Should I fight to get an APAP rather than CPAP?

[DoriC]

At first we were given a machine with no data capability as written by the sleep doc, but thanks to this forum we had our Primary Dr write a new RX for an M Series Auto w/Aflex and it was exchanged with no problem. Having the software was really the key to getting the right therapy so even with all the bells and whistles on our machine and being able to make adjustments in auto mode at first, hubby is now using straight cpap pressure at 12 with no flex settings.

[baldbaby]

Couldn't get the doc to change the prescription to APAP so I went with the Resmed S8 Elite II CPAP with heated humidifier. I'm using the Swift LT Nasal Pillows System. It's kind of a hassle to get the nasal pillows right so I get good flow. My big complaint is I can hear myself breathing in my head; it's like listening to Darth Vador with emphysema, but I do seem to be able to sleep OK. At least my wife says she can sleep now!

I was hoping to be able to see how many apneas I had that night by using the built-in readout but the tech told me it can't show that data. Does that sound right?

[hose head]

Your Elite II provides AHI, AI and HI if your tech turned on Smart Data. You get to it by pressing right and left arrows at same time for 3-4 secs. From there you follow the arrows to your data. You can not change the settings on the machine from this menu, only read data(if turned on). You can press exit until getting to start screen, or just leave it and it will return to the start after a time. You have to read settings before noon or they roll over to weekly, monthly avg.

Couldn't get the doc to change the prescription to APAP so I went with the Resmed S8 Elite II CPAP with heated humidifier. I'm using the Swift LT Nasal Pillows System. It's kind of a hassle to get the nasal pillows right so I get good flow. My big complaint is I can hear myself breathing in my head; it's like listening to Darth Vador with emphysema, but I do seem to be able to sleep OK. At least my wife says she can sleep now!

I was hoping to be able to see how many apneas I had that night by using the built-in readout but the tech told me it can't show that data. Does that sound right?

[rested gal]

I was hoping to be able to see how many apneas I had that night by using the built-in readout but the tech told me it can't show that data. Does that sound right?

The tech is mistaken. Your Elite II can definitely show AHI (apnea/hypopnea index), AI (apnea index), HI (hypopnea index), and Leak information if you follow the steps hose head described, before 12 noon the next day.

However, if the tech did not turn on the "Smart Data" feature, you'd have to either ask the DME to turn that on, or go into the "hidden" clinical setup menu to turn that feature on yourself.

Useful links:

http://www.cpap-supply.com/Articles.asp?ID=130

Brenda's post:
viewtopic.php?t=22776

My post:
viewtopic.php?p=226375#226375

[LinkC]

He was getting a little annoyed at my persistance and basically said he knew what I needed and he wasn't going to budge. He also said he had to justify the APAP to the insurance company and he couldn't do that.

It sounds like it's a done-deal (and CPAP will do just fine...but it limits your options down the road). As long as you get data, you can certainly live without APAP.

However, I think your doc is forgetting just who the customer is. And he's also either ignorant or misleading you about the insurance. CPAPs and APAPs fall under the same insurance billing code. The cost to your carrier is exactly the same, and they couldn't care less which you get. (Bi-PAP is a different story...)

[baldbaby]

Thanks hose head and rested gal. That seemed to work. The readings from last night are:
Press: no data
leak: 0.14L/S
AHI: 19.7
AI: 9.0
HI 10.7

I'll have to research what they mean. But I wonder the effect of things like shutting down the machine while I go to the bathroom and adjusting my mask for a better fit. I do these things several times a night. Is that going to distort these readings?

Linkc: The doctor definitely has an elite attitude and thinks he knows best. The DME said he was more than willing to set me up with an APAP even though he makes less money. Maybe the doctor is afraid the APAP will take him out of the loop. I suppose he could be genuinely concerned about my health, concerned that he'll loose business, or both.

Dan

[spitintheocean]

Those are some intriguing numbers that you're reporting. The good news is that's a great leak rate, if you can keep that number nice and low (and yours is) then you're halfway home. Unfortunately, that's it for the good news.

First off, there's something wrong if you can't read your pressure setting on that machine, I believe it should be the first number reported when you go into the menu in the morning, furthermore at any time during operation, the pressure should be showing during real time.

Next, your AI needs to come waaaay down, ideally to 0.1 or less which suggests that your pressure setting is set much too low and/or is further compromised by the EPR setback. This means a visit to the clinical menu and recording all your original settings, followed by an adjustment up of your current pressure but before you do that, you should come back here and let us know what your machine is currently set to.

Finally, as your AI numbers are reduced (presumably with higher pressure) your AHI should see a commensurate reduction but you shouldn't worry too much about that number until you get the AI in check, then the pressure setting can be tweaked to improve the AHI to a number less than 5.0

For the record, I'm in my fifth week of therapy and run an Autostart II at 14.2 - 18 pressure with no ramp/settling and EPR set to 1. Last night, my numbers were:

Pressure: 16.2
AI : 0.1
AHI: 3.4
Leak Rate: .022

I used to get up four or five times a night to pee, every night ........ now I sleep solidly right through the night. My point is, if you can get your pressure settings correct and keep your leak rate down, you'll probably enjoy uninterrupted, restful sleep and who could ask for more than that?

Paul

[rested gal]

Thanks hose head and rested gal. That seemed to work. The readings from last night are:
Press: no data
leak: 0.14L/S
AHI: 19.7
AI: 9.0
HI 10.7

I'll have to research what they mean.

I could be wrong, but the way I'd regard those numbers is...

leak: 0.14 L/s (liters per second) looks great to me. Ideal leak rate with a ResMed machine is 0.0 L/s because ResMed machines already account for the built-in normal mask exhaust vent "leak." That calculation is already figured from back when you chose a mask in the mask setting menu. As long as the leak rate does not get above 0.40 L/s the machine's motor can compensate by blowing harder, to keep the pressure up where it's supposed to be. I'd consider any leak rate that was not running more than .20 or .25 L/s with a ResMed machine to be fine.

AHI: 19.7 is very high to me. AHI is "Apnea/Hypopnea index" -- the average number of events per hour that happened despite treatment. It doesn't mean that a total of 19.7 apneas and hypopneas happened during the night. It means that that many apneas and hypopneas happened on average PER HOUR. That's a lot.

AHI is figured this way: Total number of events divided by number of hours slept. That gives the "average" number of events per hour...the AHI. A person could have several hours of few (or even no) apneas or hypopneas, and some hours with the bulk of them occuring then. Apneas are usually most likely to happen when people sleep on their back, or when in REM ("rapid eye movement" -- dreaming) sleep. Being in REM and on one's back is generally the worst case scenario for apneas to hit.

Here's a link to how an MIT professor kindly and patiently explained to extremely-math-challenged-me how to figure AHI! 'Cause we don't always sleep an even number of hours...it might be 7 hours and 38 minutes.
Derek explains how to figure AHI:
viewtopic.php?p=9427

Hey Rested One,
If you have a calculator, divide the number of minutes by 60 to give you the fraction of an hour, Using the example of 38 minutes -
38/60 = 0.633
so that if you slept for 7 hours 38 minutes that's 7.633 hours.

The AHI is reporting events (averaged per hour) that happened despite treatment. I'd want that number much lower. So, I'd look next at the AI (apnea index) and the HI (hypopnea index) to see which type of events caused that total AHI to be so high.

AI: 9.0 The Apnea Index. The average number of apneas that sneaked through per hour. An average of 9 per hour is a lot more apneas than I'd want. I'd want the apnea index to be 0.0 ideally, or at least no more than 1.something. To bring that number down, I'd be thinking about raising the prescribed pressure 1 or 2, or as much as 3 full cms higher. If raising the prescribed pressure brought the apnea index down, I'd figure the sleep study titration missed finding the best pressure for me.

Or.... I'd figure that the study titration was right, but if I were now using EPR at home, it could be that EPR was allowing a subtherapeutic pressure to be in place at the end of my exhalations, allowing my airway to collapse after exhalation and preventing me from being able to get the next inhalation started.

In order to continue using EPR for comfortable exhaling, I'd raise the prescribed pressure 1, or 2, or 3 cms.

My thoughts (just opinion..I'm not a doctor) about EPR:

Nov 2008
viewtopic/t35923/viewtopic.php?p=310021#p310021

Aug 2008
viewtopic.php?p=289264#p289264

Oct 2006
viewtopic/t14479/viewtopic.php?p=121621#p121621

Oct 2006
viewtopic/t14479/viewtopic.php?p=121625#p121625

Dec 2007
viewtopic.php?p=231782#p231782


If raising the pressure didn't bring the apnea index down, I'd start wondering, "Hmmm... maybe "Complex Sleep Disordered Breathing?" and want to discuss that possibility with the doctor.

HI 10.7 The Hypopnea Index. The average number of hypopneas per hour that sneaked through. I wouldn't be particularly concerned about the HI at this point. I mentally cut the Hypopnea Index number in half when using a ResMed machine, if I'm going to be comparing my numbers with those from other brands of machines I've used. Each manufacturer uses their own definitions for "hypopnea", and I've found that ResMed machine report two or three times as many "hypopneas" for me as other brands do.

That doesn't mean one brand is "right" and another brand is "wrong" about recording an event as an hypopnea, or not. It's simply a difference in the arbitrary definition for "hypopnea" that each use in the algorithms designed into their own machines. To get a taste of the difference in the manufacturers' definitions, see Velbor's cool chart:
viewtopic.php?p=353046#p353046

While the number of apneas will probably be about the same, the total number of hypopneas can be considerably different, depending on what brand machine a person is using. I invariably see a much higher "HI" (hypopnea index) reported by ResMed machines for my own data, when I switch back and forth between Respironics machines and ResMed machines. So, I mentally cut the ResMed HI in half. My "HI" reports are about the same from brand to brand then.

I wouldn't worry much about an HI that was even as much as 12, when reported by a ResMed machine. I'd consider a ResMed HI of 12 to be "6" in my own mind. I'd be comparing the ResMed "HI" to the what I usually get at the same settings, same mask, same separate humidifier, etc. with a Respironics machine.

With a ResMed machine, I'd look mainly at the APNEA INDEX (the AI, not the AHI) and I'd look at the leak figure. If the AI was very, very, very low, and the leak rate was below 0.25, and the reported HI was not more than 10 or 12, I'd figure my treatment was going very well.

Unless a ResMed machine were reporting an HI of 15 or more (I'd worry about that, then) I'd pretty much disregard the HI -- and I'd disregard the AHI, since the HI gets added into the AHI. Or I'd mentally cut the HI in half and then add that to the AI to come up with my own version of the AHI.

Bottom line -- I'd raise the pressure at least a cm or two, as Paul suggested.

Anywayyyy... all that is just my opinion. I'm not a doctor or anything in the health care field.

[Uncle_Bob]

I would DEFINITELY fight for the AUTO machine. I had to for mine with both my sleep doc and Apria. Both wanted to give me just a straight CPAP machine. I didn't ask them, I TOLD them what I wanted. It's YOUR money and YOUR life at stake here so you have the right to get what you want. Just insist on it. Call higher up at Apria and your insurance if you need to. Give yourself all the advantages you can in your treatment.


Tracy

I wish i had done that orginally tracy. I'm not sure i can do it now, I already changed from a non data machine to the Elite II. I've also already told them i like it (after renting it for 1 month) so i have it on as a purchase now through my insurance, this is before i even knew about APAP machines.

I have an appointment with the sleep doc (who has interest in on site DME) next tuesday. The fist time i mentioned APAP he said has seen much more success with the CPAP and he didn't really like the APAP.

So my plan is to bring it up again but i'm sure he will just ask why and point out that i'm on the right track and tell me to chill out relax and i'll get there etc etc.

I think i might be lucky to at least get him to change my script to APAP. My insurance covers a new machine every 3 years so i could potentially get one then.

[baldbaby]

I took my download to the DME, he read it and agreed the apnea numbers were high and the leak rate acceptably low. I've been using the nasal pillows and am not totally comfortable with them. They seem to require a lot of fiddling to get right. It's not that they leak but they seem restrictive on the air flow. I'm wondering if that has something to do with my high apnea numbers. I'm going to try a nasal mask and see if things change.

I've noticed something strange when I started using CPAP. Seems like I have to consciously make myself breathe when I put it on. I've caught myself just not inhaling when I'm in that semiconscious state. I wonder is there's a psychological effect of the CPAP that’s messing up my normal breathing signals. I know I've stopped breathing while sleeping because of what my wife says but I don't remember it happening when I'm in this pseudo-conscious state. I hope I don't have central apnea.

[spitintheocean]

Do you know what your pressure is set at? It sounds like you do have ramp/settling activated; perhaps your pressure is so low, you just don't need that feature turned on.

Paul

[SharkBait]

I took my download to the DME, he read it and agreed the apnea numbers were high and the leak rate acceptably low. I've been using the nasal pillows and am not totally comfortable with them. They seem to require a lot of fiddling to get right. It's not that they leak but they seem restrictive on the air flow. I'm wondering if that has something to do with my high apnea numbers. I'm going to try a nasal mask and see if things change.

I've noticed something strange when I started using CPAP. Seems like I have to consciously make myself breathe when I put it on. I've caught myself just not inhaling when I'm in that semiconscious state. I wonder is there's a psychological effect of the CPAP that’s messing up my normal breathing signals. I know I've stopped breathing while sleeping because of what my wife says but I don't remember it happening when I'm in this pseudo-conscious state. I hope I don't have central apnea.

Are you using the Swift LT's (it would be helpful to fill out all of your equipment...). The "swivel" on those makes a big difference in the amount of air getting thru... If you're not getting enough air, you might give the Nasal Aire II a try. Those cannulas don't mess around. You get the air...

[baldbaby]

I switched masks last night from the Swift LT pillows to a Resmed Micro Mirage. It was a little more uncomfortable on the face but provided a better no-hassle fit. My numbers from last night were still not that great but different:

pressure leak AHI AI HI EPR
nasal pillows 6.0 0.14L/S 19.7 9.0 10.7 ON
mirage micro 6.0 0.04L/S 18.8 4.5 14.3 ON

So my total is about the same but less apneas and more hypopneas.

I'm hesitant to change my pressure on my own or it might confuse the doctor when I go back and he might yell at me.

I'd like to know what my O2 is doing during the night. Does anyone know of an inexpensive oximeter with a USB or serial port, or even with a min/max memory in it so I can see how low my O2 is getting during the night?

Maybe something like this? http://www.semedicalsupply.com/cms-50e.htm

[Wulfman]

I switched masks last night from the Swift LT pillows to a Resmed Micro Mirage. It was a little more uncomfortable on the face but provided a better no-hassle fit. My numbers from last night were still not that great but different:

pressure leak AHI AI HI EPR
nasal pillows 6.0 0.14L/S 19.7 9.0 10.7 ON
mirage micro 6.0 0.04L/S 18.8 4.5 14.3 ON

So my total is about the same but less apneas and more hypopneas.

I'm hesitant to change my pressure on my own or it might confuse the doctor when I go back and he might yell at me.

I'd like to know what my O2 is doing during the night. Does anyone know of an inexpensive oximeter with a USB or serial port, or even with a min/max memory in it so I can see how low my O2 is getting during the night?

Maybe something like this? http://www.semedicalsupply.com/cms-50e.htm

Seems to me like this is YOUR therapy.....not his.

He should be able to prescribe an overnight pulse-oximetry study.....they're free. He writes the prescription and a local DME will give you a recording pulse-oximeter to wear overnight. Then you take it back and they download the results into a report that you and the doctor should be able to determine what's happening.

Den

[baldbaby]

Wulfman,

I think that could be done but it probably takes a vist to him. I guess one thing is that I don't really like the doctor that much and am wondering if I could just dial in my machine and take him out of the loop. I wouldn't be surprised if he'd want me to go in for another sleep study. I've already spent 2 nights there and this stuff gets expensive even with insurance.