Update:Titration was 14/8. High?. New with xPAP questions

I had my sleep study done on Sunday, and was diagnosed with "significant sleep apnea". I have managed to get a titration appointment for this coming Sunday, and have been frantically reading up on everything I can. I have read a good chunk of the "Our Wisdom" section this evening, and that was really helpful.

I have called my insurance for the local in network DMEs, and one of them is conveniently (for their profits!) attached to the sleep centre. I called them, and they offer Resmeds S8 Elite IIs for CPAP and VPAP Auto 25s for BiPAP, both in stock and available one or two days after getting the results (my doctor got the results later on the same day I woke up from my first sleep study!). I haven't called the other 2 DMEs yet because the high end ResMed and quick turnaround are the two most important things I was looking for- I don't feel like I have knowledge to start getting picky about brands yet, and it feels like until I have used an xPAP machine for a while, I won't really know all the features I am looking for- by which time it will be too late

I really want a fully data capable machine to monitor my progress- I think this is what I figured out so far, but please correct me where I am wrong.


They are both fully data capable
You need the DME to enable the advanced patient menu OR
Get a hold of the ResScan 3.5 software somehow (anyone?), along with the Resmed smart card reader to read the data cards (does it come with one by default?).
But preferably both...



Do Either of them report Centrals or is the VPAP better at handling them? I had one Central in my study, and I want to keep on top those as they seem kind of scary but I haven't come across much information about them yet. If not, what other options do I have for monitoring centrals at home?

When I had my study, the tech trialed me on a CPAP and BiPAP machine in case she needed to put me on a machine that night. I tried the CPAP machine first and found it very uncomfortable to breathe out against, so the tech tried me on a BiPAP and I found that very comfortable for the minute or two I used it. This being the case, should I continue to push for the VPAP Auto- it seems to do everything the CPAP does and a lot more like auto leveling. Will I have trouble getting that past the insurance company- who decides whether I get BiPAP or VPAP- my doctor, the sleep technician or me?

So, given that all this has happened so quickly and the concepts of xPAP machines, titration and apnea are all new to me this week, I am looking for things I am missing and any advice people might have for either the titration, before I go to the DME, or other questions to ask when I go to the DME.

Next thing is to figure out masks- that seems like another huge sticky area. This may seem obvious, but does having a beard make leaks much more prevalent?

Thanks,

Simon

You've got a good start, Simon. You have and are educating yourself. I'm partial to Resmeds myself but even so I have to say that I am impressed that this local DME supplier, even if affiliated w/the sleep clinic, provides the S8 Elite II CPAP and the VPAP Auto 25 as the bi-level!!! While not a Respironics fan I would be just as impressed if they provided the Respironics M Series Pro w/C-Flex and the Respironics M Series Bi-PAP Auto w/Bi-Flex. In other words they provide top of the line devices from the get-go. All four devices I've mentioned are fully data capable devices.

I would ask them about your access to the advanced patient menu. Usually the DME suppliers require that the doctor order access to that menu when writing the equipment order (script) but not always. The data card comes w/the device but the software and cable reader do not. Insurances do not usually pay for the software and cable reader. SOME local DME suppliers will sell them to you IF your doctor will give you a script for them. They can be bought online w/o a script.

Neither the Elite nor the VPAP 25 detect or report Central Apneas to my knowledge. It is my understanding that one of the Puritan Bennetts can. I'm skeptical of that but ... I haven't had the opportunity to use a PB either. ONE LONE CA is not that unusual and shouldn't be of any concern. But you can talk to the sleep doctor about that to better ease your mind.

The Elite does have the EPR function, i.e. exhalation pressure relief of up to 3 cms of pressure relief. During your titration that can be determined. Your sleep doctor has the "say" on whether you need a bi-level - but most insurance companies insist that one fail CPAP before they will reimburse for bi-level except under certain situations which "can" vary from insurance company to insurance company.

Your sleep lab sounds like an exceptionally good one so far from what you've told us. I would be suprised given your evaluation experience if you don't get a very good orientation the night of your titration, good explanations and a selection of masks tried and fitted. I wouldn't say a beard necessarily makes leaks more prevalent, BUT, yeah, most likely much more difficult to get a leak free fit. However, we have several successful "beardies" here using different masks.

So far it sounds like you are on a roll. Continued good luck!!!

Thanks for your reply, I'll see if I can figure out what the criteria is for my insurance- I know that the DME doesn't need to pre-authorize the purchase with them so hopefully I can sneak a BiPAP past them

The Sleep Lab seems great to me as well (Wisonsin Sleep)- its only been open a year, got 16 independent rooms, lots of sleep specialist MDs associated with it including the Clinic Director who has 15 years experience running sleep studies at one of the big hospitals in the areas- I have managed to land a follow up appointment with her next month where I am really looking forward to picking her brain!

Simon

I called the insurance and they don't have any restrictions on BiPAP versus CPAP- whatever a covered DME wants to give me is fine with them (with my Co-pay of course).

Almost seems too reasonable, and not what I was expecting after reading all the troubles people have.

Simon

Yeah, well, there is a BIG difference in price between an auto CPAP and a bi-level! And your DME is NOT gonna swallow that kind of price difference. Your script HAS TO SAY BI-LEVEL in order to get a bi-level so your job will be convincing the doctor to script a bi-level. CPAPs and autoPAPs are the same HCPCS (insurance) code. Bi-levels are an entirely DIFFERENT HCPCS code. Its almost guaranteed your insurance is contracted w/the local DME supplier at a set price for a specific HCPCS code, I've never heard of an insurance that wasn't. Good luck!!!

sparkinson wrote:I had one Central in my study, and I want to keep on top those as they seem kind of scary but I haven't come across much information about them yet. If not, what other options do I have for monitoring centrals at home?

Simon, welcome to the board. You're really doing your homework!

One central, or even a scattered handful of centrals for that matter, in your sleep study is nothing at all to be concerned about. There's no need for you to give that a second thought, or worry for one instant about monitoring for centrals.

Links to Central Apnea discussions
viewtopic.php?p=22702

Thanks, rested gal.

I had my titration last night- I know I slept better than my first study, and I at least entered REM sleep.

The tech said he got some good data, and I got on a BiPAP all night. In the morning he said he put in my report I couldn't use the CPAP, so I should be good to go with the BiPAP when the 'script comes in later today / tomorrow. Hopefully I'll have a machine in a couple of days, as long as the DME really has them in stock.

One thing I noticed and the tech confirmed the next morning was that they kind of forced a breathing pattern on me that woke me up- it was much shorter than I wanted to breathe and I found myself wanting to breathe as it was in an exhale cycle, and vice versa. Anyone any ideas why they do that- he said something would be in the report about it?

No real problems with the mask all night except it rubbed real bad on the bridge of my (admittedly rather large) nose- it was a resmed nose only mask. We couldn't get a good seal with a Resprionics one.

Simon

sparkinson wrote:One thing I noticed and the tech confirmed the next morning was that they kind of forced a breathing pattern on me that woke me up- it was much shorter than I wanted to breathe and I found myself wanting to breathe as it was in an exhale cycle, and vice versa. Anyone any ideas why they do that- he said something would be in the report about it?

Unless the report says they used a timed back up rate for you and the doctor prescribes a special kind of bilevel machine with the letters S/T or STA at the end of its name, a bipap machine should be in synch with your breathing.

Presumably you'll be prescribed a "regular" bilevel..not one with S/T or STA in its name. When you go to the DME to get your bilevel machine (or they bring it to your home) insist that the person setting it up for you allow you to lie down and try it out at your prescribed settings for several minutes -- to be sure it suits your breathing. Breathe normally while trying it out. Don't try to take extra long or extra deep breaths.

All bilevel machines have the basic "IPAP" / "EPAP" pressures. Most bilevel machines also have some extra settings. The names and/or existence of those extra settings vary depending on what brand of bilevel machine they give you. What those extra settings are set at can make a VERY big difference in whether the machine goes along with your natural breathing, or seems to fight you. That's why you need to try the machine out while the "set up" person is there, in case some of the extra settings need to be changed so that the machine follows YOUR lead.

If the person (even if it's an RT -- Respiratory Therapist) setting you up is not willing to let you try the machine out for at least five minutes right then and there, to be sure the machine is not fighting you while you breathe normally, that would be a warning flag for me that I wanted someone else to work with me in setting up the machine. Another warning flag, should the machine seem to cut off your inhalations, would be if the setup person is not willing to try to fix that, or is not aware that there are settings that can fix that. Or worse.... tries to pass it off by saying, "This is what the doctor prescribed. I can't change it. It takes time to get used to it."

You're not asking the setup person to change the prescribed IPAP/EPAP pressures. You're asking the setup person to adjust the "extra" settings that allow the bilevel machine to follow your normal inhalations/exhalations smoothly.

Thanks for taking the time out to give me some advice for tomorrow- I am getting a good idea what all the technical numbers mean now, but really, getting the equipment tomorrow is a journey into the unknown of DMEs- everything I know about them I have picked up from other peoples forum posts, and it doesn't generally paint a pretty picture.

On the downside, the guy I am meeting tomorrow didn't know what the model of the BiPAP machine was- just that it was a "Resmed Auto". I had previously been told they only sell the VPAP Auto 25, so at least they can't fob me off with something else.

On the plus side, it looks like the fitting itself takes place on the sleep lab's premises, and they have been nothing short of fantastic (Call me cynical, but someone at the sleep centre must have an interest in the equipment company, as they companies themselves claim to be independent of each other).

rested gal wrote:

sparkinson wrote:One thing I noticed and the tech confirmed the next morning was that they kind of forced a breathing pattern on me that woke me up- it was much shorter than I wanted to breathe and I found myself wanting to breathe as it was in an exhale cycle, and vice versa. Anyone any ideas why they do that- he said something would be in the report about it?

Unless the report says they used a timed back up rate for you and the doctor prescribes a special kind of bilevel machine with the letters S/T or STA at the end of its name, a bipap machine should be in synch with your breathing.
.

No, there was nothing special about the prescription. It was only for a short period of the night, and he said they were trying something- I got the impression it was to see how I would respond, but there was nothing in the report about it. I'll ask around tomorrow, but I think figuring it out might have to wait until I see the specialist doctor in a months time.

My prescription is a BiPAP at 14/8- is that kind of high? I got the impression most people are around 10. I know a high pressure indicates that I need more pressure to keep my airways open- is that an indication of severity at all?

Other interesting bits from the study:

I had 12 Centrals in a 4 hour period with the pressure at 10/5. Above 10/5 the centrals stopped. Most of them were on my side, not back. I haven't gone through all the many links in your post above yet, but will do.
My AHI at 12/5 was 17.1. At 12/6 it was 37.5 over a short 30 minute period before they upped the pressure- Is such a spike in the middle of a set of pressures normal at all?
At 14/8 for 90 minutes, the AHI dropped to 3.3 (all hypopneas).
They tried me at 15/9 and and 16/10 for 30 minutes with an AHI of0

At no time did my O2 levels drop below 91, which seems like a great sign.
I had 0.3% stage N3 sleep, but 24.1% REM- is that REM Rebound?

Simon

I don't know enough to comment on your questions - BUT - nah, those pressures aren't high. That 14 is just about or a shade above "average" from what little I've read. My bi-level pressures are IPAP 13, EPAP 8.

Really and truthfully, honestly, there ARE GOOD local DME suppliers out there. Keep in mind, most of us who found our way here did so in desperation BECAUSE we encountered the lousy local DME suppliers so we tend to be a biased group. Yours sounds like one of the "good guys" so don't go in w/a chip on your shoulder expecting trouble. You usually get what you are looking for.

Simon, this is not any kind of expert opinion, but it's possible they had you on Aflex. I personally can't use Aflex, it does to me exactly what you've described, and it wakes me up. Others here swear by it long and loud. I am very glad I have a APAP that allows me to use Cflex if I want to (it has Aflex too, but I don't like it).

I cannot explain all the algorithms and gobbeldy gook. I leave that in the capable hands of Laura (Rested Gal) and others. I just know I don't like it.

If you're leaning toward a Resmed machine, other folks can help you with those settings. If you end up with a Respironics M Series, I can help you there. I think all of them have slightly different features and it's just a crapshoot if you like their features or not. No one is going to bring you out 27 machines to test drive before you buy. You just have to roll the dice and pray.

Good luck!
Babs - Who got lucky with the M Series and decided to stick with it.

Slinky wrote: Yours sounds like one of the "good guys" so don't go in w/a chip on your shoulder expecting trouble. You usually get what you are looking for.

I know what you mean- I am really thankful by nature with doctors generally, especially when I find a good one (and I have been blessed by having a great family doctor and neurologist at the moment). As long as he knows more than me and sets me up as Laura suggests, I'll be happy- oh, and he activates the advanced patient menu

Simon

Babette wrote:Simon, this is not any kind of expert opinion, but it's possible they had you on Aflex. I personally can't use Aflex, it does to me exactly what you've described, and it wakes me up. Others here swear by it long and loud. I am very glad I have a APAP that allows me to use Cflex if I want to (it has Aflex too, but I don't like it).

They apparently used a Respironics Omnilab device on me. That sounds like it should do everything! If some people swear by it, maybe they just tried me on it to see if it agreed with me. As you describe it, it sounds like the sleep center being thorough.


Simon

Simon,

My 1st thought was that epap=8 ipap=14 is an odd mix of pressures but when you mentioned the centrals, that mix of pressures is not at all unusual.

The challenge with a bilevel is getting the gap right and the epap firmly set to prevent AI events (obstructive apneas). 8 CMs is your chosen epap setting. If you find 8 ok, then it may pay to not go below that.

As for brands, both Resmed and Respironics have excellent bilevels & Auto bi-levels. One thing you may want to get clarified is if you can ask for a Bilevel Auto (I think the Resmed model you mentioned is an Auto version). The reason for getting an auto over a straight bilevel is that you get more choices in setting them up - they can be run as straight cpaps, straight bilevels or in auto-adjusting bilvel mode.

The Resmed Auto allows the gap to be set and maintained (i.e. start with say epap=8 & ipap=14, if the machine senses respiratory irregularities then both pressures will be adjusted together). The Respironics Bipap Auto adjusts the epap & ipap independently and is great for many people (a very popular machine). But, if that 8 to 14 gap needs to be set and maintained, then the Respironics Bipap Auto doesn't have that ability. When it is in Auto mode it starts off at the manually set epap (8 for you) and then sets its ipap 2 CMs above epap (thus 10 for you) then as it detects events it will adjust each pressure seperately while ensuring a minimum 2 CMs gap and can vary the gap between epap & ipap up to a manually set maximum (which can't be higher than 8 ). Now, I hope I have created too much confusion but it is something you need to be aware of if you are looking at Auto bilevel choices.

Just from your comments it seems your clinic is doing a good job.

Good luck

DSM

I have used the Bipap Auto & find it an excellent machine but I don't consider myself as having identifiable centrals (2 sleep studies showed none).

dsm wrote:Simon,

My 1st thought was that epap=8 ipap=14 is an odd mix of pressures but when you mentioned the centrals, that mix of pressures is not at all unusual.

The challenge with a bilevel is getting the gap right and the epap firmly set to prevent AI events (obstructive apneas). 8 CMs is your chosen epap setting. If you find 8 ok, then it may pay to not go below that.
.

Thanks- the finer points of how centrals interact and why clinics might set the pressure they do is the kind of good info you just wouldn't be able to get without either an advance medical degree or clues from a great forum like this. Now I need to research why . I found 8 pretty easy to breathe against, which surprised me when I found out the pressure. I guess that explains the bump at 12/5 and 12/6- it makes me wonder how people that should be on BiPAP but are on CPAP get on- really, I only got a BiPAP 'script because I read the forums in advance, and was determined to get myself the best machine insurance would allow. Without that I may be "only" on a CPAP and not getting the right treatment (not that I know I am on the right treatment now, but at least all this makes me be vigilant).

Thanks again,

Simon