Best argument for an autopap??

I've been having some issues with my CPAP, and I've got an appointment with the doctor tomorrow. I'd like to argue for an autopap and I'm just wondering if anyone has any insight as far as the best way to approach it.

Here's my history so far and where it stands now:

• Diagnosed about 6 weeks ago and got my ResMed Elite CPAP about 5 weeks ago.
• Initially titrated at 7, Continued to have AHI of 10-12 (an improvement over the 20 in my original sleep study).
• I came here, learned how to self-adjust, and gradually increased the pressure to 10.4, which seemed to consistently keep the AHI under 5. For a while.
• In the last couple of weeks, there have been several nights where the AHI went above 10 again. I tried to respond by increasing the pressure for a couple nights (highest level was 12.4), then coming back down to 10.4. It's only been working sporadically since then, swinging between AHI of 5 to 10-ish with no apparent rhyme or reason related to the level I set it at. Last night I had it at 11.4 and got an AHI of 11 (with AI of 2.0).
• I still feel better generally. I am keeping the mask on all night, waking up earlier than I ever have before, and feeling less sleepy and more energetic throughout the day. But I do feel worse on the days after the AHI goes up and I'd like it to be as close to perfect as possible.

So I called the doctor's office this morning and explained all this, including 'fessing up about self-adjusting (doctor's assistant sounded a little disappointed in me, to be perfectly honest). She gave me an appointment tomorrow with someone who can discuss it with me and take a look at my machine.

What do you guys think? Is this a case of me screwing myself up by self-adjusting? Is this a case where an autopap would be the best solution? I'd sure like the simplicity of it -- turning it on and knowing it's going to automatically do the right thing. What's my best argument to get one?

OH! I forgot to mention -- I am getting the DISTINCT feeling that the airflow varies during the night, as in even though it is set at a certain pressure, it gets weaker during the night and sometimes feels like just a trickle of air -- there might also simply be a problem with my machine. I'd still like the autopap if I can swing it though.

I think the best argument is "I have done my homework, researched machines, believe that APAP would be the best therapy for me, and I am hiring you to assist me, so write me an APAP prescription."

My doc is more pro-CPAP, but she let me have the APAP after I told her my reasoning...which I'll post here:

1) My referral for sleep study was inability to lose weight even though I had been working hard at it for most of a year. Since losing weight often means a chance in pressure requirements, I want a machine that can do it by itself rather than having yet another expensive sleep study.

2) We travel a lot. Pressure requirements are sometimes different due to altitude, etc., and a I want a machine that can handle those changes.

3) In addition, we a "rainbirds" (snowbirds, except that western WA doesn't get much snow) and are gone for months at a time. If I need an adjustment of some kind, I won't be near her office and need a machine that can adjust by itself.

Good luck!

How about ..

From the results I have had thus far, I am finding that leaving the machine at a static pressure works but then does not work for me. The Auto will make that adjustment for me and provide better therapy.

ziggytosh wrote:I'd sure like the simplicity of it -- turning it on and knowing it's going to automatically do the right thing.

Ziggy,

It ain't quite that "automatic".
And, there's the limitations of the ResMed Autos responding to apneas ABOVE the pressure of 10 cm......unless they're preceded by snores or flow limitations.

I'm wondering why you haven't tried higher pressures. I noticed you went a little higher, but only marginally. And you didn't say for how long. Most changes need a number of nights to see if it makes any difference. (usually 3 - 7)
Also, what's the makeup of your AHI numbers? What part is AI and what part is HI?
Are you using EPR? And, if so, which setting?

I have several Autos but use them in CPAP mode.....I found that the pressure changes disturbed my sleep and my AHI was higher when using them in Auto mode.


Den

Thanks for both your replies, all helpful. AuntiNae, yes, I was hoping that my experience so far would point that direction. Hope my doc thinks like you do. And CorgiGirl, I'm actually starting a new government job in a few months that will have me posted permanently overseas, including in some countries where good medical care is hard to find, so the travel argument may be persuasive in my case too. It would certainly be much simpler to have a machine that adjusts automatically than to have to be sending data cards back and forth. So here are my key arguments then, so far:

• My AHI has not been stable at stable pressure settings thus far.
• I could stand to lose 10-20 pounds and plan to.
• With my new job, I will likely not be near qualified doctors that could help me adjust to any changes that affect my apnea.
• I WANT it, it's no skin of your (the doctor's) @$$, so come on man, give a brother some love ...

Thanks again for the input. This is helping me to prepare my case.

Thanks Wulfman. I did not know that about the pressures >10. Would another brand be better if I do go the APAP route?

Also, I'm just trying to be careful with the adjustments and I thought 12 was pretty high, since I started at 7. I am, after all, a n00b though. Is 12 really not that big a deal? Should I try 15 or so?

The AI component is usually pretty low, usually <1.0, often as low as 0.1. On nights when the total AHI goes above 10, it seems like the AI component goes up to 1.5-2. Oh, and I don't really use the EPR, except when I went up to 12, and I used EPR level 2. At least at the pressure levels I'm at, I don't seem to be bothered.

Thanks again for the help!

ziggytosh wrote:Thanks Wulfman. I did not know that about the pressures >10. Would another brand be better if I do go the APAP route?

Also, I'm just trying to be careful with the adjustments and I thought 12 was pretty high, since I started at 7. I am, after all, a n00b though. Is 12 really not that big a deal? Should I try 15 or so?

The AI component is usually pretty low, usually <1.0, often as low as 0.1. On nights when the total AHI goes above 10, it seems like the AI component goes up to 1.5-2. Oh, and I don't really use the EPR, except when I went up to 12, and I used EPR level 2. At least at the pressure levels I'm at, I don't seem to be bothered.

Thanks again for the help!

That's good that the AI is usually less than 1.0. Most of us get used to the pressures after a night or two, so if you want to see what it'll do to the overall AHI, I'd move it up a bit more. If the numbers get better, you'll know you're going in the right direction. From what I've read, ResMeds score higher AHIs because Flow Limitations (partial hypopneas) are scored with Hypopneas. I'd recommend moving up in 1 cm. increments for 3 - 7 nights at a time.
Respironics Autos WILL address events higher than 10 cm., but they've got their own methods of limiting runaway pressure increases. If they encounter a stubborn Apnea, they'll back off the pressure after three pressure rises (that don't clear it).
The Covidien Sandman Auto is another good machine from what I've read.....but they don't have exhale relief.

They've all got their good points and limitations. Do enough research before you make a decision on what you get.

A pressure of 12 isn't a big deal for me. I've been using that setting for over 2 years.

Edit: PS......snores and leaks will drive an APAP/Auto crazy.

Den

ziggytosh wrote: Is this a case of me screwing myself up by self-adjusting?
I'd still like the autopap if I can swing it though.

ZiggyT, I think this is a case of you, taking control of YOUR therapy.

Swing it, make it so, Number One.

My suggestion:
create some kind of log to keep track of the changes and their out comes.
It only takes a few days and you will see which way a change is trending.

I was 'scripted 8cm, and now life is so good at 12.5cm and C-flex 2.
It took 2.5mths of data and six masks to get there.
I just say NO to ramp.

Sunday night was my 5mth anniversary w/cpap.
Last night was the best sleep I have had in 10yrs.

Become your own best therapist.

Don't be too quick to make adjustments. Generally best to leave it for a week at one setting, accumulate some data and make your adjustments based on that data.

I have an Auto and find my results can vary. If I wake up at 4am and don't fall back asleep and don't remove the mask the AHI can rise... but events happening while awake are meaningless thus the reason for a higher score. I find that a sore back seems to increase my AHI as well. Lately the issue is waking up far to early and inability to get back to sleep... perhaps I am slept out by that point. <shrug>

I don't leave my Auto run on wide open mode but instead have the range set 8 - 15. Eight is what I was titrated at however it was noted in the sleep study that a higher pressure might be required to achieve better control so I generally find the machine running anywhere between 10-12 most of the night.

Arguments:

-I did not have to fight with my Doc for the Auto prescription; however...
-The Auto machine means I will be at the lowest pressure for effective treatment most of the night. Why use a pressure higher than necessary?
-Having an Auto also means you can do some measure of self-titration although not to the extent a sleep lab can.
-Some folks have trouble finding their "sweet spot" in terms of pressure with a regular CPAP and thus find the APAP works very well for them.
-There is a lot of skepticism that losing weight will affect apnea; however, if you do have weight to lose... and do lose it the Auto will self adjust to your new requirements depending on how you have the range set.


In any case, an Auto machine is really nice to have because it is essentially two machines in one in that it can function as a regular CPAP and APAP both. You might decide to try the straight CPAP mode once you have determined where your pressure spends most of the night with the APAP.

My Auto just turned over 500 hours of operation last night... wheeee! Time flies when you are sleeping better than pre-machine!

Note: You shouldn't go by "AHI" on that machine. You should only go by the "AI" or Apnea Index. "HI" on that machine can increase and decrease dramatically on a night to night basis. AHI is somewhat skewed on that machine, so toss it out. AHI can be used to glance at how you are doing, but you want to know if the pressure is keeping Apnea (AI) taken care off. IF HI is over 5, bump pressure up by .5 cm. You should be abled to get your AI down to about .8 on that machine, AI=1 is easily obtainable.

However, if your pressure needs are hovering around 10 cm, going with a Resmed auto may not change anything over what you have now expect your wallet will be lighter.

If your current AI=1.0 that is about all you can expect to get out of that machine. If AI=1 then hopefully HI is under 5, if not you need to bump pressure by .5 cm.

Use of EPR can impact your therapy (negatively) the same as using a autopap with a lower Minimum pressure, difference is the Auto will only deliver the pressure you need and it also has the same mode as current machine.

If you are wanting an autopap I would get the Sandman Auto machine if you are wanting most flexibility and best therapy.

Best argument for an Autopap? you may be losing your job and medical coverage,

WHAT IS YOUR LEAK RATE AT ALL THESE SETTINGS YOU'VE TRIED?
What Mask Selection are you using?
How are you and the Quattro full face mask getting along?

Your A #1 best argument in favor of the Resmed S8 II AutoSet (or Resmed S8 AutoSet Vantage) is that you are starting a new government job in a few months that will have you posted permanently overseas, including in some countries where good medical care is hard to find. That can also be your excuse for why you've played around w/your therapy settings since getting your Elite.

Until you have your Leak at an acceptable level you can be changing pressure settings for eons before you find the right pressure(s) for you, if ever. I had to learn that the hard way thinking a chin strap wouldn't help w/the 'lip flutters" and sure I wasn't opening my mouth to breathe during sleep (I use a nasal cushion). I've had 0 Leak rate EVERY NIGHT the last 2 weeks w/a chin strap and <5 AHIs.

I prefer the ONE CHANGE FOR ONE WEEK method, including mask changes (or chin strap use) as one change, not just pressure changes as one change. The first two nights seldom show a true picture when I make any change. (No, patience is NOT my virtue!)

And frankly, while SnoreDog can be a lovable ole curmudgeon and is a pretty sharp cookie - usually - forget the d*mn Resmed 10 cm bit!!

Here's a pretty recent thread where the virtues and limitations of several machines were er....um...."discussed".

viewtopic.php?f=1&t=36570


Den

Wow, thanks again for all the input.

Wulfman and Slinky, you both mentioned leaks and mask issues. I THINK I'm doing ok in that department. I have selected "Mir Full" in the Elite II's settings. I'm generally pretty comfortable with the mask. No real complaints. I do open one side once in a while, usually for a second or so, to scratch my nose or whatever. The straps were annoying at first, but I seem to be over it. I've kept it on the whole night all but a handful of times. The reported leaks (off the top of my head) range from almost nothing to about 0.20 (I think that's per second, not minute). From my limited understanding of how this works, I think that is within acceptable limits, right? Sounds like there are some better masks out there, and I will probably upgrade at some point, but I'm OK with this for now.

Snoredog, I'm not married to ResMed, and would definitely consider other brands. My dad got diagnosed soon after me. He got a Respironics apap (not sure exactly which one, but he's a gadget freak so paid out of pocket and got a fancy one right off the bat). If I had a choice, I'd probably get the same kind he did, just so he and I can share parts or whatever if needed. I'll definitely read up on that comparison link Wulfman posted (thanks again!), but it sounds like a Respironics APAP might work for me if I set the floor to 10 cm -- 3 cm auto increments would probably do the trick most of the time at that level and I already know I can fall asleep comfortably at 10.

Carbonman and Paul, thanks for the encouragement. I'll use the travel argument and hopefully my doctor is swayed. I'll make any additional changes slowly, but hopefully I get the APAP and don't have to do much tinkering myself after that.

I could sing the praises of my AutoSet all day long. It has really made a difference in my therapy. I was feeling better than before CPAP but I knew I still wasn't totally rested and feeling as good as I should. I just kept insisting that I still was not rested. At my last appt I told her something had to give because my 5 year old wanted to know why I was so tired all of the time. (now she's probably sorry bc mommy is cracking the whip and we're all cleaning house more often now! LOL)

Anyway, I just asked her if she would consider treating someone on a long term basis using an APAP. She said she is okay with it but since my titration was so poor... bad sleep night for me... she wanted another. They did ask me to try the static pressure for one more week. I would have good nights and bad nights and still wasn't doing well consistently so we went for the APAP.

I noticed though, that my apneas were preceeded by hypopneas/flow limitations so I knew it would kick in and take care of any apneas that still happened @10cm. I am very pleased. My AHI was 1.8 this am with an AI of 0.0. I was shocked!!

2girlsmom wrote:My AHI was 1.8 this am with an AI of 0.0. I was shocked!!

WOW! Now that is inspiring. That's where I'd like to be. Is the housecleaning mandatory though? Please don't tell my wife, ok? I can act tired if necessary.