Titration report received in the mail today

[Sheffey]

The RT was going to recommend a ResMed S9 AutoSet machine if my new pressure remained in CPAP range; 20cm or < but since it didn't and it did increase into Bi-Level range she has recommended a "fixed" Bi-Level; it will not be an "auto" Bi-Level machine.

Is this the RT at the DME? Since when does a DME rule about what machine is prescribed? This should be between you and your doctor.

Once I tried an Auto, I will never use a fixed machine again.

[Stevoreno_55]

The RT was going to recommend a ResMed S9 AutoSet machine if my new pressure remained in CPAP range; 20cm or < but since it didn't and it did increase into Bi-Level range she has recommended a "fixed" Bi-Level; it will not be an "auto" Bi-Level machine.

Is this the RT at the DME? Since when does a DME rule about what machine is prescribed? This should be between you and your doctor.

Once I tried an Auto, I will never use a fixed machine again.

The RT is with the DME who has been so nice to provide me with an S9 loaner for the last 3 months. The RT was only making a comment based upon my new pressure diagnosis as a result of my June 04, 2014 titration report. I have an appointment to see my primary care doctor next week; he will be the one to recommend which kind of a machine I need to be on. My doctor is not a "sleep doctor" but I'm also planning to see a pulmonologist who is a board certified "sleep doctor" in late July 2014. I've never been to see a "sleep doctor"; I did see an ENT several times for previous sleep study orders but his business was destroyed by Hurricane Katrina in August 2005 and rather than rebuild he decided to relocate to Texas.


Stevoreno_55
MS Gulf Coast
06/26/14

[Sheffey]

I have an appointment to see my primary care doctor next week; he will be the one to recommend which kind of a machine I need to be on.

If it were me, I would ask him to write me a prescription for,

ResMed S9 VPAP™ Auto BiLevel Machine with humidifier, https://www.cpap.com/productpage/S9-VPA ... chine.html
IPAP 18 - 22
EPAP 14 - 18

Then I would be looking at ResScan reports everyday to make sure the therapy is effective. (You can look at them infrequently and only glance daily at the display once you have the system working well.)

With that machine, I could do anything that is necessary and beneficial. Anything less and I might not get optimal results.

But that's just me.

Best of luck,

[Stevoreno_55]

I have an appointment to see my primary care doctor next week; he will be the one to recommend which kind of a machine I need to be on.

If it were me, I would ask him to write me a prescription for,

ResMed S9 VPAP™ Auto BiLevel Machine with humidifier, https://www.cpap.com/productpage/S9-VPA ... chine.html
IPAP 18 - 22
EPAP 14 - 18

Then I would be looking at ResScan reports everyday to make sure the therapy is effective. (You can look at them infrequently and only glance daily at the display once you have the system working well.)

With that machine, I could do anything that is necessary and beneficial. Anything less and I might not get optimal results.

But that's just me.

Best of luck,

Do most patients ask their doctor to write a machine order and also specify a specific set of pressures? Would my doctor think I'm trying to tell him what to do? He is the one who has M.D. after his name. Here's what the pulmonologist who scored my titration results from June 04, 2014 recommended in his report what my new pressures should be: IPAP 22cm H2O, EPAP 18cm H2O

It won't hurt to ask the doctor to consider it; all I have to do is ask. That machine in your link is a very nice machine. Would you recommend I ask the doctor to also write on his order to include a ClimateLine hose or not? Will most insurance companies agree to pay for a heated hose or will they say that's an out of pocket expense for the patient? Thanks for your feedback.



Stevoreno_55
MS Gulf Coast
06/26/14

[Sheffey]

Would you recommend I ask the doctor to also write on his order to include a ClimateLine hose or not? Will most insurance companies agree to pay for a heated hose or will they say that's an out of pocket expense for the patient?

Mine pays, but I don't know about yours. I don't see a need for a heated hose on the MS Gulf. I live on Wilmington Island, GA and don't even use a humidifier. Of course if you travel to dry or cold climates there is a different consideration. I took the heated hose for that reason as I have relatives in New England that I stay with at times.

Do most patients ask their doctor to write a machine order and also specify a specific set of pressures?

Most patients don't even know what brand machine they have, let alone what pressure they are running. But that is not our concern in this matter.

Would my doctor think I'm trying to tell him what to do?

If he hesitates, I would try to persuade him with a gentle sales pitch. If he is reluctant it could get very rough. I might walk out without a script (or be kicked out).

recommended in his report what my new pressures should be: IPAP 22cm H2O, EPAP 18cm H2O

That would get you a fixed pressure BiPAP. The range of pressures I quoted would require an Auto BiPAP.

If you check cpap.com, the price for the Auto is the same as the Fixed. I see no reason whatsoever to get a Fixed. The Auto can be run as Fixed (as you already know).

If you want the Auto, you need to put together a little "sales pitch" in case the doctor is not immediately agreeable to what you are asking for. Ask if you need help with the script, for sure some members will help you.

[Stevoreno_55]

Would you recommend I ask the doctor to also write on his order to include a ClimateLine hose or not? Will most insurance companies agree to pay for a heated hose or will they say that's an out of pocket expense for the patient?

Mine pays, but I don't know about yours. I don't see a need for a heated hose on the MS Gulf. I live on Wilmington Island, GA and don't even use a humidifier. Of course if you travel to dry or cold climates there is a different consideration. I took the heated hose for that reason as I have relatives in New England that I stay with at times.

Do most patients ask their doctor to write a machine order and also specify a specific set of pressures?

Most patients don't even know what brand machine they have, let alone what pressure they are running. But that is not our concern in this matter.

Would my doctor think I'm trying to tell him what to do?

If he hesitates, I would try to persuade him with a gentle sales pitch. If he is reluctant it could get very rough. I might walk out without a script (or be kicked out).

recommended in his report what my new pressures should be: IPAP 22cm H2O, EPAP 18cm H2O

That would get you a fixed pressure BiPAP. The range of pressures I quoted would require an Auto BiPAP.

If you check cpap.com, the price for the Auto is the same as the Fixed. I see no reason whatsoever to get a Fixed. The Auto can be run as Fixed (as you already know).

If you want the Auto, you need to put together a little "sales pitch" in case the doctor is not immediately agreeable to what you are asking for. Ask if you need help with the script, for sure some members will help you.

If my primary care doctor is not willing to consider writing me a script based upon the pressures you suggested in a previous post which might and I want to stress might allow me to get an auto Bi-Level machine should I take whatever script he does agree to write for me when I go see him next week; hold onto that script and run this all by the pulmonologist; the board certified sleep doctor who I'm planning to see near the end of July 2014 and ask the pulmonologist if he thinks I would benefit from an auto Bi-Level machine at the pressure ranges you suggested in your previous post and see what that doctor; the pulmonologist would say? If the pulmonologist says no to an auto Bi-Level machine then I'll be left with no other option but to take a fixed Bi-Level machine. Again thanks for your feedback.


Stevoreno_55
MS Gulf Coast
06/27/14

[Stevoreno_55]

Would you recommend I ask the doctor to also write on his order to include a ClimateLine hose or not? Will most insurance companies agree to pay for a heated hose or will they say that's an out of pocket expense for the patient?

Mine pays, but I don't know about yours. I don't see a need for a heated hose on the MS Gulf. I live on Wilmington Island, GA and don't even use a humidifier. Of course if you travel to dry or cold climates there is a different consideration. I took the heated hose for that reason as I have relatives in New England that I stay with at times.

Do most patients ask their doctor to write a machine order and also specify a specific set of pressures?

Most patients don't even know what brand machine they have, let alone what pressure they are running. But that is not our concern in this matter.

Would my doctor think I'm trying to tell him what to do?

If he hesitates, I would try to persuade him with a gentle sales pitch. If he is reluctant it could get very rough. I might walk out without a script (or be kicked out).

recommended in his report what my new pressures should be: IPAP 22cm H2O, EPAP 18cm H2O

That would get you a fixed pressure BiPAP. The range of pressures I quoted would require an Auto BiPAP.

If you check cpap.com, the price for the Auto is the same as the Fixed. I see no reason whatsoever to get a Fixed. The Auto can be run as Fixed (as you already know).

If you want the Auto, you need to put together a little "sales pitch" in case the doctor is not immediately agreeable to what you are asking for. Ask if you need help with the script, for sure some members will help you.

If I'm able to get a Rx from either doctor for an auto Bi-Level machine and the Rx lists the pressure ranges as those you recommended in a previous post and when it comes time for me to submit my Rx to the DME for the machine and if the DME says no to the Rx for an auto Bi-Level it's going to all boil down to cost. The auto Bi-Level probably costs the DME more than a fixed Bi-Level and they'll do what most DME's will do which is to provide to the patient a machine that will meet the doctor's Rx's requirements but also at the lowest cost to the DME; a lower cost to the DME would mean more profit for them I would think. If either doctor would agree to write the Rx for an auto Bi-Level and list on their Rx the pressure ranges you listed in a previous post and if both doctors would sign on the line "dispense as written" would that guarantee that I would be able to get an auto Bi-Level or not? Could the DME still refuse to fill the Rx if it's written that way and issue me a fixed Bi-Level machine instead?


Stevoreno_55
MS Gulf Coast
06/27/14

[zoocrewphoto]

Let me try again. Did your very competent monitoring of the data from your old machine show that the therapy was satisfactorily effective at 18 cm? Or did it show the therapy was not satisfactorily acceptable? Did you feel healthy using the old machine at 18 cm?

You know these sleep labs are getting a 7-hour snapshot of your sleep/breathing which does not necessarily represent your long-term, at-home situation.

DeadlySleep:

First of all you can stop with the sarcasistic comments about my competent monitoring of my sleep data. I never monitored my sleep data the 7 years I was on my old CPAP machine at a straight pressure of 18cm because I never got into that stuff. When my old machine quit working in March 2014 I put things into motion then to do what I had to do to get the ball rolling to get a new machine.

It sounded to me like he was trying to figure out whether your current settings were working well for you, of if things have changed. Since you have the Elite, you do have access to current data, so the old machine's data doesn't matter. How is it working for you right now? Do you feel good and have good numbers? If so, then you may not need the higher pressure. Like he said, a sleep study isn't always accurate.

If you do go a fixed bilevel, you can set it for the 22/18, and you won't be breathing against any higher pressure than you are used to now. If the incoming pressure is too high, you can lower it to 20 or back to 18 and work up to it later. If you are doing well on 18, you can set it to 18 and move it up later if you see or feel a change in the future.

I think it is nice to have an auto option, but that tends to be used more for people who need a wider range where it spends most of the time at the lower end. For example, my range is 11-17. I probably spend less than half an hour a night above 13, but it does occasionally spike to 16.9. Part of what keeps the spikes short is that I tend to roll back onto my side as the pressure goes up. Without the machine, I would sleep on my back a lot more. That higher end of pressure actually helps me stay off my back.

If I needed to use a fixed pressure machine, I would probably set it for 13 or 14 and have a slightly higher ahi.

[Sheffey]

Good post Zoo. Thank you.

I think it is nice to have an auto option, but that tends to be used more for people who need a wider range where it spends most of the time at the lower end.

... and Stevoreno could be one of these people. Since he has not used an Auto with data, no one can know at this point.

I believe many people who are titrated at pressures of 16 and above, can be treated for much of the night at significantly lower pressures. Then with the Auto, the pressure is raised for the times of night it is needed.

[Sheffey]

If I'm able to get a Rx from either doctor for an auto Bi-Level machine and the Rx lists the pressure ranges as those you recommended in a previous post and when it comes time for me to submit my Rx to the DME for the machine and if the DME says no to the Rx for an auto Bi-Level it's going to all boil down to cost. The auto Bi-Level probably costs the DME more than a fixed Bi-Level and they'll do what most DME's will do which is to provide to the patient a machine that will meet the doctor's Rx's requirements but also at the lowest cost to the DME; a lower cost to the DME would mean more profit for them I would think. If either doctor would agree to write the Rx for an auto Bi-Level and list on their Rx the pressure ranges you listed in a previous post and if both doctors would sign on the line "dispense as written" would that guarantee that I would be able to get an auto Bi-Level or not? Could the DME still refuse to fill the Rx if it's written that way and issue me a fixed Bi-Level machine instead?


Stevoreno_55
MS Gulf Coast
06/27/14

Could the DME still refuse to fill the Rx if it's written that way and issue me a fixed Bi-Level machine instead?

The DME cannot fill the prescription except as written. To do otherwise is a serious violation of their DME license.

If my primary care doctor is not willing to consider writing me a script based upon the pressures you suggested in a previous post which might and I want to stress might allow me to get an auto Bi-Level machine should I take whatever script he does agree to write for me when I go see him next week; hold onto that script and run this all by the pulmonologist; the board certified sleep doctor who I'm planning to see near the end of July 2014 and ask the pulmonologist if he thinks I would benefit from an auto Bi-Level machine at the pressure ranges you suggested in your previous post and see what that doctor; the pulmonologist would say?

I would refuse the script for a BiPAP in order to show the doctor how determined I am to get an Auto.

I have no problem with pissing off doctors who are practicing doctor-centered medicine instead of patient-centered medicine.

But you have to gauge the strength of your own personality, your determination level and the relationship you want to maintain with this doctor.

Maybe someday soon you will be able to walk into either of those docs' offices with a ResScan chart in hand showing you have used an Auto BiPAP, titrated yourself to a lower pressure than prescribed and are receiving excellent therapy.

[Stevoreno_55]

Let me try again. Did your very competent monitoring of the data from your old machine show that the therapy was satisfactorily effective at 18 cm? Or did it show the therapy was not satisfactorily acceptable? Did you feel healthy using the old machine at 18 cm?

You know these sleep labs are getting a 7-hour snapshot of your sleep/breathing which does not necessarily represent your long-term, at-home situation.

DeadlySleep:

First of all you can stop with the sarcasistic comments about my competent monitoring of my sleep data. I never monitored my sleep data the 7 years I was on my old CPAP machine at a straight pressure of 18cm because I never got into that stuff. When my old machine quit working in March 2014 I put things into motion then to do what I had to do to get the ball rolling to get a new machine.

It sounded to me like he was trying to figure out whether your current settings were working well for you, of if things have changed. Since you have the Elite, you do have access to current data, so the old machine's data doesn't matter. How is it working for you right now? Do you feel good and have good numbers? If so, then you may not need the higher pressure. Like he said, a sleep study isn't always accurate.

If you do go a fixed bilevel, you can set it for the 22/18, and you won't be breathing against any higher pressure than you are used to now. If the incoming pressure is too high, you can lower it to 20 or back to 18 and work up to it later. If you are doing well on 18, you can set it to 18 and move it up later if you see or feel a change in the future.

I think it is nice to have an auto option, but that tends to be used more for people who need a wider range where it spends most of the time at the lower end. For example, my range is 11-17. I probably spend less than half an hour a night above 13, but it does occasionally spike to 16.9. Part of what keeps the spikes short is that I tend to roll back onto my side as the pressure goes up. Without the machine, I would sleep on my back a lot more. That higher end of pressure actually helps me stay off my back.

If I needed to use a fixed pressure machine, I would probably set it for 13 or 14 and have a slightly higher ahi.

The ResMed S9 Elite loaner which I've been using for 3 months now to the best of my knowledge doesn't have any installed software on it although I haven't checked to see if it does. One thing I do check every morning is to see how many hours I slept on the machine; the on screen menu has said and still says "0" hours each morning which can't be right because I have been sleeping on the machine. Maybe the machine is showing "0" hours because there is no software installed. I don't know. The machine's run hours as of right now because I just checked is displaying "973" hours. That amount of run hours; "973"; seems to be low for a machine which my DME told me 3 months ago that it had been gently used for 1 year.

I was too glad to get the S9 loaner from my DME after my old machine quit working. The DME did ship my P.R. DS400S to Philips Respironics for me; I paid the $27.10 for the shipping which was the least I could do because Philips Respironics told me in March 2014 they didn't like patients contacting them directly nor would they agree to accept my machine for them to check it out if I shipped the machine to them myself. They told me they dealt only with DME's. The DME did receive a 1 page report back from Philips Respironics about 3 weeks later which included an estimate of just under $400.00 to repair my machine. I told the DME I was not going to spend just under $400.00 on my old machine; my DME agreed with me on that and told me I could continue using their S9 loaner until I went through my new sleep study; went to see the doctor; got an order from the doctor for a new machine; and finally did receive a new machine. With the way everything has been going so far I hope to get a new machine by the end of August 2014.



Stevoreno_55
MS Gulf Coast
06/27/14

[ButtermilkBuoy]

I would fight like hell for Auto BiPAP.

[palerider]

The ResMed S9 Elite loaner which I've been using for 3 months now to the best of my knowledge doesn't have any installed software on it although I haven't checked to see if it does. One thing I do check every morning is to see how many hours I slept on the machine; the on screen menu has said and still says "0" hours each morning which can't be right because I have been sleeping on the machine. Maybe the machine is showing "0" hours because there is no software installed.

i'm probably going to regret this, but.... what the hell... seems i've got a history of tilting at windmills and attempting surmount the insurmountable... in this case, enlightenment.

the "software" that people talk about all over the forum is either SleepyHead or ResScan, one is an independent opne source free software that is written buy a bloke in australia who frequents this forum, the other is a product of resmed.

the *very* first post on the front page of this forum, Pugsy's Pointers is a nice overview of how to get, install, and use sleepyhead to read the data that's stored on a SD card that's plugged into the back of the machines, on the resmed machine, it's directly behind the power button, on the back. it's possible your loaner doesn't have an sd card in the slot, no problem, any sd card 2gig or bigger will work, just pop it in, the rest is automatic.

if you read any other threads, you'd see people discussing these topics, and posting pictures of data showing how their nights went, like, oh, this one:


this, by the by, would be part of what deadly sleep was referring to about your being competent at monitoring your treatment.

[robysue]

Piggybacking on palerider's post.

It would help all of us help you better if we knew something about what's going on when you are using the S9 Elite with a setting of 18cm.

Are you using EPR? If so, what's it set for?

And what does your AHI usually look like? And what's the breakdown of events?

Here's the thing: If you are having a whole boatload of events right now because 18cm really is NOT enough pressure, the longer you delay getting an appropriate machine, the longer you're going to be sleeping with an AHI that's too high. And you might still not win the battle to get an S9 VPAP Auto or a PR BiPAP Auto in the end.

Your bi-level script is for IPAP = 22 and EPAP = 18. There's not a lot of room for an auto-bilevel to work with, particularly since you have expressed the fear of having the IPAP that high already. Chances are if you have an auto bilevel, the mine EPAP is still going to need to be set in the 16-18cm range. And with a PS = 4, that's going to give you a min IPA = 20 anyway.

I agree that an auto bilevel would be *nice*. But all bilevels record full efficacy data, and the ability to record full efficacy data is MORE important than having an auto. In my opinion, you'll be better off getting a machine that can deliver the pressure you need NOW rather than continuing to fight for a machine that will provide only a bit more flexibility that you may or may not even like. You have, after all, slept with straight CPAP for a large number of years.

[Stevoreno_55]

Piggybacking on palerider's post.

It would help all of us help you better if we knew something about what's going on when you are using the S9 Elite with a setting of 18cm.

Are you using EPR? If so, what's it set for?

And what does your AHI usually look like? And what's the breakdown of events?

Here's the thing: If you are having a whole boatload of events right now because 18cm really is NOT enough pressure, the longer you delay getting an appropriate machine, the longer you're going to be sleeping with an AHI that's too high. And you might still not win the battle to get an S9 VPAP Auto or a PR BiPAP Auto in the end.

Your bi-level script is for IPAP = 22 and EPAP = 18. There's not a lot of room for an auto-bilevel to work with, particularly since you have expressed the fear of having the IPAP that high already. Chances are if you have an auto bilevel, the mine EPAP is still going to need to be set in the 16-18cm range. And with a PS = 4, that's going to give you a min IPA = 20 anyway.

I agree that an auto bilevel would be *nice*. But all bilevels record full efficacy data, and the ability to record full efficacy data is MORE important than having an auto. In my opinion, you'll be better off getting a machine that can deliver the pressure you need NOW rather than continuing to fight for a machine that will provide only a bit more flexibility that you may or may not even like. You have, after all, slept with straight CPAP for a large number of years.

Robysue:

First of all; thanks for the feedback. I have an appointment to see my primary care doctor next week where he'll go over my recent sleep study report and I also hope to receive a script from him that same day for some kind of a new machine. As far as whether or not my S9 loaner has software already installed in it or if "EPR" is turned on; I don't know.

I did tell the RT with the DME several weeks ago it would have been nice if she had brought out an owner's manual with the machine when she brought it out to the house and set it up because I would have been reading that manual. As I have already stated I was too glad to have received a machine to use that was set to 18cm with zero ramp because my old machine is DOA. Robysue explain this to me; why is my S9 loaner showing "0" hours of use during the night when I check it each morning because I have been using it? Could there be something wrong with the machine's hardware? Later now you hear.


Stevoreno_55
MS Gulf Coast
06/27/14