titration=10cm how to justify apap?

[flylow]

I know I want to be in control of my therapy but with a titration of 10, straight cpap will probably work best (my guess).

Of course I have no idea of how accurate the titration is as I have not seen the report. I do want an apap so I can be in control and have the flexibility to change if desired or needed. I need the collective wisdom and experience of this group so that I can make that happen. Advise is greatly appreciated.

I briefly spoke with the sleep doc on the cell phone while I was driving so I couldn't get into details especially since I don't yet have the report so I am working on getting the report now and to have a discussion with the sleep doc. It would be best to be armed at that point to get what I want. Thanks in advance.

[blarg]

If it were me, I wouldn't bother trying to get an APAP out of your insurance. I'd just go to CPAP.com and send them my CPAP scrip while ordering an APAP. They'll do that no problem.

To me it's not worth that much of my time/heartache/frustration to argue with people. Certainly it won't hurt to say, "I want to be in control of my own therapy, and I want to be involved. I therefore want to have an APAP so I can track the changes and stay current. If it takes much more than that (and your doctor is less than excited that you want control) then that's about all you need to know.

My doctor was decent about it, and while there was a little bit of telling people what I wanted, that's about as rough as it should get.

[DreamStalker]

Blarg is absolutely right.

I too initially thought ... well dangit, I paid insurance premiums and therefore insurnace should pay the 80% as agreed to. What I did not know is that the price structure is set up so that you end up saving a lot less than 80% when you consider how much it costs to buy straight out of pocket from an online vendor (and CPAP.com is very competitive online).

So you pay a little more to save the frustration of dealing with an uncooperative DME or sleep doc ... I too think it is worth it.

From another perspective ... how much was the last television that you bought?

Did insurance help pay for that? Does the TV help prevent heart attack and strokes and allow you to sleep and feel rested?

It's all a matter of priority. Is the cost for the best PAP equipment worth more than the last TV you bought? Is the cost of fighting with uncooperative health industry worth more than the additional cost of buying online?

[flylow]

I have 90% coverage so I would like to go with the insurance. I guess I will see where the discussions go and keep an open mind. It is well worth the argument since we are talking the better part of nearly $1,000. I shouldn't have any trouble convincing my family doc to write the scrip as needed if the sleep doc won't.

[ZZZCPAPZZZ]

Where did you get the $1000 figure, cpap.com charges $579 for a REMstar M Auto with Aflex. I just purchased one from them and I believe it is one of the best Auto machines on the market, but that is only my opnion.

[Guest]

You can still be in control of your therapy on straight pressure if you have a machine that records nightly details......apneas, hypopneas, snores, leaks, etc.

An APAP is not necessarily the "end all - be all". If you get the REMstar M Series Pro, from your DME, it'll tell you what you need to know. Most people do just fine (or better) on straight pressure. With a machine that reports data, you can still tweak your pressure for best results. AND, it'll probably be much easier to get through your insurance, too.
Don't let them just hand you a "Plus" machine that doesn't record stats.

Den

[rested gal]

You can still be in control of your therapy on straight pressure if you have a machine that records nightly details......apneas, hypopneas, snores, leaks, etc.

An APAP is not necessarily the "end all - be all". If you get the REMstar M Series Pro, from your DME, it'll tell you what you need to know. Most people do just fine (or better) on straight pressure. With a machine that reports data, you can still tweak your pressure for best results. AND, it'll probably be much easier to get through your insurance, too.
Don't let them just hand you a "Plus" machine that doesn't record stats.

Den

Den's right. Don't settle for a machine with "Plus" in its name.

One of the many nice things about getting an autopap is that it's like owning two machines in one. You can always set an autopap to operate in straight cpap mode if that suits you better. Very versatile.

[Babette]

I told my doctor that I'd already lost 6 pounds since starting therapy, planned to lose more, and was tweaking my asthma/allergy meds. I told her I wanted to be able to adjust my pressure, as needed, and to occasionally auto-titrate, as changes occurred to my body. She totally understood, and was very happy to write me the scrip, and even offered to argue with the insurance about it, if I needed her to.

I did tell her I would find a qualified RT to read my card, and download reports, and bring her the reports for evaluation. I did not mention that the RT was a hottie I met online on a cpap users forum... Nor did I mention that I would be buying my own card reader and software and looking at my own reports...

I'm very very very lucky!!!! But before that conversation, I downloaded a letter posted here, and wrote up a very large proposal to her about why I wanted an APAP. Turned out I never took it out of my bag.

I then took the scrip and bought what I wanted from cpap.com. I then submitted a claim to my insurance. I haven't heard anything from them yet, but I'm going to give them a little more time before I start badgering them, and sicking the doc on them.

Good luck!!!
B.

[flylow]

[quote="ZZZCPAPZZZ"]Where did you get the $1000 figure, cpap.com charges $579 for a REMstar M Auto with Aflex. I just purchased one from them and I believe it is one of the best Auto machines on the market, but that is only my opnion.

[DreamStalker]

Where did you get the $1000 figure, cpap.com charges $579 for a REMstar M Auto with Aflex. I just purchased one from them and I believe it is one of the best Auto machines on the market, but that is only my opnion.

worst case scenario with humidifier and dme inflated prices... actually could be more.

I agree that straight cpap may be best but apap gives me the flexibility. Looking at the report, I can probably run auto reigned in from 8 to 10 and do fine but spend most of my time at the lower and more comfortable pressure.

huh?

The REMstar M Auto with Aflex is an APAP ... w/ HH is still well under $1000 if you get online.

[sleepinginseattle]

I agree that straight cpap may be best but apap gives me the flexibility. Looking at the report, I can probably run auto reigned in from 8 to 10 and do fine but spend most of my time at the lower and more comfortable pressure.

I think the APAP run at 8-10 would be a waste of money. You can always change the pressure on the CPAP (but IMHO you should only do so in consultation with your doctor). As far as lower pressure being more comfortable. That's a big unknown. All these machines have ramp functions that bring pressure up gradually and get most people comfortable at lower pressures. And when you're asleep? I'd rather know my pressure was set to the prescribed pressure that controls all my events. (Please don't flame me about titration errors, I'm sure they exist but I don't think you'll find any consensus outside of this forum.)

APAPs do adjust for "events" but rely on a variety of algorithms and the sound of snoring. This adjustment takes time and doesn't always offer an effective treatment. As one study of five APAP machines noted: "All apnoeas were suppressed, whilst the reaction to repetitive hypopnoeas was dependent on the airflow shape. In some devices, repetitive hypopnoeas were changed to flow limitation. Artificial snoring caused a pressure increase in four devices, and constant mask leak was not systematically compensated. Only one device did not raise pressure in response to central apnoeas with opened upper airways. These findings show that, in some devices, event classification failed and normal airflow was not fully restored, resulting in elevated residual event indices."

Pretty technical stuff, but I think you'll find that the research into the effectiveness of APAP therapy is inconclusive.

A Respironics M Series Auto A-PAP with heated humidifier runs $694 on the commercial side of this site. A Respironics Remstar Pro2 CPAP with heated humidifier runs runs $540. Both have event recording with Encore Pro smart cards.

Wouldn't the $150 savings be nice for testing additional masks which may be a bigger factor in your therapy than the machine itself?

Just my $.02.

[Guest]

I know I want to be in control of my therapy but with a titration of 10, straight cpap will probably work best (my guess).

Of course I have no idea of how accurate the titration is as I have not seen the report. I do want an apap so I can be in control and have the flexibility to change if desired or needed. I need the collective wisdom and experience of this group so that I can make that happen. Advise is greatly appreciated.

I briefly spoke with the sleep doc on the cell phone while I was driving so I couldn't get into details especially since I don't yet have the report so I am working on getting the report now and to have a discussion with the sleep doc. It would be best to be armed at that point to get what I want. Thanks in advance.

worst case scenario with humidifier and dme inflated prices... actually could be more.

I agree that straight cpap may be best but apap gives me the flexibility. Looking at the report, I can probably run auto reigned in from 8 to 10 and do fine but spend most of my time at the lower and more comfortable pressure.

Is insurance paying or are you buying out of pocket?
If you're also going through a local DME, you can probably not count on an APAP/Auto......which was the logic behind my first post in this thread.

I agree that an Auto is a more versatile machine.....I have 2 of them, myself (and a Pro 2).....but run them all at single pressure.
And, if you're going to run an APAP in a 2 or 3 cm. range of pressure.....why bother with Auto settings? A setting of 8 or 10 isn't that much difference. If you snore, I can guarantee it's probably going to be changing pressure often.....or else go to 10 and stay there. That's one of the main reasons I decided against an Auto in the beginning.....chasing my snoring. My subsequent trials with my autos confirmed it.

What gives you the "flexibility" is the software......to tell you how you're doing.

Den

[ozij]

Please don't flame me about titration errors, I'm sure they exist but I don't think you'll find any consensus outside of this forum

.

This forum is where many of those who want their therapy to succeed arrive when they find nothing on the "outside" you seem to represent.

The others, those 50% non-compliers with cpap therapy are not here. Neither they nor their doctors know if their non-compliance was a result of titration error, or improper support in getting into the therapy.

Let me sugges a simple operational definition of titration error: Any kind of titration that does not result in 100% compliance and a significant improvement in how a person feels is a titration error.

The right kind of titration is the one that
1. Helps the patient comply
2. Can be a basis for going to higher pressure if that is necessary to get rid of apneas.

Some of the medical community's consensus about titration is still stuck in the tracheotomy days: You do it once, and then the patient has the solution.

And, when the perscribed therapy doesn't work, blame the non-compliant patient.

There have been a few papers showing that compliance is better when patients have more support. Most of us here have not experienced it.

Unlike human psychology, which doesn't change through the years, technology does. The paper sleepingiseattle quotes was done on older technology, and - worst of all - it was not done with human beings. So, while it proves different machines have different reactions to simulation, it is meaningless as far as human beings are concerned.

Here's what happens when an automatic machine meets a human being:

http://meeting.chestjournal.org/cgi/con ... 8/4/223S-a

EMPIRIC TREATMENT OF CLINICALLY DIAGNOSED OBSTRUCTIVE SLEEP APNEA USING AUTO-TITRATING CONTINUOUS POSITIVE AIRWAY PRESSURE
Fitzgerald E. Drummond, MD*, Peter Doelken, MD and Michael D. Frye, MD
Medical University of South Carolina, Charleston, SC

PURPOSE: To evaluate the efficacy and safety of empiric auto-adjusting CPAP to treat suspected OSA in veterans awaiting polysomnography.

METHODS: Consecutive patients referred for polysomnography were screened. Exclusion criteria were: known OSA, risk of central apnea, insomnia, narcolepsy, or severe comorbid disease. Inclusion criteria were positive findings in two of the following three categories: severe snoring, daytime sleepiness, and either hypertension or BMI>30. Eligible subjects were seen in clinic and randomized either to treatment with auto-adjusting CPAP or to usual care at the VA. Subjects completed the FOSQ quality of life indicator and the Epworth sleepiness scale at the initial visit and again after 4 weeks.

RESULTS: 338 patients were screened. 58 patients met entry criteria and were enrolled. Of these, 39 have completed the initial and follow up questionnaires, 24 in the treatment group and 15 in the control group. The groups did not differ significantly at the start of the study. At follow up, the mean Epworth scores in the treatment and control groups were 11.67 and 15.13 respectively (p=0.01). The mean FOSQ scores in the treatment and control groups were 15.14 and 13.43 respectively (p=0.055). There was a statistically significant improvement in the Epworth scores of patients treated with auto-CPAP. A trend toward improvement in FOSQ was observed that did not reach statistical significance. There were no adverse events documented. One patient withdrew for reasons unrelated to the study.

CONCLUSION: These data suggest that auto-CPAP significantly improved the Epworth scores of veteran patients likely to have OSA while awaiting polysomnography. This is an encouraging finding and warrants continuation of this trial to its planned enrollment of 300 subjects.

CLINICAL IMPLICATIONS: While the prevalence of OSA in the veteran population is likely higher than in the general population, the waiting time for polysomnography can be long. These data suggest empiric treatment while awaiting a polysomnogram may be safe and effective in select patients.

My empahsis.

And here's some more info about titration accuracy from "outside this forum"

http://www.ncbi.nlm.nih.gov/sites/entre ... t=Citation

Respir Med. 2004 Feb;98(2):152-4. Related Articles, Links


Relative accuracy of algorithm-based prescription of nasal CPAP in OSA.

Stradling JR, Hardinge M, Paxton J, Smith DM.

Oxford Centre for Respiratory Medicine, Osler Chest Unit, Churchill Hospital, Oxford Radcliff Trust, University of Oxford, Oxford OX3 7LJ, UK. john.stradling@orh.nhs.uk

BACKGROUND: Patients with OSA on nasal continuous positive airway pressure (CPAP) have considerable night-to-night variation in their pressure requirements, suggesting that a one-night titration might not be very precise. This study investigates the likely error incurred using a one-night titration, and explores whether an algorithm-based approach to determine the pressure is as accurate. METHODS: Thirty patients with OSA used an autotitrating CPAP device for 28 nights and the average was regarded as the 'reference' pressure for that patient. Using estimates of precision and bias, this 'reference' pressure was compared with (1) an algorithm-derived pressure (based on neck circumference and OSA severity), (2) a one-night titration (using four alternative nights), and (3) a fixed pressure of 10 cmH2O. RESULTS: The mean 'reference' pressure for the group was 9.83 (SD 2.12) cmH2O. There was little bias from any of the alternatives. However, the precision varied between 1.65 and 2.45 cmH2O for the four one-night titrations, was 2.00 for the algorithm, and was 2.12 using a fixed pressure of 10 cmH2O. CONCLUSIONS: Considerable night-to-night variation means that a one-night titration is not very precise and is subject to random variation. A one-night titration has a similar inaccuracy to that resulting from using an algorithm, based on OSA severity and neck circumference. Setting all patients with OSA at 10 cmH2O is little worse.

My emphasis.


O.

[RosemaryB]

I do agree with Den that the FULLY DATA CAPABLE machines are the most important part of the treatment. I fought for an auto and got one from my DME. I have a DME that's not the worst, but not the best either. Today, I might want the A-flex machine, which has better pressure releif and only comes in apap machines. Respironics M Series with A-flex. The problem is that you never know if these features will help or not until you try them. Unfortunately there's no way to try a number of machines and then pick the one that works best for you. So, I think people want all the different features (like auto and aflex) in case they need them.

I don't snore, but did find after a couple of months that a straight pressure of 8.5 works best for me. Still glad I have the apap, though. If I ever lose or gain weight, it will make it easier to find an optimal pressure. It could be done with the straight cpap data capable machine, too. It just might be a bit more involved.

The main reason I went with a local DME is that I was able to find one that was decent in letting me try on a number of masks. I did get a good fitting mask and that's harder to do online unless you have a sleep lab that does mask fittings. You could get the fitting done there and then buy from cpap.com.

However, I get everything that my insurance won't pay for through cpap.com. They are great !

[DreamStalker]

Wouldn't the $150 savings be nice for testing additional masks which may be a bigger factor in your therapy than the machine itself?

Just my $.02.

Good point but there is another perspective ... Wouldn't the $150 be worth not having to go back and forth to the doctor or even worse, the sleep lab, until they get your correct pressure tweaked?