getting defective CPAP machine fixed

Folks:

My Respironics REMSTAR -- BiPap Auto 500M is about 30 months old --6 months out of warranty I believe-- and it is now emitting a loud high-pitched whine, loud enough to be heard over the "covering noise" of a box-fan running at medium at the foot of our bed. My wife can't sleep through this and I'm on the living-room couch for the duration. (Another example of how each case of Sleep Apnea can affect more than one person.) This is entirely unacceptable.

(The process of figuring out the source of the noise is documented on another recent thread.)

So, what to do?

Resources: I have a primary care physician with a major U.S. HMO. He is a great guy but doesn't seem to know much about Sleep Apnea. He did the original screening from a checklist. The Sleep Doc confirmed the diagnosis by remote control -- I've never seen him. I was handed off to a well-known DME vendor. The people in their local office have consistently demonstrated no interest in my care, just concerned about doing as little as possible and billing my HMO for as much as possible. (Thanks for listening to this bit-of-a-rant. I'm sure it is a familiar story. )

Respironics apparently provides no direct user service, nor does their website list any independent service vendors. A quick Google didn't show any independent service companies in my area (SF Bay). If I locate an independent service company there's still the issue of repair logistics. Are there _any_ such companies. If so: Are loaners or overnight exchanges available?

I think I can buy a new machine from some independent suppliers, but (presumably) only with a prescription. I think my HMO won't supply prescriptions that are usable outside their system. I don't want to pay street price for a new machine, but that is actually preferable to dealing with my DME vendor.

Right now I have an urgent request into my primary care doc: "My CPAP machine is defective, must be fixed or replaced. YOU need to handle this. I do not trust <the DME>."

If this doesn't produce a fast, full fix, what are my options? Try to educate my G.P.? Loan him a copy of Dement's book? Demand an appointment with the Sleep Doc, who might be more understanding? Bump the issue up the HMO grievance ladder? Accept driving to a more distant office of the same DME company? Eat crow and go to the same DME after all? Go to the same DME "under protest"?

Suggestions, please!

I should make this clear: Overall, the CPAP treatment isn't trouble-free, but it is working and I feel incredibly much better. I'm not a complainer. I definitely don't want to expend a lot of energy hassling about the DME. I just want to get the machine working as is should, quietly, and get back to normal. The couch isn't exactly perfect...

TIA,

Hen3ry

I don't understand your reluctance to bring this to the attention of your DME. Your primary physician can't issue equipment or repair it. I assume you have a prescription, and your device has malfunctioned. Get the DME to exchange it, or ask if they need a new prescription.

You will need to take it back to your (or a different) DME to get it repaired. There are no authorized CPAP repair companies that I know of. When we send a machine back for repairs it always goes to the manufacture. Your HMO "should" either pay for the repairs or purchase a new machine for you if the machine is out of warranty. They "should" also give you a machine to use while yours is in for repairs.

Thanks for your responses.

To repeat, I don't want to make this a gripe session.

I just heard from an assistant in the office of my primary care physician. Based on her questions, I think I'm beginning to grasp the root of the problem:

My HMO in general --and my primary care physician specifically-- don't really know much about treating sleep apnea. They believe that the DME is responsible for my treatment, under only the most general supervision of my primary care doc. The local DME personnel believe their job does not extend much beyond taking equipment off a shelf and handing it to people who show up with the right paperwork.

One of these interpretations is wrong, or there's an additional group of people at the HMO whose job it is to monitor long-term care of sleep apnea patients and take care of any issues that come up. If so, no one told me about them, and the assistant didn't know who they are, either.

I gained the most traction with the assistant when we discussed who was responsible for periodically reading the data card in my CPAP, interpreting the data, and making adjustments accordingly. Clearly she recognized this to be essential. She said she didn't think it was the DME's responsibility. I asked, "Could Dr. Smith (her boss) do it?" "Definitely not!" Then who? She didn't know, but promised to find out.

---

In perspective, when I arrived at the DME 30 months ago, I was befuddled, ignorant, and incapable of being my own advocate. With the help of the CPAP machine, I'm sleeping much better and thinking much clearer. Dr. Dement's book and you in this group have helped me learn about sleep apnea and to take control of my part of the treatment.

Today, I'm learning what mechanisms exist -- or should -- and what words work best.


----

Another call from the assistant just now. Oh, it just happens that there's a new department, "Outpatient Respiratory Care", whose job it is.... This is a hopeful sign. I'll post back what I discover, hopefully early next week.

---

Seems to me that most (all?) sleep apnea suffers should definitely receive clear answers to the following questions:

1. If my cpap machine appears to be malfunctioning, what is the exact process for evaluating the problem and getting it fixed or replaced as necessary?

2. What, in general, is the treatment protocol? Who is monitoring the long-term results of my treatment? Specifically, who is responsible for reading the data card periodically and making any adjustments to the machine or my use of it? How often does this occur, and what is the exact process?

3. Who can help me with using the cpap machine? Pick a new mask? Make adjustments? Know if I need a humidifier? Does this require an appointment? Can someone answer such questions on the phone or by email?

Hope this helps,

Hen3ry

This is a good point for having some type of back-up plan in place prior to a break down.

For me that means I have an extra machine available that I purchased used. I have two perfectly good machines (actually 4 as I have two older machines as well) that I can fall back on if needed.

sleepycarol:

Good point about a back-up plan. In theory, living in a massive urban area (San Francisco Bay) not far from the HMO and DME, I should be able to depend on the DME stock to get immediate replacement. (I've also wondered about problems while traveling, especially to 2nd or 3rd world countries. But that's a completely different issue.)

Only a bit off-topic, some follow-up questions:

1. Will reputable vendors sell such machines without a prescription? Will doctors issue such?

2. Did you get your used machines from private parties? If so, how confident are you in the machines? How do you establish your settings on a machine obtained this way? Do you have the "inside" information?

3. What is your experience with Remstar M Series Auto machines? Have you had breakdowns similar to mine? (This is the second machine I've used that developed an unbearable noise -- the first was a loaner.)

Thanks,

Hen3ry

Might check out this site: http://www.acbio.com/

This is kind of an old thread, but it got my attention as we run across these concerns during the course of business at our company. Here are my answers to these thoughtful questions that may be of some concern to others:

1. I don't know of any reputable company that would sell a xxPAP device without a prescription. The downside of having an FDA visit for selling equipment without proper documentation is not worth the risk. We get requests from people that are doing EWOT (exercise with oxygen therapy) that want to buy an oxygen concentrator and we cannot sell the concentrator to them unless they get a prescription from their doctor. In that case we would be dispensing a drug (oxygen) that is controlled. Additionally, we set up the cpap/bipap machine according to the script. We are licensed by the Missouri Board of Pharmacy and are obligated to abide by their rules.

2. Buying a machine from a private individual is, in my opinion, like buying anything else...cavaet emptor. There probably won't be any warranty as typically manufacturer warranties are void with a change of ownership. Also the machine will not be set up to the new owners specifications and it may be difficult to find someone to perform that if the new owner isn't "tech savvy". As mentioned above when we sell a rebuilt cpap or bipap we take the prescription and set the machine according to those specifications.

3. In our experience your breakdowns are not typical of this model. It sounds like bearing noise may be the culprit. Basically that's a blower malfunction.

Hope this has been clear and helpful. Please let me know of any other questions I may be able to answer.

accurate-Ian:

Thanks for your very informative post.

It seems that xxPAP therapy occupies a kind of grey area in the minds of many health-care professionals: It'simportant but not important enough to provide more than minimal contingency planning with respect to equipment failure.

My introduction was a 20-minute perfunctory training by an RT at the DME, which started with unpacking the machine and peaked at mask-putting-on ("Yep, it's on. Now take it off, pack up, and get out of here."). One sentence about potential equipment failure: "Your machine has a 2-year warranty, so you'll be fine."

Sorry, I can't help noting that docs, RT's, and executives of xxPAP manufacturers all might have a different viewpoint if more of them required xxPAP every night -- but I wouldn't wish sleep apnea on anyone.

Thanks for the observation that the breakdowns I've seen are not typical of this model. Have you ever seen systematic reliability data and failure analysis for this model? I haven't seen any, though I can't claim to have looked. My guess is that no one involved in my care has seen any. So, it's "Your machine has a 2-year warranty, so you'll be fine," for pretty much everyone. Sigh.

That said, as a (former) tekkie with lots of experience in making computer-chip-containing boxes --which is what xxPAP machines are-- I'm ready to believe that reliability is generally extremely high. As long as the owner uses reasonable care, the electronics should be bullet-proof. But tekkies also know that moving parts are the weak links of such systems, and my experience seems to confirm this.

So, in your experience, do you have any proven or at least reasonably certain guidelines for preserving the health of xxPAP boxes? Does air travel seem to have an effect? Rough handling? (If so, can you give an idea of what's OK and what's "rough"?) Operating conditions -- for example, do the machines suffer from not being on a flat surface while running?

TIA,

hen3ry

First off if your going through your insurance, they may not elect to purchase new equipment, they may elect to repair. Your DME has a responsibility to you to help you with this. Technically since your Insurance purchased your equipment, its your responsibility to get it fixed, but this is very bad business. Your DME should send your equipment off to be repaired or replaced (Depends on your insurance) then bill your insurance for either the repair or replacement. Most reputable DME's will provide you with loaner equipment while your primary machine is away for repair. If your DME won't do this then check other DME's in your area, as I said earlier, if the equipment is purchased then any DME can effect the repair or replacement process (most DME's are always looking for an easy way to pick up new patients).

hen3ry wrote: That said, as a (former) tekkie with lots of experience in making computer-chip-containing boxes --which is what xxPAP machines are-- I'm ready to believe that reliability is generally extremely high. As long as the owner uses reasonable care, the electronics should be bullet-proof. But tekkies also know that moving parts are the weak links of such systems, and my experience seems to confirm this.

So, in your experience, do you have any proven or at least reasonably certain guidelines for preserving the health of xxPAP boxes? Does air travel seem to have an effect? Rough handling? (If so, can you give an idea of what's OK and what's "rough"?) Operating conditions -- for example, do the machines suffer from not being on a flat surface while running?

You seem to be avoiding answering the questions in your original thread regarding how you handled this piece of equipment. That void leaves some reason to suspect you know what happened. Really!!

Then there is this:

GumbyCT wrote:Gumby has a theory about how travel affects cpap equipment. I am beginning to wonder if when traveling people aren't simply emptying the humidifiers "completely" (or at all) and any remaining water makes its way into the electronics of the machine. And when the power is applied the water shorts out the components which have water on them. Squealing noises can be caused by bearings.

Some folks may not even realize when this has happened while others are certain to outright deny they played any role in the fate of their equipment. After all, it's always someone elses fault, isn't it?

Probably the best way would be to carry 2 humidifier chambers, the 2nd doesn't even have to hold water or be a good one. Just use it to put in the machine when packing because you know it is DRY. Take the other, empty, water chamber and put it into a plastic bag and pack it separately. This way any remaining water drops can't get close to your working machine.

I would use the empty water chamber only to help keep dirt and other contaminants out of the inside part of the machine.

If you can dedicate a machine just for travel is probably the very best way bc if it is lost or damaged you will still have a machine. You are less likely to forget things this way. Plus you can pack everything you need up way ahead of time and not rush or forget to empty the water chamber in the morning. Well except for the return trip.

HTH

Really:

Thanks for your response:

Really wrote:You seem to be avoiding answering the questions in your original thread regarding how you handled this piece of equipment. That void leaves some reason to suspect you know what happened. Really!!

Hmmm, I don't think so. In my original thread I was trying to diagnose the problem, which at first I thought was a mask issue. Once I realized something was wrong inside the box, I started a new thread. In my posts on this second thread I've disclosed everything I can think of that might have caused the problem to develop. I didn't go into detail, but yes, the way I've arranged the box, it's tilted about 30 degrees during operation. That should not be a problem --I don't recall any "keep horizontal" kind of warnings. By mentioning it I figured I might jog someone's memory.

I'll revise my profile to eliminate mention of a humidifier. I used one briefly just after starting treatment, but I have not used it since. I failed to distinguish between equipment I own and equipment I use.

The point in GumbyCT's post is important for any kind of electronic equipment, and the solution looks like a good one.

Bottom line: I am certain I didn't mishandle my machine. I'm very careful with it -- because it helps keep me alive, and also because I have a very strong desire to avoid the difficult people at my DME vendor.

Thanks,

hen3ry

Henry,

Good questions (and I'm afraid lousy answers).

We have a non disclosure agreement with our warranty contracted manufacturers so forgive me if I appear somewhat "overly discreet". I am not able to put into specific numbers our failure rate tracking.

However, I did ask the head of our biomedical department if he could supply me with the cause of the largest amount of cpap failure. His response was that the biggest volume of repairs that we perform are caused for two reasons:

1. Filters are not changed regularly. I know this sounds very elementary but you would be amazed at what we find inside some of the cpaps we repair. If dust or foreign matter works its way through the filters two things will happen. First the dust and debris will work its way into the bearings of the blower motor and cause the eventual failure of that component. Secondly dust will eventually collect on the printed circuit board and cause shorts between circuitry and cause a failure of the control board.

2. Humidifiers. Again elementary, but we do see a plethora of cpaps that have been damaged by water. Typically, they fall off the nightstand or table that they rest on during the night and water enters the system and creates havoc. Sometimes people move the cpap with the humidifier attached and water sloshes into the intake. Then when they turn the unit on water enters the unit.

As far as tilting the cpap there should be no adverse effect as long as long as the angle is not so severe as to allow the humidifier's water to enter the machine. I would not suggest operating the unit on its side.

Air travel, as long as the machine has some cushioning around it when packed, should not be an issue. However, I have seen baggage handlers performing the ever popular "how far can I throw this suitcase" game and I would pack the cpap very carefully. I was thinking that putting it in carry on would be the alternative but then wondered about TSA and how much scrutiny they would place on a small square box with electronics.


I would say any drop from around 12" is cause for concern as the internals (particularly the blower) could be shocked out of alignment.

I agree with your comments as to the lack of empathy exhibited by various professionals in the industry.

I hope I have been some help on this and have not appeared condescending to an experienced audience that deals with this equipment on a daily basis.

Ian:

Thanks for your generous and not-at-all condescending response.

Actually I wasn't asking you to produce reliability data. If the data is good, it should be freely available from the manufacturers. To us cynics, lack of availability implies that the data isn't favorable.

It seems strange to me that stuff in the airway through could find its way to the inside of the box. I would expect the path from the inlet port to the hose output port to be tightly sealed. Ditto the motors and the bearings themselves.

I am also surprised to hear that detritus from the airflow causes circuit board failures. Aren't the boards coated? Admission: I've seen exactly 1 photo of the inside of a CPAP machine and I am only fairly certain that board was coated. I'm extrapolating from poor data -- but long experience that circuit boards these days are often coated against contamination. Also, in my experience, most air-borne "stuff" is non-metallic. I've seen some very dirty circuit boards inside hi-fi's and computers with no problem. Clearly, the story would be different, say, in a machine-shop.

All that said, yes, of course, users should clean/change filters, regularly and often, for many reasons. If failure to do this damages the machines, maybe they could use a bit of re-design to isolate the airway better, and to remind the user to change the filter when it becomes blocked. My old $60 room air-filter has such an indicator.

As I noted in an earlier post, I got a humidifier early on and discontinued using it soon after, because the slight benefit to me didn't outweigh the hassle of maintaining it, plus the very evident risk of spillage during use and handling. Even without the humidifier, I realized quickly that my machine isn't really safe on the nightstand -- an unanchored small object on a table with a long "tail"is gonna be dragged off. That's what happened, too often, until I figured out I could put the machine in the top drawer of my nightstand, tilting it up somewhat to clear the side of the drawer.

Air travel? Usually I put my machine in my carry-on alongside my camera, wrapped in a cloth. TSA wants to see CPAPs, and this way it is easy to extract and present to them. (They take it away and swab it, I guess, for traces of explosives. In every case, they have been respectful of me, and careful with the machine during this process.) It's a bit more trouble to do this, but it avoids the baggage handlers, and gives me a slight edge if my checked baggage is mis-routed.

Thanks,

hen3ry

Some of the problems with dust that gets inside xPAP machines may happen when water gets mixed with it. This could create conductive goo that shorts out PWA's. Especially modern ones with lots of surface mount parts. But I think manufacturers are starting to 'compartmentalize' their machines so that the PWAs can not easily get exposed to the air flow. I strongly suspect my IntelliPAP machine is like that because it has an internal power supply, and is 'double insulated'. It also has an 'IPX 1' rating, which indicates a certain amount of resistance to water. You might see if your M series is also like this (although double insulation is not needed if it uses an external 'brick' power supply. I bet it is IPX 1 as well.

Bearings can fail without an external cause. If they didn't get built with enough lubricant, for instance. I bet though, that more than 80 percent of the mechanical failures in xPAP machines are blower bearing failures. You are right in that properly designed modern electronics are extremely reliable.

The biggest issue I can see here though is a little 'fear' of taking your therapy into your own hands. You should get the clinician's manual for your machine, and learn how to adjust pressure, etc. You should learn how to adjust your mask, if you don't know already. You should also learn how to choose a new mask using the various online fitting guides. You are learning how this therapy works here, and that is an important basic step. With the advice given here about dealing with doctors and DME's, you will soon find that you have mastery over your therapy. You will control your therapy, instead of the therapy controlling you.

Unless you insurance offers you no other options, you should also find yourself a competent sleep doctor. Although managing your own therapy is a very good thing, you should have expert input available when you need it, and to monitor your long-term performance.