Have hi-end CPAP, considering a backup APAP

mister_hose · Post by **mister_hose** » Thu Aug 03, 2006 9:10 am

Hey folks. I have the REMstar Pro M-Series, which is a CPAP but with the same detailed data recording as an APAP. My prescribed pressure CPAP pressure is 13cm. It's rented from my local DME, and will probably eventually be "bought", or however they handle that sort of thing.

I'm considering picking up the REMstar Auto M-Series from cpap.com as a backup machine, entirely on my own. A doctor friend of mine will write the necessary script. The purpose would be to have multiple redundancy (two machines) in case one has a problem, and also to play around with the APAP mode and see if it gives me some extra insight into my condition and treatment. Not that I really NEED it desperately, since I'm running about 3.0 AHI now, and with system leak of around 46-48 L/min when my mask's inherent leak ("bias flow") is 44 L/min at my prescribed pressure. Seems my current rig is working well, but I'm a tinkerer, and I'd like to see if I can improve things a little more. Heck, why not?

In particular, I'm thinking of using the APAP mode with the lower limit set at 13cm (my prescribed CPAP pressure) and the upper limit higher, maybe 16cm, 18cm or even 20cm. The idea is that it can't work any less effectively than CPAP at 13cm, yet will have the extra power to clear infrequent, more challenging apneas.

However, I think I heard that having pressure too high can cause central apneas, which would naturally be bad. But wouldn't the APAP be smart enough to avoid this, and back off the pressure if it starts seeing centrals? Wouldn't it only kick up the pressure when it's truly necessary, not when it's harmful?

I'm thinking of getting the bundle from cpap.com that includes the M-Series Auto, the M-series humidifier, the software and the card reader. This would be nice because I need the software anyway because my current Pro records detailed data.

The $950-ish price isn't a problem for me, at all. What do you guys think about doing this? Do you think it's worthwhile, or would simply paying $170 for the software and card reader be a better idea? Opinions? I'm really inclined to get the whole shebang, for multiple redundancy, flexibility (APAP can accomodate differences from the situation on your titration night, including weight gain/loss, position changes, etc., and APAP can be set to CPAP mode), and insight (let's see what pressures APAP thought I needed last night!). But I'd like to get your opinion, guys.

Thanks!

inacpapfog · Post by **inacpapfog** » Thu Aug 03, 2006 9:14 am

With money not being a problem, why not go ahead and purchase an auto ?Then, you are able to monitor your pressure need variences and related sleep patterens! Go for it!

oldgearhead · Post by **oldgearhead** » Thu Aug 03, 2006 9:14 am

Unless you can get a better deal buying it all at once, I would buy the software first to get baseline info on how your treatment is working..

mister_hose · Post by **mister_hose** » Thu Aug 03, 2006 9:24 am

I'm tempted, I really am. Oh, another thing, will my Fischer and Paykel HC431 full-face mask work with the REMstar Auto? I remember somebody saying it doesn't give proper "feedback" to the Auto. Someone here recently reassured me it was fine with the Pro (for data recording purposes), but what about the Auto (for data recording and pressure decision purposes?) I don't want to buy a shiny new Auto only to have the mask's bad feedback cause it to peg at the max or min pressure constantly, or suffer other problems. Anybody successfully using a REMstar Auto with an F&P HC431 FF mask?

And I'm still wondering about the possible/potential "causing centrals" aspect of pressures above my prescribed 13cm. Is the Auto smart enough to keep that from being a problem? That has me hesitating, but on the other hand, thinking that 4 hours of sleep in a strange lab room in a strange bed with strange pillows is going to ACCURATELY titrate me to what I need in my bedroom is a little silly... that's why I like the APAP 13-20cm idea. (Since I don't mind 13cm continuous, there's no need to drop below it and possibly miss "fast-onset" apneas).

Decisions, decisions... =)

oldgearhead · Post by **oldgearhead** » Thu Aug 03, 2006 9:46 am

With the auto, and software, you should be able to answer all of your questions...

-SWS · Post by **-SWS** » Thu Aug 03, 2006 10:04 am

PAP-machine central apnea induction is thought to be pretty rare. And for the most part autoPAP algorithms take great care not to exceed central-apnea related thresholds. AutoPAPs don't treat central apneas, rather they go out of their way, algorithmically, to avoid inducing them.

With that said, anyone who is known to have a primary case of central apneas should avoid basic-model autoPAPs in my honest opinion. By "primary central apneas" I mean not just the usual incidental low numbers of central apneas that most of us experience, and not machine induced either. But a true apnea etiology that is central or mixed versus purely obstructive. Additionally, those very rare individuals who experience machine-induced central apneas are better off avoiding autoPAPs as well.

My advice is to go for it! You may be pleasantly surprised as I was and discover that you sleep at least a little better with autoPAP than CPAP. However, there are plenty with PAP machine preferences and needs that are the exact opposite of mine. Good luck, mister_hose!

mister_hose · Post by **mister_hose** » Thu Aug 03, 2006 11:26 am

-SWS wrote:PAP-machine central apnea induction is thought to be pretty rare. And for the most part autoPAP algorithms take great care not to exceed central-apnea related thresholds. AutoPAPs don't treat central apneas, rather they go out of their way, algorithmically, to avoid inducing them.

Okay, cool, so I should be okay. Neither sleep study technician nor sleep doctor ever mentioned the word "central" or "mixed" to me, so I'm assuming I have plain old typical OSA.

-SWS wrote:With that said, anyone who is known to have a primary case of central apneas should avoid basic-model autoPAPs in my honest opinion. By "primary central apneas" I mean not just the usual incidental low numbers of central apneas that most of us experience, and not machine induced either. But a true apnea etiology that is central or mixed versus purely obstructive. Additionally, those very rare individuals who experience machine-induced central apneas are better off avoiding autoPAPs as well.

Okay, so my pal, who was diagnosed as mixed (80% obstructive, 20% central) probably should either forget buying an APAP, or talk with a doctor. He doesn't have health insurance, which would make talking with a doctor problematical.... so perhaps he ought to skip the APAP altogether for now and stick with CPAP until he has health insurance again and can chat with a doctor (which should be soon).

-SWS wrote:My advice is to go for it! You may be pleasantly surprised as I was and discover that you sleep at least a little better with autoPAP than CPAP.

I think I will, thanks! And if I hate APAP, I just turn it into a second, backup CPAP unit, just like my REMstar M-Series Pro. Hard to lose, when you consider that. The AHI data should tell the story about which mode to use, making it relatively easy, too.

Has anyone else moved from CPAP at X cm to APAP at X cm to >X cm? If so, what were your results? I may post a separate thread on this, to make it more visible, if I don't get enough feedback this way... this is important to me. I suspect it'll work as well or better than CPAP at X cm, but I'd like more opinions. =)

Thanks all!

Wulfman · Post by **Wulfman** » Thu Aug 03, 2006 12:07 pm

mister_hose wrote:Has anyone else moved from CPAP at X cm to APAP at X cm to >X cm? If so, what were your results? I may post a separate thread on this, to make it more visible, if I don't get enough feedback this way... this is important to me. I suspect it'll work as well or better than CPAP at X cm, but I'd like more opinions. =)

Yep! Used my REMstar Auto at a range of 10 to 15 for a week and then went back to CPAP at 10. For various reasons, I do better on a single pressure.
But, I'm still glad that I have the ability to try different things.

Best wishes,

Den

snoregirl · Post by **snoregirl** » Thu Aug 03, 2006 12:27 pm

I went from 13 cm on a Remstar Pro to my Remstar Auto 10 - 15. I have software but am waiting to make the compliance so the insurance will buy before I set it up.

I just don't want to risk pulling out and in the card wrong and mess up the data and have them deny purchase, so I can't say exactly how I am doing with data yet.

But I do know I spend lots more time at 10 than 13 and for me that is good. Less pressure on my poor ears (hearing is worse since starting all forms xpap but I would never give it up since I feel soooo much better). Seems to plug up my ears due to pressure and by the time it is getting better it is time to go to bed again!

I can easily tell without looking (from the feel of the exaust on my swift on a hand) if I am at 10 or 13.

mister_hose · Post by **mister_hose** » Thu Aug 03, 2006 12:40 pm

snoregirl wrote:I went from 13 cm on a Remstar Pro to my Remstar Auto 10 - 15. I have software but am waiting to make the compliance so the insurance will buy before I set it up.

I just don't want to risk pulling out and in the card wrong and mess up the data and have them deny purchase, so I can't say exactly how I am doing with data yet.

Hmmm, how does this work? Looked at my forms last night that came with my REMstar Pro, and there was a section for "compliance achieved" or something (not yet filled in, as I got the form on the same day as the machine), and the "Rented" checkbox was checked, not the "Purchased" one.

Do I have to use it a certain percentage of the time before the insurance company will buy it for me? I never knew this...

Oh, and thanks for the info, Den!

Wulfman · Post by **Wulfman** » Thu Aug 03, 2006 12:47 pm

You might want to check with your insurance provider to see what they're doing in regard to your rental/purchase contract......just to make sure. There are any number of options and length of time on these contracts

Sounds like you're renting.....but for how long?....and when is it considered paid for?

Den

mister_hose · Post by **mister_hose** » Thu Aug 03, 2006 12:59 pm

Will check, Den, thanks. And I'll hold off on my independent purchase of an APAP until I'm sure I "own" the insurance-provided CPAP. Otherwise every night I spend on my self-bought APAP will hurt the compliance data on the insurance-provided CPAP unit, and possibly cause me problems in getting to "keep" it. I'll just use the CPAP exclusively until I'm sure I own it, then get the APAP with my own money, as planned.

Thanks!

-SWS · Post by **-SWS** » Thu Aug 03, 2006 6:08 pm

mister_hose wrote:Okay, so my pal, who was diagnosed as mixed (80% obstructive, 20% central) probably should either forget buying an APAP, or talk with a doctor. He doesn't have health insurance, which would make talking with a doctor problematical.... so perhaps he ought to skip the APAP altogether for now and stick with CPAP until he has health insurance again and can chat with a doctor (which should be soon).

Talking with a very good sleep doctor is a good bet with an 80% 20% mix, IMHO. The doctor may want your friend on one of the various BiLevel platforms, which unfortunately is more expensive than either CPAP or basic AutoPAP. If the doctor determines that CPAP is okay for your friend, then that friend may still favor trying AutoPAP, on the chance their 80% 20% mix is well treated by AutoPAP (420e would be my personal first APAP choice to try with an 80% 20% mix). Again, that friend can always revert their AutoPAP back to fixed pressure while still collecting sleep data.

Snoredog · Post by **Snoredog** » Thu Aug 03, 2006 6:52 pm

script: you don't need any special script for purchasing an autopap. You can use the same one your DME got for current CPAP machine, that is if you have a copy of it. Just order the machine you want and fax over a copy of your original script.

Centrals: It is true too high a pressure can trigger/induce central apnea and central hypopnea. If you are prone to those events they should have shown up on your original PSG as CA or MA events. There is NO cut n dried set percentages, you can have a dozen or only 1 or 2. If the PSG shows none, then don't worry about it. However, if they were seen, you need to be aware of that and you can easily avoid them by setting up the autopap correctly. I think the autopap actually does a better job avoiding them by use of lower pressure. It is only a problem when people incorrectly set up their autopap with pressure ranges well above their known titration pressure.

Pressure: The pressure found in the sleep lab (think you said it was 13cm) should be the Max. pressure setting set on the autopap, NOT the Minimum pressure. The only time you should exceed that pressure is when you suspect that the current pressure is possibly not high enough. Then you only by increase it 1 to 2cm over your last titration (from 13cm to 15cm) to see if that is truly the case.

Your Min. pressure can be anything from 4cm to the 13cm value. When you turn on the autopap it will start at the Min. pressure then increase up to the Max. pressure (if needed). Default Min. pressure is 4cm from the factory but that is too low for most people, so starting off at 5 or 6cm is a better Min. pressure.

If you set it at 13cm same as the Max. pressure it becomes a cpap machine. There are modes you can set different pressures and then just switch modes on the autopap. It is also very easy to see central apnea if you have the reporting software. Applying some common sense can easily avoid those, if you increase pressure and the numbers don't go down then you decrease pressure.

Spare/Backup machine: I think it is a GOOD idea to have a backup machine.
If that machine is a autopap all more the better. For example if you camp and get campfire smoke in your primary machine you are pretty much hosed when you get home as it is very hard to get that out of the machine. Having a spare machine and leaving your primary machine at home you know when you get home your main machine will be there ready to go. With the software, you can also use the autopap to find your ideal pressure then use it to set the pressure on the cpap machine. I have had some machines go bad, but for the most part they are very reliable, I haven't had any problems with any of the 5 or so Remstars I have owned.

I think the M series Remstar Auto is an excellent choice. You will get the setup manual card instructions so you can program it yourself, they are very easy to program from the LCD.