Correct Prescription based on these figures?

[Fitdiculous]

Not sure what to make of it as this is still very new to me.... I've been told by a few people that an auto machine (apap) is overkill for me. At this point I would like to get some opinion on more experienced people with OSA, and perhaps could give some advice. Here were my results for my first (and only so far) test and the sleep clinic:

- slept within 11.3 minutes and for 5 hours and 13 mins with efficency of 72.4% (normal: >than 80%)
- Stage 1 Sleep: 16.3% (normal: 4.44%)
- Stage 2 Sleep: 68.3% (normal: 45.54%)
- Stage 3 Sleep: 0.8% (normal: 6.21%)
- Stage 4 Sleep: 7.3% (normal 14.88%)
- REM Sleep: 7.3% (normal: 28.00%) and a REM sleep latency of 228 minutes (normal: 90 to 120 minutes)
- Had 2 REM periods and 58 awakenings during the night
- Had 275 obstructive apneas and no central apneas of which the duration of the longest event was 28.1 seconds
- Had 49 obstructive hypopneas of which the longest was 33.0 seconds in duration
- Gave an overall AHI of 62.0 per hour (normal: <5 per hour)
- AHI in supine position was 71.7 and 57.4 per hour in REM sleep
- mean blood oxygen saturation overnight was 94% and decreased to 88% during respiratory events
- Loud snoring observed overnight
- EKG showed normal sinus rhythm averaging 63.1 beats per min, no arrhythmia's observed
- 31 spontaneous arousals, 138 respiratory arousals and no periodic limb movement arousals giving an overall arousal index of 32.3/hour

I'm 29 years old, 5'9" and weigh 196 lbs... the Rx was 7cm, and my question is, is that enough? how/where do they base that number? I have been diagnosed with SEVERE OSA, and seen different ranges of pressures for different people and noticed as well machines go up to 20? I'm "wanting" an auto machine since I tend to move around a lot in my sleep, but have to jump through hoops here in Ontario to get any type of coverage/support to even get one ... do I NEED one? or are these figures not enough to tell? Any help would be greatly appreciated! this has been such a frustrating experience... both at the sleep clinic and with the DME. Sorry for the long post as well, I wanted to be as detailed as possible.

TITRATION RESULTS POSTED ON SECOND PAGE

[jules]

were you put on the machine during the sleep test? (the calibration is called titration)

if so what was the result of that part?

if not, then is this the standard procedure used by this lab until such time a titration is done (and when will it occur?)

the pressure is what you need - not based on severity - you need to go back and ask them how they decided on 7 and what is the next step.

you will have problems getting an APAP in Ontario based on other ppl's stories - it can be done but you have many hoops to jump through to get there

[roster]

I always maintain that it is important to get a machine with full data capability, a card reader, and the machine software. Then you can check daily at home under your normal sleeping conditions whether the pressure is correct or not.

[Hose_Head]

Not sure what to make of it as this is still very new to me.... I've been told by a few people that an auto machine (apap) is overkill for me. At this point I would like to get some opinion on more experienced people with OSA, and perhaps could give some advice.

Here's the trick. No matter what they do, DON'T BUY ANY MACHINE UNTIL AFTER YOUR TITRATION STUDY.

My experience in Ontario is that the titration study (a second sleep study while using an auto pap in the sleep lab) will be about a month after your first sleep study. Until then, your sleep doctor has given you a temporary Rx with a pressure of 7 cm h20 (just a guess on his part) to get you started. ( I don't know why your doctor hasn't explained this to you; mine didn't, either) The DME then can give you a loaner-cpap set at that pressure. The idea is to allow you to use and get used to the cpap so that during your titration study, you will be less likely to be fighting the mask, rather than sleeping through the titration study.

The DME will give you a loaner cpap for this purpose. From experience, the DME also will try to get you to buy a cpap after a week or two and quite likely before your titration study. Don't buy it. Try to get them to continue with the loan, instead.

You cannot tell whether you need or would qualify for an auto pap until after you've had your titration study. And you won't even know the results of the titration study until you've seen your doctor to go over the results (perhaps a week or two after the study). So ask your DME and/or your doctor to allow you to stay on a loaner cpap until you've met with your doctor to determine your exact needs.

If your DME won't give you a loaner for this entire period, ask your doctor to find you a new DME, and tell him / her why you need a new one. Don't worry about the DME's desire not to give you an extended loaner. They're making huge profits on the xpap that eventually they will sell to you; those profits are supposed to cover this kind of overhead.

AFTER THE TITRATION STUDY, you will meet with your doctor to go over the results of the study. At that time, you can discuss with your doctor your needs and wants. You then will have opportunity to try to convince him of your need for an auto-pap. No matter what he decides, make sure that he gives you a detailed prescription, a letter that describes your need for xpap, and a copy of your sleep study. The detailed prescription should specify the type of machine (i.e. cpap, apap, bipap, or whatever), your pressure(s), and "mask of choice". The letter of need is something that you may need to take with you (a copy) when travelling, just in case some airline decides you don't need to carry your equipment on-board. The copy of your sleep study is something that belongs to you and you likely will want to refer back to it from time to time.

When you eventually buy your machine from the DME, the Rx will say it all to them. Just be certain that no matter what machine you get, make certain that it's fully data capable. If in doubt, post here for advice about the machine they want to sell you. Note that fully data capable means that the machine will collect more than just hours and dates of use (i.e. compliance data). Fully data capable machines also record apneas, leak data and a host of other information.

Good luck. You're asking the right questions!

[Fitdiculous]

were you put on the machine during the sleep test? (the calibration is called titration)

if so what was the result of that part?

if not, then is this the standard procedure used by this lab until such time a titration is done (and when will it occur?)

the pressure is what you need - not based on severity - you need to go back and ask them how they decided on 7 and what is the next step.

you will have problems getting an APAP in Ontario based on other ppl's stories - it can be done but you have many hoops to jump through to get there

no, have not had the first titration yet, only the very 1st sleep study to help diagnose the OSA.

My first titration is scheduled for June 8th (3 weeks), but I have yet to get a machine yet (will 3 weeks be long enough to get "used" to one?)

from the info that the sleep clinic told me it almost seemed like they didn't LIKE giving out prescriptions for apap's... like there was extra work involved or something???

[jules]

A lot of ppl don't get any kind of script in US until after the titration is done - getting a trial on a mask pre-titration would help many of them.

An APAP is Ontario needs a pressure over 10 I think I have read.

I think Hose_Head and other forum members from Ontario can be helpful in all the next steps.

[dsm]

Not sure what to make of it as this is still very new to me.... I've been told by a few people that an auto machine (apap) is overkill for me. At this point I would like to get some opinion on more experienced people with OSA, and perhaps could give some advice. Here were my results for my first (and only so far) test and the sleep clinic:

- slept within 11.3 minutes and for 5 hours and 13 mins with efficency of 72.4% (normal: >than 80%)
- Stage 1 Sleep: 16.3% (normal: 4.44%)
- Stage 2 Sleep: 68.3% (normal: 45.54%)
- Stage 3 Sleep: 0.8% (normal: 6.21%)
- Stage 4 Sleep: 7.3% (normal 14.88%)
- REM Sleep: 7.3% (normal: 28.00%) and a REM sleep latency of 228 minutes (normal: 90 to 120 minutes)
- Had 2 REM periods and 58 awakenings during the night
- Had 275 obstructive apneas and no central apneas of which the duration of the longest event was 28.1 seconds
- Had 49 obstructive hypopneas of which the longest was 33.0 seconds in duration
- Gave an overall AHI of 62.0 per hour (normal: <5 per hour)
- AHI in supine position was 71.7 and 57.4 per hour in REM sleep
- mean blood oxygen saturation overnight was 94% and decreased to 88% during respiratory events
- Loud snoring observed overnight
- EKG showed normal sinus rhythm averaging 63.1 beats per min, no arrhythmia's observed
- 31 spontaneous arousals, 138 respiratory arousals and no periodic limb movement arousals giving an overall arousal index of 32.3/hour

I'm 29 years old, 5'9" and weigh 196 lbs... the Rx was 7cm, and my question is, is that enough? how/where do they base that number? I have been diagnosed with SEVERE OSA, and seen different ranges of pressures for different people and noticed as well machines go up to 20? I'm "wanting" an auto machine since I tend to move around a lot in my sleep, but have to jump through hoops here in Ontario to get any type of coverage/support to even get one ... do I NEED one? or are these figures not enough to tell? Any help would be greatly appreciated! this has been such a frustrating experience... both at the sleep clinic and with the DME. Sorry for the long post as well, I wanted to be as detailed as possible.

Hmmmm,

Interesting. My 1st reaction is - sheesh - only 7 CMs to deal with an AHI over 60 !!!. But you don't seem excessively overweight (perhaps only a tad - having been heavier that that myself )

Yes, I would ask for an Auto - Just very hard to believe that 7 CMs can do anything but resuscitate a mouse (maybe a big mouse )

At least an Auto will help you validate hwere you spend most of the night (pressurewise).

Good luck

DSM

[Fitdiculous]

Hose_head: Thank you for your reply and in depth information... I never considered getting a loaner... I know the DME I went to said that they do have loaner's, but no apap loaners (or there is a ridiculous waiting list for one right now).

To clear something up though... you mentioned that DURING the 1st titration, I will be hooked up to an apap? and yes, that will be in 3 weeks from now (my original sleep test was Apr 13th). What if I can't get a loaner apap machine? should I just take a regular cpap loaner? I actually have been "borrowing" a very basic Fisher and Paykel cpap from a friend who cannot stand using it (funny he got his machine covered with ADP and Insurance, but was never fully diagnosed with OSA). His pressure setting is at 6, and I initially got used to it, but now find myself taking the mask off in the middle of the night and find it very uncomfortable.

What my DME had also mentioned was to buy a machine (I'm looking at the Resmed S8 Elite II Cpap) and to use that, and if required, can "upgrade" to an apap after (but they never confirmed ADP would cover more or the remaining balance, they just said I could). They just wrote a quote saying "Resmed Elite II CPAP machine with humidifier, w/ compliance package - $1410". The mask that I tried on (only one) was the Resmed Swift LT and they quoted $275 for that.

I just don't want to get a loaner from the DME I'm using for a couple of weeks, and like you said being FORCED to buy one before/shortly after my 1st titration study. I think the majority of the people that go through this clinic and have been diagnosed with OSA don't go on forums like this. They get "referred" to a DME, told that they should buy xpap, and that ADP will cover $780, and boom, all your problems go away (all without getting the "proper" machine and or mask)

So lets say I don't qualify for an apap, would you still suggest getting the cpap from the DME at insanely inflated prices? I heard that the machines sold at local DME's don't allow you to analyze the data (no software is provided?), that it's only for clinics and professionals?

I noticed that you have an apap... did this go through DME? did you have ADP support? again, I really appreciate your help!

[Fitdiculous]

Hmmmm,

Interesting. My 1st reaction is - sheesh - only 7 CMs to deal with an AHI over 60 !!!. But you don't seem excessively overweight (perhaps only a tad - having been heavier that that myself )

Yes, I would ask for an Auto - Just very hard to believe that 7 CMs can do anything but resuscitate a mouse (maybe a big mouse )

At least an Auto will help you validate hwere you spend most of the night (pressurewise).

Good luck

DSM

so 7 is just a guess or "safe" guideline for these doctors to use then huh? I wouldn't consider myself overweight by any means! I have gained weight over the last 4-5 years, but I like to attribute that to working out, at least a part of it ... I haven't changed in height since puberty, but I had always been struggling to gain weight up until 25-26 years old.... I was 155-160 soaking wet... but for the most part when I did start working out 4-6 times a week and just eating A LOT more, I slowly got to where I want... at least mass wise... could I lose a few lbs? sure, why not... but I certainly don't think it made/makes my OSA THAT much more bad. My Dr. said I've had OSA for a LONG time, probably since childhood, as it's due to the shape of my jaw, size of tongue and now obviously "looser" lower pallet. I don't doubt losing some weight will help, but at an AHI over 60, it SEEMS pretty bad

I just want the best machine I possibly can get... I'm not trying to "cheat" the system or anything like that... just looking out for my health

[ozij]

Having read Hose_Head's info, I would definitely wait till after the titration to find out which machine was recommended, and which machine I may want to fight for.

Getting used to a pressure of 7 before titration sounds like a wonderful idea.

Severity of OSA is not necessarily related to the pressure you may need to keep you airway open (patent). And you can be prescribed a fixed pressure machine at any pressure up to 20 - though it's not a good idea:
At pressures above 15 most people do better with a machine that gives them one pressure level for inhaling and another for exhaling (those are called BIPAP or BPAP or Bi-Level or VPAP) - they are distinctly more expensive.

An automatic machine varies the pressure for minutes at a time, based on its analysis of your needs - and some people do best with automatic bi-level machines.

Whoever told you an auto was an overkill for you was speaking from his own pocket - not from knowledge about your needs. You'll know your needs after the titration - and you will be able to base you requests on pertinent data then.

O.

[Fitdiculous]

ozji: Makes sense... there really is no way of telling until the titration is there? one thing question that I forgot ask, if they do provide loaner machines, will I have to purchase that specific mask? I doubt they have or give out "loaner" masks too? (sanitary reasons?) I wouldn't want to be stuck with $200++ mask the DME charges during this trial period...

[Hose_Head]

ozji: Makes sense... there really is no way of telling until the titration is there? one thing question that I forgot ask, if they do provide loaner machines, will I have to purchase that specific mask? I doubt they have or give out "loaner" masks too? (sanitary reasons?) I wouldn't want to be stuck with $200++ mask the DME charges during this trial period...

That's an excellent question. I wish I had a definitive answer to it.

My experience, a little over a year ago, was that they insisted that I buy that first mask. It was the cheapest mask going. $60 Canadian - from a Canadian DME, too! It was a piece of sh*t that I used only through that early, trial period. Had I known better, I would have insisted from the outset that they give me a decent mask and work with me to get it working, or to provide a better mask. In the end I was stuck with that mask; at least it was inexpensive!

Later, I was able to convince this DME, and later a different DME, to allow me a trial period of up to about 2 weeks with a mask. I've tried an Activa, Activa LT, Swift II and Swift LT masks in this fashion.

So to answer your question: yes, the DME will give you a loaner mask. But you have to fight for it, and maybe have to switch DMEs to get it. These loaners may be used. Don't worry about it, they have a sterilization regimen that they use. Just don't accept one that smells of smoke or worse!

They're not losing money on this given the outrageous cost to you to purchase a mask from them. Once you find a mask that you like, my recommendation is that you buy periodic replacements from cpap.com - it's far cheaper.

[Fitdiculous]

ozji: Makes sense... there really is no way of telling until the titration is there? one thing question that I forgot ask, if they do provide loaner machines, will I have to purchase that specific mask? I doubt they have or give out "loaner" masks too? (sanitary reasons?) I wouldn't want to be stuck with $200++ mask the DME charges during this trial period...

That's an excellent question. I wish I had a definitive answer to it.

My experience, a little over a year ago, was that they insisted that I buy that first mask. It was the cheapest mask going. $60 Canadian - from a Canadian DME, too! It was a piece of sh*t that I used only through that early, trial period. Had I known better, I would have insisted from the outset that they give me a decent mask and work with me to get it working, or to provide a better mask. In the end I was stuck with that mask; at least it was inexpensive!

Later, I was able to convince this DME, and later a different DME, to allow me a trial period of up to about 2 weeks with a mask. I've tried an Activa, Activa LT, Swift II and Swift LT masks in this fashion.

So to answer your question: yes, the DME will give you a loaner mask. But you have to fight for it, and maybe have to switch DMEs to get it. These loaners may be used. Don't worry about it, they have a sterilization regimen that they use. Just don't accept one that smells of smoke or worse!

They're not losing money on this given the outrageous cost to you to purchase a mask from them. Once you find a mask that you like, my recommendation is that you buy periodic replacements from cpap.com - it's far cheaper.

I actually have an appointment tomorrow with a different DME and I asked them if they provide loaner machines/masks, and to my surprise the person I was speaking to say they do! and of course at no extra charge... they MAY even be able to loan out a machine longer than a month (since I won't know the results of my 1st titration until early July).

I'm not 100% sure how long I'll be able to have the mask.. maybe a week? which should allow me to try 4-5 different masks before I decide on knowing which one works best for me....

so you're saying to just bite the bullet and buy the 1st mask from the DME and subsequently get replacements through an online vendor?? I have to double check, but I think my insurance covers replacement masks every 6 months... I'm going to try and see if the basic mask that they provide for you (within the package) can be "deleted" and credited towards an upgraded mask as well.

what other questions SHOULD I be asking tomorrow with this other DME?

[Hose_Head]

no, have not had the first titration yet, only the very 1st sleep study to help diagnose the OSA.

My first titration is scheduled for June 8th (3 weeks), but I have yet to get a machine yet (will 3 weeks be long enough to get "used" to one?)

from the info that the sleep clinic told me it almost seemed like they didn't LIKE giving out prescriptions for apap's... like there was extra work involved or something???

It sounds as though your sleep doctor follows a different process from the one that I went through. After I first met with my sleep doctor, after the first sleep study to diagnose OSA, I was immediately ushered into the office next door (same sleep clinic) to meet with the DME. (terrible conflict of interest in that). There, the DME gave me a loaner CPAP and sold me a piece of cr*p mask to use.

Have you been scheduled to meet with a DME? Is that meeting before your titration sleep study?

Everyone seems to react differently to cpap. Personally, I took to it like a duck to water. Lucky I guess. Others struggle with it and I'm led to believe that there's a very high failure rate.

Some sleep doctors don't like apaps, under any circumstances. Other's are willing to prescribe, but are sensitive to the problems with getting approval from ADP so that the cost is covered by OHIP. They have some additional paperwork to fill out for ADP to justify the need for apap.

If you are willing to buy the apap without a claim to ADP, discuss that with your sleep doctor when you get your prescription. He may not see the need for an apap but might be willing to prescribe it in this circumstance. However, why bother when you can buy an apap with a cpap prescription and for a much lower price from cpap.com!

[Hose_Head]

I actually have an appointment tomorrow with a different DME and I asked them if they provide loaner machines/masks, and to my surprise the person I was speaking to say they do! and of course at no extra charge... they MAY even be able to loan out a machine longer than a month (since I won't know the results of my 1st titration until early July).

I'm not 100% sure how long I'll be able to have the mask.. maybe a week? which should allow me to try 4-5 different masks before I decide on knowing which one works best for me....

so you're saying to just bite the bullet and buy the 1st mask from the DME and subsequently get replacements through an online vendor?? I have to double check, but I think my insurance covers replacement masks every 6 months... I'm going to try and see if the basic mask that they provide for you (within the package) can be "deleted" and credited towards an upgraded mask as well.

what other questions SHOULD I be asking tomorrow with this other DME?

[/quote]


This is good news!

Just be upfront with your DME about what it is that you need and want to do. Tell them that you need a cpap and mask to get you through until such time as you are ready to buy a machine. That will be after you meet with your sleep doctor to go over the results of the titration study.

I'm not recommending that you buy a cheap mask, up front. That's what happened to me because I didn't know better. As I said, "at least it was inexpensive".

Check with your private insurance. They may cover you for two masks up front. Mine did (in my first month, I bought both an activa and a swift II mask) and my insurer, Great West Life, paid 100% of both. I did not press my luck by submitting a claim for that $60 mask, although I guess it's possible that it would have been covered, too.

Questions for the DME?

Ask about the different machines that they sell. Ask to see them and to experience them (while wearing a mask) to check sound levels, ease of use, etc.

Check out the operation of the humidier; how to fill it; how to clean it

Check out different masks while in the store. My DME will allow you to try them on and "power them up".

Ask about availability for purchase of data card readers and software! (My DMEs just about choked on that one! - I purchased online)

I recommend reading as much cpaptalk as possible. It seems that few on this board (myself included) have much confidence in what DMEs tell us. They have a terrible conflict of interest given that their primary motive seems to be maximizing profit and minimizing work for themselves.

That's a pretty negative image of DMEs, I know. It's entirely unfair to the good ones out there. I just wish I knew who they are!