. The machine won't go there if it doesn't think it has a reason to go there. Usually the titrated fixed pressure recommendation is a "worst case scenario" pressure and you may not need that much all night.

Now you can also simply use fixed 13 cm cpap mode if you wish.

Some people do well with apap auto adjusting pressures and some don't for various reasons. You won't know until you try which camp you will be in.

If it were me...if I wanted to try apap mode in this situation with 13 being the prescribed setting...I would start with minimum of 11 cm and probably just leave the maximum wide open but you can limit it if you wish to something like 15 or 16. If the maximum is never reached it doesn't really matter what it is.

Pugsy wrote:If 13 was what was advised....I usually like to start apap mode maybe 2 cm below titrated pressure recommendation and maybe use 2 to 4 above it for the range maximum. The machine won't go there if it doesn't think it has a reason to go there. Usually the titrated fixed pressure recommendation is a "worst case scenario" pressure and you may not need that much all night.

Now you can also simply use fixed 13 cm cpap mode if you wish.

Some people do well with apap auto adjusting pressures and some don't for various reasons. You won't know until you try which camp you will be in.

If it were me...if I wanted to try apap mode in this situation with 13 being the prescribed setting...I would start with minimum of 11 cm and probably just leave the maximum wide open but you can limit it if you wish to something like 15 or 16. If the maximum is never reached it doesn't really matter what it is.

Thank you very much Pugsy! So let's say I use the machine in regular cpap mode with the constant pressure at 13cm. Would I still be able to use the EPR mode to reduce the pressure during exhalation so that it can be easier for me to fall asleep and stay asleep?