As a result of my sleep study in August, I was referred by the sleep doctor to a DME where I was given a Remstar Pro 2 with C-Flex & a heated humidifier. The pressure was set at 12 cm, which was the point at which all apneas and hypopneas ceased in my study. (I don't recall the setting for the C-FLEX.)
After 2 months of renting the Remstar (necessary before purchase by my insurance company), I asked the DME to rent me an APAP to try out, as I had been having some difficulty breathing against the pressure prescribed, and felt that my therapy could possibly be improved. They told me that they really didn't think an APAP was a good idea. In fact, they said of more than 600 of their clients using sleep machines, only one, or possibly two were using APAPs. I persisted, and they said that they would do so only if the doctor called them and requested it for me. I spoke with the doctor and he flatly refused to prescribe an APAP. He said that the technology was unproven, and that patients had to suffer apnea events before the machine would respond with additional pressure. He reviewed my sleep study and offered to have the DME reduce the pressure in my machine from 12 to 9, since 9 seemed to relieve nearly all of the apneas; while 12 relieved ALL events, including hypopneas. I explained that this seemed to me the perfect scenario for an APAP---less pressure for most of the night, making it easier to breathe, and increased pressure when needed. He was not happy that I had done research on my own and he told me that if I didn't wish to follow his advice, he would give me the name of another sleep lab, and that I could become their patient.
Well, my inclination is to no longer use his services, but it appears that I am not going to be able to try out an APAP before making a decision as to whether it would actually work better for me or not. I am aware that I can order equipment from Internet vendors such as cpap.com, and I may very well end up doing so, but it looks as if I will be doing so without the opportunity of trying it out first.
From reading this forum, it seems to me that there are a good number of folks using both types: CPAP as well as APAP. Without a trial of an APAP to compare against my two months on a CPAP, what do those of you who have used both think, taking into account my pressure(s)---12 or 9---depending on what one chooses to go with (I am still breathing 12 at the moment.)
And, which of the major APAPs would be best for me considering the pressures mentioned (I gather that all use their own algorithms to detect events.)
Sleep Doctor Refuses to Allow APAP
Did you turn on the c-flex? Or was it an older moder that didn't have it. Look for the blue c-flex logo on the machine.
Get another Doc. Your family doc should be willing to give you a Rx for cpap. Then order apap online.
You can always operate it as a plain cpap if you choose
Your doc is way behind the times or a lier . So is your DME.
Beware of the EVIL DME
:twis ted:
Get another Doc. Your family doc should be willing to give you a Rx for cpap. Then order apap online.
You can always operate it as a plain cpap if you choose
Your doc is way behind the times or a lier . So is your DME.
Beware of the EVIL DME
:twis ted:
follow your impulse.
fire your doctor. and your DME.
There are plenty of doctors who keep up with the profession and the technology, don't waste your time with the "old school".
I can't personally tell you based on experience that it would help you. But that is the theory of what APAP is all about, backing off on the pressure when you don't need it. I CAN tell you based on very limited experience that the C-FLEX technology sure makes it easier to exhale, and therefore get a good volume "amplitude" on the breathing cycle. I almost couldn't use the CPAP the sleep center connected me to, even on a fairly low setting, it was impossible for me to stop "mouth breathing" which I learned (mostly HERE) that that is a NO NO!
I think you should be allowed to try it, even if your doctor can't imagine letting you. The trend "nowadays" is for patients to take responsibility for their own care and be involved with the decision process. Your doctor may have the best intentions, or he may be invested in getting you out the door as cheaply as possible. Who knows. You are the one who has the most invested in the outcome. I'd say shop around.
There are plenty of doctors who keep up with the profession and the technology, don't waste your time with the "old school".
I can't personally tell you based on experience that it would help you. But that is the theory of what APAP is all about, backing off on the pressure when you don't need it. I CAN tell you based on very limited experience that the C-FLEX technology sure makes it easier to exhale, and therefore get a good volume "amplitude" on the breathing cycle. I almost couldn't use the CPAP the sleep center connected me to, even on a fairly low setting, it was impossible for me to stop "mouth breathing" which I learned (mostly HERE) that that is a NO NO!
I think you should be allowed to try it, even if your doctor can't imagine letting you. The trend "nowadays" is for patients to take responsibility for their own care and be involved with the decision process. Your doctor may have the best intentions, or he may be invested in getting you out the door as cheaply as possible. Who knows. You are the one who has the most invested in the outcome. I'd say shop around.
He who dies with the most masks wins.
The C-Flex is set on 1. Is this the lowest setting? Since I am using C-Flex already, does that mean I would be better off ordering a Remstar APAP with C-Flex, or would ResMed or Puritan Bennett do just as well? It appears that I will be placing an order with an Internet vendor without actually trying out an APAP machine, much less a variety of machines.
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Masked Ranger
- Posts: 29
- Joined: Thu Oct 27, 2005 5:34 pm
- Location: Connecticut
Call your doctor and ask for a referal for someone else or find another doc on your own. Also let him know you aren't happy with his services. My first ENT doctor was from the old school and didn't believe in apap, bi-pap or the newer machines. I dumped him and found a great doc that worked with me to find the right machine. Don't give up!
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| Mask | |
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Guest-Ramona
I'm sitting here wondering why your doctor got so defensive when you told him you wanted to try APAP. Is he unsure of his knowledge/skill or does he have a "relationship" with the DME? Here's the bottom line. You need to be able to trust your doctor. If, for whatever reason, you cannot do that, then it's time to look for another doctor. My doctor knows that I will come into her office with an armload of research. She usually already knows all the stuff that I found and we discuss my condition and treatment. It's time for you to look for another doctor.
I agree about finding another doctor. My pulmonologist gets "kickbacks" from the DME. Yeah... really...and it's NOT unusual for these arrangements to exist.
My PRIMARY physician, however, knows me well, treats me well, and is open to new things especially when there is verifiable data. When I asked my pulmonologist recently about replacing my 5 year old CPAP that sounds like it may be on its way out... I was given an appointment. FOR JANUARY 17th !!!
I asked for a prescription for an auto CPAP and was told he needed to see me before writing a script.
Called my primary. Told her I felt more llike a part of someone's billing cycle than part of their care (referring to the pulmonologist). Asked for a script for an auto CPAP. She said, "OK, but why an auto?". I told her that if I take my machine to the DME they send it out for repair. They send me home WITH AN AUTO while waiting for my machine to be declared dead. I told her that in the last 5 years my pressure requirements may have changed. And 5 years from now they may also be different. The auto will let me see where my pressure needs are and I can download teh data from the machine to make sure I'm setting the pressure range correctly and having a range may allow me to have as little or as much pressure as I need rather than just a single setting all the time.
She was like... "wow... you've done your homework. Can you bring me a report on the data next time I see you?" I said "sure!".
Maybe an ideal situation, but SHE appreciates that I'm taking an active role in my treatment. *I* appreciate that she's open to this.
If your doc is steadfastly AGAINST this and bases his decision on outdated or old school assumptions... then it's time to find a new doctor.
Just my 2 cents... now I'm broke!
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CPAPopedia Keywords Contained In This Post (Click For Definition): auto cpap, CPAP, DME, Prescription, auto
My PRIMARY physician, however, knows me well, treats me well, and is open to new things especially when there is verifiable data. When I asked my pulmonologist recently about replacing my 5 year old CPAP that sounds like it may be on its way out... I was given an appointment. FOR JANUARY 17th !!!
I asked for a prescription for an auto CPAP and was told he needed to see me before writing a script.
Called my primary. Told her I felt more llike a part of someone's billing cycle than part of their care (referring to the pulmonologist). Asked for a script for an auto CPAP. She said, "OK, but why an auto?". I told her that if I take my machine to the DME they send it out for repair. They send me home WITH AN AUTO while waiting for my machine to be declared dead. I told her that in the last 5 years my pressure requirements may have changed. And 5 years from now they may also be different. The auto will let me see where my pressure needs are and I can download teh data from the machine to make sure I'm setting the pressure range correctly and having a range may allow me to have as little or as much pressure as I need rather than just a single setting all the time.
She was like... "wow... you've done your homework. Can you bring me a report on the data next time I see you?" I said "sure!".
Maybe an ideal situation, but SHE appreciates that I'm taking an active role in my treatment. *I* appreciate that she's open to this.
If your doc is steadfastly AGAINST this and bases his decision on outdated or old school assumptions... then it's time to find a new doctor.
Just my 2 cents... now I'm broke!
_________________
CPAPopedia Keywords Contained In This Post (Click For Definition): auto cpap, CPAP, DME, Prescription, auto
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| Mask: Swift™ FX Nasal Pillow CPAP Mask with Headgear |
| Humidifier: S9™ Series H5i™ Heated Humidifier with Climate Control |
| Additional Comments: original pressure 8cm - auto 8-12 |
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Sleepless on LI
- Posts: 3997
- Joined: Mon May 30, 2005 6:46 pm
- Location: Long Island, New York
Not to beat a dead horse, but auto machines can also operate in cpap mode, depending on which option you use. So why should he be opposed to a machine that if you try and are not happy with the auto, you can always use as cpap, too? More bang for your buck. There is definitely more than meets the eye to this one.
L o R i
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rested gal
- Posts: 12881
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You're exactly right, wpinef. C-Flex set at 1 gives the least relief when breathing out. 2 gives more relief, and C-flex at "3" gives the most relief -- the most pressure reduction for exhaling.
slept, good job doing your homework! You might find this topic interesting:
Feb 19, 2005 subject: "Sleep Doctor" doesn't like autopaps
slept, good job doing your homework! You might find this topic interesting:
Feb 19, 2005 subject: "Sleep Doctor" doesn't like autopaps
My perspective is a little different than what has been posted, except for the CFLEX setting as RG points out above. Move the setting to 3 and you’ll notice an easier exhalation.
As for the APAP vs. CPAP, the doctor is correct about how the logic in the APAP machines work. My machine is a REMStar AUTO w/CFLEX and I set the CFLEX setting at 3 on the second night. I’m still in AUTO mode because that is how I want my treatment to work. With that said, Auto’s biggest advantage is that it would allow you to use the 9CM setting the doctor mentioned, and still have the capability of reaching 12CM when you needed it. For certain, the machine must see something happening in the way of an obstructive event for it to react with more pressure, but if the mask leakage hits the Large Leak threshold used by the machine, it won’t respond with more pressure. Instead, it will stay at the 9CM setting and act like a CPAP generating 9CM of pressure.
If I were in you shoes and you like how you’ve worked with your sleep MD, I would ask him why it makes sense to drop the pressure to 9CM on a CPAP and it doesn’t make sense to set an APAP at 9CM with an upside setting of 12CM or higher. For certain when I’m very tired, I notice my machine pushes the upper limit I have set at 14CM, but if I’m not exhausted when I hit the pillow, the machine will usually run around 12.5 CM.
Auto’s give you the flexibility to begin the night at a lower setting and still have the ability to progress to a higher value when your events begin too show they aren’t responding to the current pressure level. This isn’t possible when a machine is set to CPAP mode. An area where Auto’s can be a problem is when people set them too low in the hope they will climb to where they need to be to handle the events. This is where the Auto logic is faulty. I’ve not seen my machine do a good job of reaching to where the events are handled properly when the low side setting is too low. To some extent, I think the machine’s range limitation in the software that makes decisions, tries to keep the machine from escalating to too high a pressure when it is interpreting the information incorrectly and this restriction limits the machine’s ability to do a good job of being where you need it. For example, noise that isn’t a snore can be seen as a snore by the machine and it will try to raise the pressure. Hypopneas are another area where the machine gets confused and of course the Auto feature goes to sleep if the mask is showing a maximum leak value. Even short period leaks will cause the machine to drop to the lowest setting and stay there for a while, so when you think about APAP, don’t think it makes exhalation easier, although working at a lower pressure helps, think that you’ll need to have the machine’s working range set near to where your obstructions are handled properly. This is where the APAP will shine.
Maximum leaks are the biggest weakness my Auto seems to have. Last night I began the process of trying to use a full face RESMed Ultra and was surprised to see the data card show that I spent 86% of the night in a large leak state that made the machine stop recording events that happened during that period. As a result of the leak, the machine ran at the bottom setting of 12CM for most of the night and I didn’t even know I had a maximum leak during that period.
If you go the APAP route, keep these limitations in mind and do it because you want to be a more active contributor to how your titration is being administered. If the MD is going to make all the decision, then APAP vs. CPAP won’t have much of an advantage. If you are going to collect the data and review the results each day, then an AUTO will make collecting the data easier because you’ll be able to see how it responds to obstructive events and you’ll be able to set it at the low setting you mentioned and still reach the high setting when the obstructions aren’t responding. You’ll also be able to do some tweaking based upon how the long term trends of the data show what is happening. Keep in mind that one sleep study and even 2-weeks of information are more than likely only simple non-significant pieces of data. Collect a few months of information and look at what is happening, and then you’ll be in a better position to know what to tweak and why.
Good luck on your decision!
As for the APAP vs. CPAP, the doctor is correct about how the logic in the APAP machines work. My machine is a REMStar AUTO w/CFLEX and I set the CFLEX setting at 3 on the second night. I’m still in AUTO mode because that is how I want my treatment to work. With that said, Auto’s biggest advantage is that it would allow you to use the 9CM setting the doctor mentioned, and still have the capability of reaching 12CM when you needed it. For certain, the machine must see something happening in the way of an obstructive event for it to react with more pressure, but if the mask leakage hits the Large Leak threshold used by the machine, it won’t respond with more pressure. Instead, it will stay at the 9CM setting and act like a CPAP generating 9CM of pressure.
If I were in you shoes and you like how you’ve worked with your sleep MD, I would ask him why it makes sense to drop the pressure to 9CM on a CPAP and it doesn’t make sense to set an APAP at 9CM with an upside setting of 12CM or higher. For certain when I’m very tired, I notice my machine pushes the upper limit I have set at 14CM, but if I’m not exhausted when I hit the pillow, the machine will usually run around 12.5 CM.
Auto’s give you the flexibility to begin the night at a lower setting and still have the ability to progress to a higher value when your events begin too show they aren’t responding to the current pressure level. This isn’t possible when a machine is set to CPAP mode. An area where Auto’s can be a problem is when people set them too low in the hope they will climb to where they need to be to handle the events. This is where the Auto logic is faulty. I’ve not seen my machine do a good job of reaching to where the events are handled properly when the low side setting is too low. To some extent, I think the machine’s range limitation in the software that makes decisions, tries to keep the machine from escalating to too high a pressure when it is interpreting the information incorrectly and this restriction limits the machine’s ability to do a good job of being where you need it. For example, noise that isn’t a snore can be seen as a snore by the machine and it will try to raise the pressure. Hypopneas are another area where the machine gets confused and of course the Auto feature goes to sleep if the mask is showing a maximum leak value. Even short period leaks will cause the machine to drop to the lowest setting and stay there for a while, so when you think about APAP, don’t think it makes exhalation easier, although working at a lower pressure helps, think that you’ll need to have the machine’s working range set near to where your obstructions are handled properly. This is where the APAP will shine.
Maximum leaks are the biggest weakness my Auto seems to have. Last night I began the process of trying to use a full face RESMed Ultra and was surprised to see the data card show that I spent 86% of the night in a large leak state that made the machine stop recording events that happened during that period. As a result of the leak, the machine ran at the bottom setting of 12CM for most of the night and I didn’t even know I had a maximum leak during that period.
If you go the APAP route, keep these limitations in mind and do it because you want to be a more active contributor to how your titration is being administered. If the MD is going to make all the decision, then APAP vs. CPAP won’t have much of an advantage. If you are going to collect the data and review the results each day, then an AUTO will make collecting the data easier because you’ll be able to see how it responds to obstructive events and you’ll be able to set it at the low setting you mentioned and still reach the high setting when the obstructions aren’t responding. You’ll also be able to do some tweaking based upon how the long term trends of the data show what is happening. Keep in mind that one sleep study and even 2-weeks of information are more than likely only simple non-significant pieces of data. Collect a few months of information and look at what is happening, and then you’ll be in a better position to know what to tweak and why.
Good luck on your decision!
Roger...
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ProfessorSleep
- Posts: 338
- Joined: Sat Sep 10, 2005 7:42 pm
- Location: Wisconsin
Re: Sleep Doctor Refuses to Allow APAP
Sounds to me like your plan of action is right there!slept wrote:
He was not happy that I had done research on my own and he told me that if I didn't wish to follow his advice, he would give me the name of another sleep lab, and that I could become their patient.
Only if you do change docs, be sure to get a copy of any studies/labs or whatever that already have been done. Sounds like he might not be too interested in helping you make the transfer to a new place other than perhaps closing the door as you leave. Geez - what a #$(*% !
Anyway, you've got some great advice above. I have an auto I run in cpap mode since the pressure is low (8cm) and the constant pressure is less disruptive than the changes, plus it takes care of the events (I think - gotta check the software again). But it's nice to have the data and the options!
What's with this condition and all the forced helplessness cast upon us?
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neversleeps
- Posts: 1141
- Joined: Wed Apr 20, 2005 7:06 pm
- Location: Minnesota
I'm going to suggest (as I have on many occasions in the past) to those doing battle with uninformed and misinformed docs/DMEs to skip that expensive, unnecessary middleman and order from cpap.com. Get the equipment YOU want at a significantly lower cost. It still boggles the mind that the equipment docs/DMEs prescribe is regularly the result of limited knowledge or a big profit margin, and not the features of the machine or the best available. They also need to protect their interests. They need us to need them.
Once the initial PSG has been conducted, the more we know via software and self-titration experiments, the less we need the docs/DMEs. No need to waste time and money with appointments, no need to drive anywhere, no need to have someone view our data, and no need to have someone else perform the oh-so-complicated procedure of adjusting pressure.
Speaking of viewing data, how many times have we read here the only data checked at these appointments (if any) is compliance? Good grief! We know more via our software than they do!
In the case of an auto, perhaps they just don't know enough about it. Time and again we find individuals on this forum with a better understanding of auto machines than their sleep docs/DMEs. It's really a frightening thought. Sadly, in other cases, you are simply prescribed the cheapest, most outdated machine because the DMEs (and docs through kickbacks) stand to make the most money from doing so. What a racket!
You can use your auto in straight cpap mode or auto mode, so you can't go wrong. With software to evaluate your nightly results (not just compliance), you'll be able to determine what works best for you.
Once the initial PSG has been conducted, the more we know via software and self-titration experiments, the less we need the docs/DMEs. No need to waste time and money with appointments, no need to drive anywhere, no need to have someone view our data, and no need to have someone else perform the oh-so-complicated procedure of adjusting pressure.
Speaking of viewing data, how many times have we read here the only data checked at these appointments (if any) is compliance? Good grief! We know more via our software than they do!
In the case of an auto, perhaps they just don't know enough about it. Time and again we find individuals on this forum with a better understanding of auto machines than their sleep docs/DMEs. It's really a frightening thought. Sadly, in other cases, you are simply prescribed the cheapest, most outdated machine because the DMEs (and docs through kickbacks) stand to make the most money from doing so. What a racket!
You can use your auto in straight cpap mode or auto mode, so you can't go wrong. With software to evaluate your nightly results (not just compliance), you'll be able to determine what works best for you.
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Sleepless on LI
- Posts: 3997
- Joined: Mon May 30, 2005 6:46 pm
- Location: Long Island, New York