Newbie mtg DME soon- Help me pick right machine

[RedLabMom]

Hello everyone. Have been reading the posts for newbies and feel confident I am in the right place. A REALLY BIG THANK YOU to all who give their time & experience. I value your support and advice! Have found posts by Restedgal, Rooster, Wulfman and Velbor especially helpful. However, at the moment my brain seems overloaded with information and I'd like some help in selecting the right CPAP machine and navigating the frustrating road ahead.

I recall somebody, somewhere advised a newbie to post specific sleep study data. Actually, the newbie is my 21 yr old son. He's a college student, trying to hold it together & make it to the end of the semester. Asked me to research, make the appts, & said it was ok to share his data. I'm a registered nurse, so perhaps I have a better starting point than most? Have been reading this forum and have quickly realized I have a lot to learn. I like to think I have enough sense to know when I am out of my league. And right now, I'm way out there! Really need your advice. So..here's some info.

Even as a baby this kid didn't sleep well. Moderate snoring, trouble falling asleep, have seen apnea when he naps (as an adult), irritable in mornings, takes a long time to wake up out of his morning 'fog'. Also has creepy leg sensations (RLS) at night, & during the day walking helps. Sometimes takes naps during the day. Tires easily when driving long distances. Recently dx'd w/ GERD (related to OSA?). Attempted a split sleep study 1 month ago. Didn't meet the 'appropriate benchmarks' to advance to the titration portion of the study so the tech just let him sleep and continued recording data. I'll refer to this one as the Diagnostic study. (Surprise?!) Sleep MD diagnosed- Severe OSA, Restless Leg Syndrome & Insufficient Sleep Syndrome & recommended drive w/ caution, alcohol with caution, lose weight (5'7" 175 lbs BMI 27.4), check iron level as RLS associated w/ anemia, stop daytime naps, eliminate caffeine, and do a repeat sleep study for CPAP titration.

Did the Titration study 2 weeks ago. It was interpreted by a different sleep MD in the same office group. Titration study done using a full Face Mask. He tried 2 face masks & 3 nasal masks @ 4 or 5 cm H2O ( about 10 min each mask) and found the ResMed Mirage Quattro size Med the best for him. Titration study was done with a ResMed VPAP TX machine. (CPAP was initiated @ 5 cm H2O and titrated upward. Various pressures were titrated & highest pressure attempted was 9cm H2O.) He slept at this pressure for 280 min with 31.3% being REM sleep. AHI @ this pressure was 0.2 as compared to an AHI of 7.9 in the diagnostic study. On the Diagnostic study he had 35.4 RERA's per hour to make an RDI total of 43.3 (AHI + RERA's per hour). Ok, I'm getting confused . I'll post the data like this to make it easier to compare- Diagnostic number/Titration number.

Sleep Onset Latency- 7 min/16.5 min. Wake After Sleep Onset (WASO)- 16.5 min/17.0 min. Sleep Efficiency -94.6%/92.6%. Arousals & Awakenings- 44.0 per hour/13.9 per hour.
Sleep architecture fragmented in both studies. Stage I- 3.7%/2.8%. Stage II- 66.5%/57.1%. SWS- 7.0%/20.6%. REM- 22.9%/19.5%.

Respiratory Events- Total number Apnea-5/0. Hypopnea 49/3. Mixed Apnea- 0/0. Central Apnea- 0/2. RERAs- 242/ ?? (titration study does not list RERAs?).
Index per hour Apnea- 0.7/0. Hypopnea- 7.2/0.4. Mixed Apnea 0/0. Central Apnea 0.3.
Average Duration, Index in NREM & Index in REM.
AHI NREM total- 9.5/0.9. AHI REM total- 2.6/0.0. AHI Sleep 7.9/0.7.

Oxygen Saturation- Have data but doesn't seem too out of place- O2 Sat was above 90% 99.9% of the time. Below 90% 0.1% of the total time.

Arousals to sleep stage index. It breaks down the arousals into respiratory, spontaneous, PLMS, Snoring & RERA events. The Total Index is 44/13.9. Most all the events are in RERA section- 34.7/11.4.

Periodic Limb Movement- Arousals Indexed- 0.1/1.0.

Heart Rate- Average- 79/68. Lowest- 58/48. Highest- 92/86.

After diagnostic study, he commented that he slept lousy- his "usual crappy sleep". After titration study, he commented "I've never felt this awake in the morning!", said he felt good ("Is this a "cpap high?"). Was great until... around 2 pm when he "kinda crashed" & started feeling crappy again". (related to the cpap or coincidence?).

He remembers waking up twice in the night with a choking sensation,but could 'deal w/ it". (normal or cpap learning curve?)

Am concerned about the central apneas during the titration study-none in diagnostic study. They happened in NREM w/ average duration of 19.1 sec. What causes central apneas? Could it be related to the machine somehow? How does the machine know the difference between an RERA, an obstructive apnea and a central apnea?

Considering the above data, which CPAP machine do you think will best meet his clinical & lifestyle needs? I am leaning toward Respironics One REMstar Auto CPAP w/ A-Flex.

I have copies of both studies and CPAP rx from referring MD (not sleep MD). Rx is for CPAP w/ heated humidifier, 9 cm H2O w/ 15 min ramp.

Was ready w/ list of questions from Rooster's post (Things to Ask About your PSG & Titration study, Jan 2010), but referring MD was (I'll try to be nice) less than helpful. Refused to consider APAP machine or data capable machine & software to monitor apneas. My gut feeling is that I will have difficulty convincing the DME to order the autopap b/c MD 'really likes" this particular DME & Rx written on DME's letterhead, with a separate box to check if requesting Auto Pap.

Am considering a consult with a different physician (2nd opinion) to review sleep studies, discuss options and perhaps obtain new Rx that specifically contains the words "Auto CPAP & efficacy data compatible".

Thanks again for your support & advice.

[Janknitz]

First, welcome!

Second, would you PLEASE break your post into paragraphs? That is one overwhelming chunk of text! You'll get better answers if we can get to the important parts.

Now, may I suggest you read "What you need to know before you meet your DME" linked in my signature below--you will find helpful info before you ever see the DME.

As for the RX., ANY MD can write the script so perhaps your son's PCP can write exactly the sx
Script you want and you can use ANY DME the insurance will work with.

Good luck!

[RedLabMom]

Thanks for the great article about DME's! I will be sure to do my homework.

As for the huge chunk of text, you're absolutely right. Nearly unreadable. Sorry about that. Will see if I can clean it up a bit.

Thanks, again.

[robysue]

I have copies of both studies and CPAP rx from referring MD (not sleep MD). Rx is for CPAP w/ heated humidifier, 9 cm H2O w/ 15 min ramp.

Was ready w/ list of questions from Rooster's post (Things to Ask About your PSG & Titration study, Jan 2010), but referring MD was (I'll try to be nice) less than helpful. Refused to consider APAP machine or data capable machine & software to monitor apneas. My gut feeling is that I will have difficulty convincing the DME to order the autopap b/c MD 'really likes" this particular DME & Rx written on DME's letterhead, with a separate box to check if requesting Auto Pap.

You are under no obligation to use the DME that the MD "really likes". And it sounds really, really suspicious to me that the prescription is written on the DME's letter head and NOT the doctor's letterhead. If the doc has a financial interest in the DME, then no wonder he's saying "no need for APAP and no need for full data."

Pick up the telephone and start shopping for DMEs. Tell them you have a written prescription for CPAP with heated humidier at 9cm but that you'd like to obtain an APAP and have it set in CPAP mode. Or at least a full data machine. You might get lucky (I did) and find a DME that will provide the machine you want since both it and a dataless brick have the same insurance billing code.

[DreamDiver]

You are under no obligation to use the DME that the MD "really likes". And it sounds really, really suspicious to me that the prescription is written on the DME's letter head and NOT the doctor's letterhead. If the doc has a financial interest in the DME, then no wonder he's saying "no need for APAP and no need for full data."

While you're at it, I'd start shopping for a new sleep doc too. Anyone who attempts to hamper your therapy is only in your way. And tell him why when you leave. Get the fully-data-capable machine of your choice -- preferably an auto.

[msradar65]

I would run from this doc. Get a full copy of your results and go to a different sleep doctor. Sounds fishy to me. When I asked my sleep doc about a pulse oximeter he was more than happy to write the script and was pleased that I was taking control of my therapy. He response was call me if you have any issues and we will help you work through them.

I would also report your doctors refusal to provide the machine that can help you improve therapy to your insurance if you are using insurance. If you are a cash pay...get a script from your family doc...and move on to a new doc. This one is a shady!

[Otter]

Am concerned about the central apneas during the titration study-none in diagnostic study. They happened in NREM w/ average duration of 19.1 sec. What causes central apneas? Could it be related to the machine somehow? How does the machine know the difference between an RERA, an obstructive apnea and a central apnea?

I imagine in the sleep study they identify RERA's by comparing EEG traces with data from the respiratory effort sensors. With no EEG input, the home machine doesn't identify any sort of arousal. It doesn't even know if you're asleep. It also doesn't sense respiratory effort. Hence Philip's RERA detection is more AI guesswork than actual data, and the other manufacturers don't even try to detect RERA.

The lab machine and the more advanced home machines can distinguish OA from CA by sending a pressure pulse, or series of pulses, to check whether or not the airway is clear. Machines like the Philips PR1 and the Resmed S9 will not increase pressure when the airway is clear, thus minimizing pressure induced apnea. Less advanced machines simply don't automatically raise pressure past a certain point in response to apnea because they can't tell OA from CA.

Pressure can cause central apnea, but it's more a matter of reduced sleep quality than immanent death. If someone tries to tell you that your son could die from this if his pressure is set too high, tell them you'd like to read about the documented cases where this happened. Many people are given dire warnings about the dangers of pressure induced central apnea as part of their training, but as near as I can tell, there is about as much scientific evidence for this being immediately dangerous as there is for the existence of the boogeyman. When I asked an RT with 22 years of experience about this and other supposed dangers of CPAP, he used the word "hogwash".

Considering the above data, which CPAP machine do you think will best meet his clinical & lifestyle needs? I am leaning toward Respironics One REMstar Auto CPAP w/ A-Flex.

That one would work well. Also look at the S9. They are similar, but not the same. A lot of it comes down to your son's personal preference, but don't dismiss these "comfort" issues. He'll get the best sleep with the machine he's most comfortable with.

I chose the S9 because, in the subtle differences, it seemed to me that Resmed was more focused on sleep, while Philips is more focused on apnea, and hence a few people find they don't sleep as well with the Philips machine. As far as I know, no one is studying arousal caused by the actions of the machines themselves. Instead, they wait for users to complain, and then perhaps do something about it, and perhaps not. It's only sleep after all, how important could that be?

Here are some things to think about.

On screen data:
PR1: 7 and 30 day averages are useless for analyzing last night's sleep.

S9 gives a little more data, though for anything in depth, your son will need his computer.

Humidification:
PR1: Adjusts humidity based on ambient conditions.

S9: Heated hose. Option for 80% humidity at a selected temperature or select constant heat and heated hose temp to avoid rainout. I find that the tank on this humidifier is too small to run 8 hours without going dry, even though I'm not living in the desert, but I have humidity cranked up pretty high.

OA/CA detection:
Philips sends a single 2cm pressure pulse that some describe as a puff. In the most recent revision of the machine, this is more gentle, but some still find it keeps them from falling asleep. It's worth finding out what flow generator was used at the sleep lab. If it was a current-generation Philips, then this style of airway analysis does not bother your son.

Resmed uses a series of undetectable pulses at a lower pressure.

Exhalation relief: This might not matter at all because your son's pressure is fairly low. Also he might not even use ER.

Philips has c-flex+ and a-flex. The advantage to these is that the pressure comes back before the user is done exhaling, thus avoiding airway collapse. The disadvantage is that the pressure comes back before the user is done exhaling, thus causing some people to feel rushed to breathe.

Resmed has EPR, which is basically BIPAP's kid brother. The pressure does not come back until after inspiration begins. Hence, to keep his airway open in the ER trough, your son may need to raise the minimum pressure, but if he turns out to be one of the people who feel their breathing style is cramped by flex, he'd prefer EPR. And since his pressure is low, he could still have 3cm H2O ER without blasting the mask off his face.

Oh, I almost forgot about the Devilbiss Intellipap. This sounds like a very good machine. The only downside is that it doesn't record low-level data, so your son wouldn't be able to see traces of his flow and the machine's pressure. Because I didn't have a sleep study, that was essential to me, but your son might not care.

Even with a sleep study, though, I think there's something to be said for being able to see what happened, breath by breath, the night before. I have a better understanding of my OSA than I would without the graphs. Also, I've discovered that I can exclude some events that occur while I'm not asleep by breathing in a noticeable pattern once I'm settled -- three deep inhalitions, three normal, another three deep. When I look at the traces, I can spot this easily and so I know if the central apnea near the beginning of the session was really a CA or whether I was just unconsciously holding my breath while I fussed with the mask or hose.

Fisher & Paykel is another option, but for some reason their current generation of flow generators don't get as much attention as the competition.

I have copies of both studies and CPAP rx from referring MD (not sleep MD). Rx is for CPAP w/ heated humidifier, 9 cm H2O w/ 15 min ramp.

Was ready w/ list of questions from Rooster's post (Things to Ask About your PSG & Titration study, Jan 2010), but referring MD was (I'll try to be nice) less than helpful. Refused to consider APAP machine or data capable machine & software to monitor apneas. My gut feeling is that I will have difficulty convincing the DME to order the autopap b/c MD 'really likes" this particular DME & Rx written on DME's letterhead, with a separate box to check if requesting Auto Pap.

Am considering a consult with a different physician (2nd opinion) to review sleep studies, discuss options and perhaps obtain new Rx that specifically contains the words "Auto CPAP & efficacy data compatible".

Good idea. My gut feeling is that the first sleep doc is more concerned with his profit than your son's therapy. Find someone who encourages your son to be an active participant in his own therapy and gives him the support he needs to do this, even if it means lower profit from the doctor's DME business. For some reason (or lack thereof), insurance pays DMEs the same no matter what equipment they provide. Hence if you get the cheaper machine, the DME makes a bigger profit, and there is a clear conflict of interest when a sleep doctor has a financial stake in the DME he refers his patients to.

[Janknitz]

Thank you for dividing your post into paragraphs--much easier to read now!

You mentioned your son woke up with a choking feeling twice during titration. GERD and/or LPR (laryngeal pharygeal reflux) are common with OSA--narrowed airways and the struggle to breathe create a vacuum effect that suctions stomach and esophageal contents up into the throat during apnic events.

For some people like me, CPAP helps my GERD enormously. Others report MORE symptoms on CPAP, possibly because of aerophagia or because the air pressure tends to hold the sphincter open slightly. If it's the aerophagia that's causing symptoms, learning to sleep with the tongue on the roof of the mouth helps--it seals off the nasopharynx and reduces the amount of air swallowed. The other cause is more difficult to manage.

So this is something to watch with your son--he may need to talk to the doctor about PPI's if it persists, or it could just have been that he woke more easily with all the apparatus and wiring and was simply aware of his apneas as he would not be during normal sleeping conditions.

[RedLabMom]

Thanks to everyone for the wisdom. We are definitely shopping for a good DME and will tell referring MD to take a hike.

Does anyone have a good sleep MD in the Houston area?

Can anyone recommend a DME in Houston that provides quality service in an ethical manner?

My son is very tired of being "so damned tired" all the time. He seems highly motivated to make CPAP therapy work. He was very encouraged the morning after the titration study. Said he "felt very good and had never felt this awake in the morning". After reading all these posts, I know it is not a particularly easy process. So.... want him to have the best shot at sucessful therapy, and detailed data from a quality machine should certainly help in solving problems.

Am still trying to grasp concept of central apneas. Otter, your post was very reassuring. Thanks. Still trying to digest the info.

I am leaning toward the Phillips Respironics PR system One Auto CPAP b/c I know I can get the EncoreViewer Software. Have also considered the ResMed S9, but ruled it out b/c I thought I'd have difficulty getting detailed data from the machine. Isn't the S9 software restricted to healthcare providers only? Where can we get software & card reader for ResMed S9? BTW we have a Mac computer. Is this a problem with Respironics or ResMed's software?

Any suggestions on how to try out both machines to determine his preferences before buying? Is he too new to the CPAP therapy to have developed a preference? Forgive me if these are obvious or stupid questions. Does any particular nugget of data in the sleep study point to one machine over another? or am I splitting hairs? Am hoping either PR1 or S9 will get us close.

Am feeling pressure to make a decision/purchase soon b/c of insurance. Good news is that we are very close to hitting our out-of-pocket maximum and have already met our deductible for the calendar year. insurance will pay 100% after I write a small check to somebody. Bad news is that calendar year starts over again on May 1st. Want to purchase before May 1 or get to build the o-o-p max & deductible again.

Thanks again to everyone for their input. You guys are awesome!

[archangle]

Re: Choking

Part of the reason for a titration study is to figure out what pressure does NOT work and to observe his apnea. Maybe a choking sensation during a study is not that bad a thing. Logically, you'd lower the pressure to the point where he has some apneas and then dial the pressure up till they go away.

[RedLabMom]

Otter said" OA/CA detection...worth finding out what flow generator used at the sleep lab".

It was a RedMed VPAP TX machine.

Am confused Did the increasing pressure caused the CA?

Titration study says

AHI 0.0 @ 5cm AHI 0.0 @ 6cm AHI 2.4 @ 7cm (1 hypopnea, 2 centrals) AHI 1.5 @ 8cm AHI 0.2 @ 9cm

Perhaps they raised it too fast?

[cflame1]

the Mac thing... TalonNYC has a good post on Rescan and Encore software on a Mac. Between his and some other posts, you'll need to run either Bootcamp or Parallels in order to run either software.

[Otter]

Can anyone recommend a DME in Houston that provides quality service in an ethical manner?

CPAP.com has a bricks and mortar in Houston. If it's anything like their online service, they'd be head and shoulders over any of the DMEs I've encountered here.

Am still trying to grasp concept of central apneas. Otter, your post was very reassuring. Thanks. Still trying to digest the info.

I don't fully understand them either, but Mark Seager, the RT who owns SecondWindCPAP.com, has emphasized to me that they are fairly rare, and that one would start breathing again long before there was any danger. We were speaking of the pressures available from a typical cpap machine, and I suppose some of the FUD may be the result of what can happen at much higher pressures. There does seem to be a booming business in unnecessary sleep studies, though, and one way to justify those is to make cpap seem a lot more dangerous than it really is.

I am leaning toward the Phillips Respironics PR system One Auto CPAP b/c I know I can get the EncoreViewer Software. Have also considered the ResMed S9, but ruled it out b/c I thought I'd have difficulty getting detailed data from the machine. Isn't the S9 software restricted to healthcare providers only? Where can we get software & card reader for ResMed S9?

You can probably get a card reader for the S9 or the PR1 at Walmart. Both use standard SD cards, just like a camera.

You can download Resmed's ResScan directly from their site.
http://www.resmed.com/int/assets/html/s ... c=patients

If you don't want to register, here's the direct link.
http://storage.resmed.com/software/ress ... n_3.13.exe

And here is the clinician's manual.
http://tinyurl.com/24x73ws

Encore Pro is not freely available on the Respironics site, however, people have been known to help each other with such problems. The people here on this forum are very helpful.

BTW we have a Mac computer. Is this a problem with Respironics or ResMed's software?

I suspect it would be a problem for both, but not an insurmountable one. I was unable to get ResScan to install under Windows XP Pro X64, even though it has compatibility modes for all of the operating systems that ResScan's installer asked for. Hence, I doubt you'd have much luck running it in an emulator. But you should be able to run both applications under Windows xp in VirtualBox. You would need Windows to do that, but you could run it from MacOS without having to reboot. There is also a user-created online data viewer for the PR1. And soon there should be an an open source viewer will work with data from either machine on any common OS, coded by one of our own.

I'm using another open source application, EDFBrowser, to view my data. Because this program is not specific to the S9, it takes a bit more effort to load the files, but I can see everything that gets logged. They don't release binaries for Mac OS, but you could compile from the source yourself.
http://www.teuniz.net/edfbrowser/

Any suggestions on how to try out both machines to determine his preferences before buying? Is he too new to the CPAP therapy to have developed a preference? Forgive me if these are obvious or stupid questions. Does any particular nugget of data in the sleep study point to one machine over another? or am I splitting hairs? Am hoping either PR1 or S9 will get us close.

The only stupid questions are the ones you need an answer to, but do not ask. Yes, you are splitting hairs, but only because there isn't much more than a hair's breadth difference between the machines. Both work very well for most people. I don't blame you for wanting to get the best one for him, though, and I applaud you for helping him out when he's too tired to do it himself. You might find a local DME that would let him try both machines at least in their office.

I just went through this myself. Trying things at the local DME was not an option because they won't have anything to do with me unless I shell out three grand for a sleep study, never mind that I have the full support of my doctor in self-titrating with APAP. I was told several times that either the PR1 or the S9 would work well, and I believe that. But not having insurance, I wanted to get it right the first time, and I chose the S9 for my first machine because in all my reading, very few people complained that it wouldn't work for them. Few people complained about the PR1 either, but there was a significant minority who couldn't tolerate some of its features, and I decided that, with everything else being more or less a wash, it was best not to gamble.

For me, it really came down to the philosophy implied by the features of the two machines more than anything concrete. In the medical community in general the attitude that sleep is unimportant is fairly common. Just stroll down the hall of the monitored ward at the hospital here and listen to the cardiac monitors shrieking every time a patient rolls over, and you'll see what I mean. These folks really need their sleep, and the point of wiring them up to the sending units is that they can be monitored from the nurse's station. So why all the beeping BS? Obviously, someone puts sleep far down the list of priorities.

Philips seems to me to be closer to that camp. Their focus seems to be on preventing apnea at all costs. CPAP machine induced arousal is not considered. Anything can be done to a sleeping person if it prevents apnea. But if you took this philosophy to the extreme, the perfect CPAP machine would be the one that does not allow the user to fall asleep in the first place. No sleep, no sleep apnea. Problem solved.

Resmed's machine, OTOH, seems designed to tiptoe around the sleeper, even to the point of allowing an occasional apnea to slip through under EPR. Whether or not the s9 delivers superior therapy for me, I don't know, but "first do no harm" seemed like a better place to start.

I did not think that the on screen data would be a major factor because without the traces, who really knows what was scored as an apnea. But now that I've used it, I'm glad to be able to see a few basics when I wake up in the night without having to get out of bed and go to the computer.

The only nugget that stands out for me is the 9 cm h2o pressure. Because his pressure isn't that high, everything will be a bit easier, and finding a good machine and mask won't be as difficult. But I'm new to this myself, and perhaps someone else will see something to point you one way or the other.

OTOH, this did stand out:

My son is very tired of being "so damned tired" all the time. He seems highly motivated to make CPAP therapy work. He was very encouraged the morning after the titration study. Said he "felt very good and had never felt this awake in the morning".

Obviously whatever they used at the lab worked for him. It may be that the lab's machine delivers air in an identical way to a home therapy machine form the same manufacturer. See if you can find out what the practical differences are between the Resmed VPAP and the S9 at 9 cm straight CPAP.

BTW, it's the mask that usually trips people up rather than the flow generator. You're unlikely to go wrong with either the PR1 or the S9, but even the most popular masks don't work at all for a good chunk of the cpaping population.

[Otter]

Am confused Did the increasing pressure caused the CA?

Titration study says

AHI 0.0 @ 5cm AHI 0.0 @ 6cm AHI 2.4 @ 7cm (1 hypopnea, 2 centrals) AHI 1.5 @ 8cm AHI 0.2 @ 9cm

Perhaps they raised it too fast?

Maybe the centrals were pressure-induced, maybe not. Keep in mind that an AHI below 5 is considered normal. All "central apnea" means is that your son didn't try to breathe for a while. People do that all the time, even while they're awake. In fact it's possible that both the hypopnea and the centrals occurred while he was in a semi-waking state, but the tech either didn't catch it or decided your son was asleep enough. Also keep in mind that you're only looking at a few hours worth of data there. The AHI of 0.2 at 9cm h20 does look like a good place to start though, eh?

[rested gal]

Welcome to the board, RedLabMom.

First of all, I'd pay no attention at all to the miniscule amount of central apneas that showed up during your son's titration study. Two centrals are nothing. Nothing.

Here's what the manager of an accredited hospital based sleep lab wrote to someone else who wondered if a few centrals appearing in their sleep study was something to worry about:

At another apnea support forum, in a reply titled "Nope" sleepydave (RRT, RPSGT, and manager of a hospital based accredited sleep center) responds to honda's question:
____________________________________
honda wrote:
"Thanks for the comments, one other question though, do the 4 central apneas have any significance ?"

"None whatsoever.
sleepydave"
___________________________________

sleepydave's nicknames on cpaptalk are "deltadave" "StillAnotherGuest"(SAG), "Muffy", "NotMuffy", and "deltadave."

Everything about the titration night of your son's sleep study looks wonderful. He and "CPAP" are made for each other.

It was good to see such a low index for arousals from limb movements. Doesn't look like his daytime possible Restless Legs sensations will cause him a problem during sleep since they were not causing "arousals" to a significant degree.

As the others mentioned, any doctor can write the prescription for the machine. Since you're an RN, you probably know a doctor or two who will write the Rx for the exact machine you want your son to have.

The machine you are thinking about -- the Philips Respironics System One REMstar Auto with A-Flex would be an excellent choice. So would the ResMed S9 Autoset with EPR. Either one would be fine. Personally, I'd choose the ResMed machine.

A pressure would have to be stated on the Rx. A good range of pressures (using an autotitrating machine like those two machines are) for a person whose sleep study titration suggested a single pressure of 9 ... would be 8 - 16, for example. That would be what I'd suggest be put on the Rx; but, hey, I'm not a doctor!

If a doctor friend is willing to write the Rx but is hesitant about choosing a range of pressures to put on the Rx, the doctor could simply write "set for CPAP mode at 9 cm H2O." instead of stating a range of pressures. An autopap machine can be used in either straight CPAP mode or in "autotitrating" mode. You and your son could make whatever mode of operation and pressure changes you want later. It would be a good idea to use whatever machine you get in CPAP mode at 9 for a week or two, however. Good to get a baseline look at how that one single pressure of 9 handles things for him. You might find that straight 9 is the best, easiest, most comfortable for him. Or straight 10, perhaps.

If insurance will be paying for the machine, the doctor also needs to add "heated humidification" to the Rx so the humidifier can be reimbursed, too.

About the humidifer... one thing kind of out of the ordinary that I'd suggest is this:

Rather than getting the integrated humidifier for either of those machines (or any brand of machine, for that matter) I'd get a separate stand-alone heated humidifier. I'd get the Fisher & Paykel HC 150 heated humidifier. It comes with a short connector hose, so can be used with any brand/model of machine. Integrated humidifiers look pretty, matching the machine as they do, but when it comes to performance and reliability, ease of filling, size of water chamber, adjustability... many reasons... I don't think the F&P HC 150 humidifier can be beat. Best of all, if a person decides to get a different brand of CPAP machine in the future, or a second machine, it's not necessary to buy yet another "proprietary" humidifier to fit the new machine. The F&P can be used with another machine as easily as with the first machine.

At first glance, it might look like an integrated humidifier would take up less space on the nightstand, but the opposite can be true, depending on the nightstand. If the nightstand has a shelf under the top, the F&P standalone humidifier can be put on the shelf. The machine (with no integrated humidifier stuck on its side) then has a much smaller footprint (about half the size) on top of the nightstand than does a machine with a humidifier stuck to its side. There are machines that sit on top of their integrated humidifier, but then you have a taller more "tower-like" look on top of the nightstand.

Your son might prefer the look of matching machine/humidifier. But at least you can give him some info to decide if he wants a pretty, integrated humidifier, or a more practical (to me, anyway) standalone humidifier. If "rainout" (drippy water condensation in the main air hose) gives him a problem, he can get a heated hose... again, a standalone heated hose (rather than a proprietary heated hose) so it can be used with other brands of machines.

You've been doing your research on behalf of your son very well, RedLabMom. He's fortunate to have you helping him!

Glad to hear the CPAP titration night gave him a taste of how much better he can feel with a little extra push of plain old room air letting him actually breathe easily while he sleeps.

P.S. A doctor friend could write the Rx this way for a range of pressures:

Philips Respironics System One REMstar Auto
Mode - auto
pressure range 8 - 16 cm H2O
A-Flex 3, Flex lock Off, Resistance Lock Off
No ramp
Auto On - On
Auto Off - Off
Show AHI/Leak/PB - On
Heated humidification
Mask - patient's choice

Or...this way for using the autopap in CPAP mode:

Philips Respironics System One REMstar Auto
Mode - CPAP
Pressure 9 cm H2O
C-Flex+ 3, Flex lock Off, Resistance Lock Off
No ramp
Auto On - On
Auto Off - Off
Show AHI/Leak - On
Heated humidification
Mask - patient's choice