Need help to convince Dr about APAP vs CPAP

Late next week I have an appointment with my sleep doc for a follow up on my treatment at about 9 months since starting with CPAP. I would like some advice from you all on how I should proceed. I have been monitoring myself with the Encore/MyEncore software and I have consistently been up somewhere between 6 to 10 AHI every night. I need to take Provigil to keep myself functioning normally at work otherwise I still have major daytime sleepiness. I have varied from my titrated pressure of 10 up to 13 cmw with no change in AHI. When I talked to my doc after my 1st sleep study in August 2005 I was a newbie here and heard about APAP and questioned the doctor about it. He told me that he did not feel secure with APAP because it was an unproven technology and that I would get a CPAP machine. Of course both the doc and my DME told me that the only information they can get from my smart card is compliance data I don't know if this is what they actually believe or if they were just trying to sell me a line.

My questions to you all are these:

Do you think I would be better off treatment wise if I had an APAP instead of a straight CPAP?

Can someone give me any hard data/studies that would suggest APAP is better at controlling apnea? To help convince the doc.

I talked to my DME yesterday and they told me that they believed my insurance company was going to start denying payment to them soon on my CPAP machine so in essence I will have purchased it in a month from now. Since this machine is about to be mine and since I feel the treatment is not going as successfully as it could go I will prod my doc to give me a prescription for an APAP machine if could possibly help control my OSA better than my CPAP.

Any advice would be greatly appreciated!

Dale

Most of the studies suggest that APAP is at least as effective as CPAP. I don't know of any that say that APAP is MORE effective than CPAP. Also, since each of the manufacturers have develoepd their own controlling algorithms, its tough to talk about APAP as a whole. Respironics APAP is very different frrom ResMed APAP which is very different from Puritan_Bennett APAP.

If you want a place to start looking for yourself, try the Respironics or the ResMed web-sites that have panes for clinicians. These will give you refernces for studies. The ResMed site will actually give you links to at least the abstracts for the studies. From these abstracts, you can get links to MANY mores studies. The Respironics site will give you their own abstracts, but NO links.

I started xPAP tx in the beginning of April on a Fisher&Paykel CPAP, then went to a ResMed S8 Vantage AutoSet APAP. I'm planning to talk to my Sleep Doc now about setting my AutoSet to run in CPAP mode, since I'm NOT sleeping better in APAP mode.

Everyone on this forum is enthusiastic about APAP, for good reason. it makes a lot of sense. But, its not the be all and end all, for everyone. Find what works best for you by sensibly experimenting till you find the best combo of machine, mask, hose, hose management, sleep hygiene, protocol, etc. Don't get hung-up on initials.

Chuck

APAP means OPTIONS.
We're all different. Don't go for an APAP because you think they must be "better" than CPAP. As you've seen, some folks do better on straight CPAP.

If all they can get from your machine is compliance data, then the only thing they are basing all of their decisions on is a sleep study in a lab. Compliance data doesn't tell them how you're doing. Only that you're using the machne ( or not using it ).

Using myself as an example ... I was able to print out DATA from my EncorePro/MyEncore as saved by my Respironics APAP with CFLEX and integrated humidifier.

"here is how it came initially set for range pressure"
"Here is how I set it to narrow the range"
"See how little pressure I need most of the time?"
"I do apparently need more than my titrated pressure at times. Maybe position-related... see here?"
"This is where I raised the top of the range by 1cm to 11. Looks like it helped lower my AHI average over the next couple of weeks. Maybe having the ability to go that high cuts out a couple of episodes."

The APAP itself is not the be all and end all. Don't buy a machine to have a new gadget or because someone else has it. If you are doing WELL on straight CPAP... it's one of those, if it ain't broke don't fix it things...
However if you are NOT doing well... especially after 9 months.. ask yourself FIRST if you are being compliant. Honestly. If you ARE or you are honestly TRYING but the machine or something is not working out, THEN you need to look at making changes or you'll be stuck with a machine that possibly isn't doing all that it CAN for you.

APAP is all about options. If your doctor has concerns, tell him you'd like to do this APAP because of the data you can collect. And that you understand that you may eventually be setting it in a straight CPAP mode, but that you think it would be valuable to see the data over the long term and what effects the various pressures have on your apnea.

When my first machine was broken and was going to be in the shop for a while. Know what the DME was sending me home with?

You guessed it... an APAP.

Thanks for the replys Chuck and Yardbird. I am not set on getting an APAP machine only asking if it might be a better machine treatment wise than a straight CPAP unit. I have been 100% compliant from day one except for 5 days in the hospital for an emergency appendectomy.

I have been at this for only 9 months but in those months aside from the initial few weeks of euphoria with treatment I am slowly slipping back to my post treatment state.

Make no mistake I am better off than I was before treatment but and this is an important "but" I am not where I should be. I may not ever get back to what non-hoseheads enjoy but I want to get as close as possible. I have extreme daytime fatigue that was making my work dangerous. I work around machinery and I had a hard time focusing on my work with power tools. I do not want to lose a hand or arm because I did not realize what I am doing so I am taking Provigil to help me keep alert.

I am only looking for the best possible treatment that I can get that will help me live a more normal life. I feel I am not close to what CPAP treatment should be doing for me, especially since I am compliant. I have had issues with masks as you can see from my "comment" section but I dutifully wear them each night.

It will ultimately be up to my sleep doc to determine what course I will have to take. I know a lot of people have opinions on doctors and whether or not they truly know the treatment end of their business. I want to be an informed health care consumer so I take in as much information I can and discuss "all" the options with any doctor I see, then we, the doctor and myself determine what to do. Most importantly I place a lot of trust in the physician a lot of it because of the intense studying they all do to be able to practice medicine. I am not saying there are no bad doctors I am just saying in general doctors are usually more informed than even the most informed patient. Us hoseheads can be highly informed but I doubt that we can say as a rule because we use the equipment we know more than the doctor about the treatment. We have anecdotal evidence from some about how their treatment works by doing this or that but that is what it is only anecdotal evidence, it may not work for anyone else. I am not trying to put down what others here in the forum do only that as most of the very helpful people state in their posts "in my humble opinion" or " I am not a doctor but this is what I recommend"

Thanks again for your posts

Dale

Just curious Dale,

Your equipment list shows a Remstar Plus. This machine does not record treatment data other than usage. Is this the wrong machine listed? If not then how are you getting the treatment data?

Sorry Handgunner45 I didn't realize I had the wrong one selected. I have the Remstar Pro 2 with Cflex and heated humidifier. I will have to go into my profile and find the correct one.

Thanks

Dale

Dale92:
The reason I purchased an APAP CFLEX is due to flexibility and the data it records. The flexibility gives me more options, and the data collection allows one to 'tinker' for their best settings without a sleep lab*. Also, the data collected can be provided to doc/lab tech so that they know how you're doing under different settings, if you choose/need to change them.
(*) Sleep lab: I've had two different sleep labs provide me with different results and recommendations!! Flow rate, need for oxygen, and addition of CFLEX were amonth the differing results.

If you're getting good results (how you feel, and tracking info is satisfactory to your doctor) go with what you have.

I have other 'issues', PLMD for one, thus I want more data collected, and that option is only available on other machines.

This is just MY opinion, based on MY needs, or what I FEEL that I need, since the professinal advice has been conflicting.

Something to consider. I don't know if since you are so close to purchase on your current machine you will get insurance approval for another (APAP). I would assume that it would only be with the support of your doctor saying that the current machine is not working for you (like a change in Blood Pressure meds when there are 20 days of pills left)

I know you havn't decided that you really want an APAP, but if you do decide that it would be best for you, check to see if it is even possible to get the insurance to pay.

If not, and you decide that you want one anyway, take your prescription (the one for your current machine which everybody should get from their doctor as soon as it is written, and hold themselves, no matter what anyone tells you -- gives you options and power) and order what you want from Cpap.com.

I just read the prescription requirement section of this web site and it looks plain to me that a CPAP prescription is valid for APAP

https://www.cpap.com/cpap-faq/Prescriptions.html#133

$700 - $800 or so. your currernt hoses and masks should be fine.

What this means to me is your doctor DOESN'T HAVE to agree. You can get whatever you want, just not with insurance.

Good luck with whatever you decide.

Dale, as Yardbird already said, some folks do better on CPAP than APAP. I haven't read an instance where anyone has said they get lower AHI on APAP, but some get relief from aerophagia and feel better by spending part of the night at lower pressure.

FWIW, I found out recently that mouth breathing has been a contributer to my own AHI staying high like yours. My AHI has been hovering around 5 or so. I finally started using the Poligrip strips a few nights ago and when I can manage to keep my mouth shut for most of the night my AHI drops markedly. May not apply in your case, but thought I'd mention it.

Regards,
Bill

Snoregirl:
I talked with my insurance company 2 days ago, fortunately a very friendly rep. They know nothing, nor do they care about what KIND of CPAP machine; they pay submitted charges from the DME until the 'computed cost' (that's done by computer, they have no control) rejects the claim. At that point, whatever machine you're renting is YOURS. So, if you have a few months left on rental (assuming that's what you're doing), you can request an upgrade from the DME. If they claim not to 'have' it, you can then find another DME who does, and switch to them. Granted, the 2nd DME won't be getting the $$ for what they provide, but it's too bad that we need to ignore that fact.
I recently requested from sleep lab nurse practitioner that she write me a new Rx indicating that I receive "CPAP CFLEX machine OF MY CHOICE". I intended for her to indicate APAP, but the 'choice' should cover that. I'll find out.

Dale,

Do you have a copy of your sleep study results? Did you have any incidence of central apneas. Central apneas will not be corrected by CPAP.
Your 6-10 AHI indicates that you are not receiving complete treatment. You should be below 5 to be considered successfully treated although any treatment is better than nothing. I would seriously push you Dr to at least order a titration study with an APAP to see if a higher pressure would help to reduce your AHI further. You can also do this with the CPAP. Just increase 1 step at a time and try it for a week.

I occasionally have nights with my AHI up around 6 and I know that I do not feel as good during the day as I do if my AHI is around 2 where it is normally.

Thanks all for the replys they are much appreciated and helpful!

Handgunner45 I do have a copy of both of my sleep studies, my original from August of 2005 and the one I had in January 2006. I guess I misspoke I actually had another study in 1999 that did not find any "significant" anpeas even though I have had the same symptoms since then, funny how a different doctor, different tests Anyhow I am pretty sure I did not have any central apneas in either study but I will look back and check. Also the 1st study set my pressure at 18 which I had no problem handling except finding a mask that would keep a seal. Then in January I had a mandibular advancement device made and was retested and the pressure was set at 10.

Who knows maybe the last test was a fluke and I really need to be at the higher pressure of 18?

Thanks again

Dale

There is absolutely nothing wrong with the machine you have now. The REMstar Pro 2 is used by many people on this forum and they do just fine. And just as Yardbird says some people do better on a CPAP than they do on an APAP. The APAP just opens some more options for you. For example the APAP can be set up to operate as a straight CPAP with or without C-flex provided it's a Respironics model. If an APAP is what you want then go for it but don't let a few tell you that it provides better treatment than a CPAP because it doesn't. What it may do is allow you to be more compliant with your treatment but from what you post that is a non issue. There are people out there that use an APAP to determine their best treatment pressure and then set the unit up in CPAP mode at this pressure for treatment. Nothing wrong with that. Look for a hot post from a user going by the profile name "Jerry69". He uses the pro 2 unit, posted his sleep data graphs and describes how he found his best treatment pressure. His is probably a prime example of how well one can do on a machine such as this. Good luck with your quest. .