CPAP with capable of lower presurre during exhalation

I was diagnosed with moderate sleep apnea in the March of 2009. My DME gave me a Fisher Paykel Sleep Style 234 Cpap machine. The pressure was set to 17 cm h20. Unfortunately, after receiving the machine , my job relocated me out of the country (Toronto, Canada) for a year. In Canada, I had problems getting to sleep with the machine on. When I did manage to fall asleep, when I would awake, my mouth and nose be so dry I would gag for ten minutes. Other times, the noise from the machine and breathing into the mask kept me awake. So shortly after relocating to Canada, I stopped using the machne.

I recently returned to the States and I went to see my sleep Doctor and told her about my problems. She wrote me a new prescription for different mask and a new machine which is capable of having different pressures for inhalation and exhalation. I took the new prescription and the old machine to my DME and was told that because I was out of the country and had not used the machine I was out of compliance. I had to pay $1075 to keep the existing machine and continue to be supported by the DME or I had to return the machine and no longer be supported by the DME or my insurance company for CPAP equipment. I have Blue Cross /Blue Shield Comprehensive insurance. So I did a quick check of the internet and found that this equipment could be purchased for much less than they were asking, so I chose to return the equipment. So now, I have to purchase my CPAP equipment with my own money. So I want the best!

Now my questions,

1. Can anyone recommend any specific models that meet my requirements
A. Different pressures for inhalation and exhalation
B. Very Quiet
C. Excellent Humidifcation Control
D. Reliable

Are the Resmed S9 Elite and Phillips Respironics RemStar Pro good candidates?

Does APAP machines offer any advantages over CPAP machines with C-Flex or EPR

2. Can anyone recommend any specific site to order from that provides good customer service and competitive prices (I live in Michigan)?

3. I need recommendations for a mask. The one I have now fits over my nose and leaves my mouth uncovered. Would a full face mask reduce air leakage from the mouth and reduce morning dryness in my mouth? Would full face masks make more or less noise when breathing than nose only masks? Does Nose pillows make the least amount of noise when breathing? Do nose pillows have other advantages and disadvantage?

Please recommend specific masks to try?

Welcome to the forum, spartancal!

It would help if you could clarify something. You said that your first machine, a F&P Sleep Style 234 CPAP, was set to pressure of 17. Upon your return to the U.S., you were given a prescription for a new machine, this one to have "different pressures for inhalation and exhalation." Can you tell us exactly what this new prescription says? I ask because at a pressure of 17, you may have been prescribed a BiPAP machine (which has different inhalation/exhalation pressures), rather than a regular CPAP/APAP machine.

I'm not very familiar with the Respironics machines, but I can tell you that the most exhalation relief that a ResMed CPAP/APAP with EPR can give you is 3 cm H20, so you would be exhaling against a pressure of 14 with that. I'm not sure if that is what was intended on your prescription, so it would help to know that. Once that's clarified, I'm sure you'll get some recommendations regarding the machine.

I will try to address some of your other questions....

This forum is sponsored by https://www.cpap.com. Many of us purchase from them and have been very happy with their service, and they will match competitors' prices. They are great to work with, and they have optional "mask insurance" in case you may need to return it. Some people purchase masks and supplies at http://www.cpapauction.com and mask parts on eBay. Some masks come with all sizes included, which can help when you're not sure of the proper size. There are some mask size templates and a mask selection guide at cpap.com that may help.

CPAP vs. APAP: A CPAP machine is set at one continuous pressure. An APAP can be set to deliver a range of pressures, within specified minimum and maximum pressures. The APAP senses subtle changes in breathing and automatically varies the pressure to keep the airway open. An APAP is more versatile, in that it can also be used as a set-pressure CPAP. Most of us here strongly prefer machines that are capable of reporting full data (AHI, leak rate, etc.) so that we can monitor our results and optimize our therapy.

Recommending a mask is difficult because our faces, preferences and needs are all different. A full face mask allows breathing from both nose and mouth. The therapy air is kept within the mask, though, unlike when you breathe through your mouth while using nasal pillows or nasal masks. Some people do have dry mouth even when using a full face mask if they mouth-breathe.

Some of us are able to use nasal pillows/nasal masks successfully by also wearing a chin strap and/or taping our mouth closed. There is lots of information about mouth-taping on this forum. The chin strap that I prefer is called the PAPCap. It works very well for me, but for some people a chin strap isn't enough to prevent mouth-breathing or mouth-leaking. At your higher pressure, I suspect that may be a problem. It's important that therapy air isn't escaping from your mouth when using nasal pillows or nasal mask. The resulting dryness can be very uncomfortable, but it also reduces the effectiveness of your therapy since your airway isn't getting the full benefit of the pressurized air.

As far as mask noise goes, it really depends on the specific mask. Some nasal pillows can be quite noisy, while others aren't. Your pressure is quite high, so nasal pillows may not be a good option for you, although some people using higher pressure do fine with them. One advantage of nasal pillows is that there is less touching your face. And they can be easier to use when side-sleeping, as larger masks are sometimes more easily dislodged by the bed pillow. Some people use special bed pillows for that reason.

I can tell you MY favorite masks, but they may not be suitable for you. You just have to try on various styles, in different sizes, while under full pressure and moving around, and see what works best. Consider your facial features, usual sleeping position, whether you mouth-breathe, and what style works best at your machine pressure. My pressure is quite low and a chin strap solves my mouth-leaking, so I prefer nasal pillows -- AEIOMed Headrest and F&P Opus 360. My favorite nasal mask is the ResMed Mirage Activa LT. It seals very well for me and is comfortable. I haven't found a regular full face mask that works for me, but I do like one of the Hybrid masks -- InnoMed/RespCare Hybrid. It has both nasal pillows and a silicone cushion that fits over the mouth. The other hybrid mask, the Liberty, didn't work for me at all, but others here like it. A lot of people like the ResMed Quattro and Ultra Mirage full face masks. If you search for masks at cpap.com, you can sort them by "top sellers," "highest rated," etc. And search forum posts for recommendations too. There's a lot of great information here!

I hope that helps. With more information from you regarding your prescription, we'll be happy to address the questions regarding machines. I just didn't want to send you in the wrong direction regarding machines if what you actually need is a BiPAP.

Best wishes with your therapy!

geez, what dream on said...

great post dream on! you are all over it!

do you know how much you are appreciated?????

Thank you, Elena. Just trying to pay back all the kindness that has been given to me here.

P.S. It's 1:30 in the morning! I gotta get to bed!!!

Wow DreamOn, what a great post! I wonder what other info you might include after a good night's sleep? Tsk,Tsk!!

DreamOn wrote:
I hope that helps. With more information from you regarding your prescription, we'll be happy to address the questions regarding machines. I just didn't want to send you in the wrong direction regarding machines if what you actually need is a BiPAP.

Best wishes with your therapy!

The other consideration is that if Spartancal was prescribed a bipap then he/she "failed" cpap and the insurance should continue to pay. Not for Cpap but for Bipap. At least that's my understanding. Maybe somebody more knowledgeable can confirm or not?

My prescription says

CPAP
Pressure 17 cm H20

Mask type: Refit patient with vendor

Equipment: Headgear, Hoses, filters, Mask, heated Humidifer

Duration of need: 12 months

Other: C-Flex CPAP machine pressure to be set at 17 cm and 13 cm of H20, Fit patient with new mask with headgear, housing and filters
Follow-up in clinic 30 days after Bilvl/CPAP Usage

My prescription says

Diagnosis: Obstructive sleep apnea (adullt) (pediatric) [ 15 < AHI < 30 ]
Organic sleep disorders

CPAP
Pressure 17 cm H20

Mask type: Refit patient with vendor

Equipment: Headgear, Hoses, filters, Mask, heated Humidifer

Duration of need: 12 months

Other: C-Flex CPAP machine pressure to be set at 17 cm and 13 cm of H20, Fit patient with new mask with headgear, housing and filters
Follow-up in clinic 30 days after Bilvl/CPAP Usage

DoriC wrote:I wonder what other info you might include after a good night's sleep? Tsk,Tsk!!

I know, Dori. My eyes were closing as I was typing, so I was surprised that my post made any sense. Sometimes my sleep cycle gets messed up, mostly due to "poor sleep hygiene" (including computer use). I do still get my 8 hours of sleep, though. I'll try to get back on track. Really, I will.

spartancal wrote:My prescription says

Diagnosis: Obstructive sleep apnea (adullt) (pediatric) [ 15 < AHI < 30 ]
Organic sleep disorders

CPAP
Pressure 17 cm H20

Mask type: Refit patient with vendor

Equipment: Headgear, Hoses, filters, Mask, heated Humidifer

Duration of need: 12 months

Other: C-Flex CPAP machine pressure to be set at 17 cm and 13 cm of H20, Fit patient with new mask with headgear, housing and filters
Follow-up in clinic 30 days after Bilvl/CPAP Usage

Well, I'm no expert regarding prescriptions, but that one's a bit confusing to me. "EPR" is the name given to ResMed's form of exhalation relief. In ResMed's case, the machine can be set to EPR off or EPR of 1, 2 or 3. As I said earlier, an EPR of 3 would give you an exhalation pressure of 14. That's as low as you can set exhalation on a ResMed CPAP/APAP machine if your inhalation pressure is 17.

I'm not very familiar with the Respironics machines, but my understanding is that their form of exhalation relief is called C-Flex or A-Flex. I believe the settings on their CPAP/APAP machines are off, 1, 2 or 3 as well, but as I understand it the exhale pressure isn't actually decreased by that many cm of H20. I'm sure someone will correct me if I'm wrong about that, or confirm if I'm correct.

So, I don't believe that your prescription, as written, can be filled by using a regular CPAP machine since there are two pressures mentioned, 17 cm and 13 cm, which is a 4 cm spread, if that's supposed to be inhalation/exhalation pressure. The Rx says "Follow-up in clinic 30 days after Bilvl/CPAP Usage," which adds to my confusion. If a bilevel (BiPAP) machine is really what you need, then neither the Resmed S9 Elite nor Phillips Respironics RemStar Pro would fit the bill. They are both quiet, have excellent humidification control and are reliable, but neither would give the amount of exhalation relief that your prescription seems to be calling for.

Here is some general information about bilevel machines: wiki/index.php/BiPAP.

Perhaps you should take your prescription to a different local DME (or several), and see what each will offer you. Perhaps, as snnnark mentioned, insurance would pay for your new machine if you do need a bilevel, which is a different insurance billing code than a CPAP/APAP. Bilevel code is E0470, and CPAP and APAP are E0601. It may be a good idea to discuss this with your insurance. You may need your prescription written more clearly too, specifically for a bilevel machine if that is what the doctor intended.

I'm hoping that someone else here will weigh in and give you further recommendations.

A few additional thoughts, added later: If you don't actually need the 4 cm of exhalation relief that the doctor prescribed, then I would probably go with an APAP machine instead of a CPAP machine, as long as it has exhalation relief. APAPs don't cost that much more than CPAPs when buying out of pocket, and if another DME can convince your insurance company to cover it, there shouldn't be any cost difference. The APAP could be set to work within a range of pressures, and it's possible that you would need a lower pressure than 17 at least some of the night, which may make it easier for you. I believe you can use EPR or C-Flex/A-Flex with the APAP machines these days, but someone else will have to confirm that. Most online DMEs will accept a prescription written as CPAP for an APAP machine. An APAP machine can also be used as a CPAP machine, and they may set your pressure to a straight pressure of 17 since that's the way the Rx is written. The machine could later be changed to APAP mode if needed.

I'm not aware of any bilevel (BiPAP) machines that have the same humidity control features as the newer CPAP machines that you mentioned. And I don't know how quiet they are, compared to a CPAP/APAP machine. They're more expensive too. But if you do need that 4 cm of exhalation relief, you may need to go that route.

I really hope that all this information doesn't confuse you. I'm just hoping that it explains some of the options, so you make the best buying decision for your situation. I hope you'll let us know what you decide and how you're doing!

DreamOn wrote: APAPs don't cost that much more than CPAPs when buying out of pocket, and if another DME can convince your insurance company to cover it, there shouldn't be any cost difference. Most online DMEs will accept a prescription written as CPAP for an APAP machine. An APAP machine can also be used as a CPAP machine, and they may set your pressure to a straight pressure of 17 since that's the way the Rx is written. The machine could later be changed to APAP mode if needed.

The only cost difference is for the DME who makes more profit on a basic machine. The insurance company reimburses them the same amount for either one. If I remember, when I wanted to exchange the basic Plus model for an Apap,the DME just wanted a new RX written with min/max pressure setting.

DoriC wrote:

DreamOn wrote: APAPs don't cost that much more than CPAPs when buying out of pocket, and if another DME can convince your insurance company to cover it, there shouldn't be any cost difference. Most online DMEs will accept a prescription written as CPAP for an APAP machine. An APAP machine can also be used as a CPAP machine, and they may set your pressure to a straight pressure of 17 since that's the way the Rx is written. The machine could later be changed to APAP mode if needed.

The only cost difference is for the DME who makes more profit on a basic machine. The insurance company reimburses them the same amount for either one. If I remember, when I wanted to exchange the basic Plus model for an Apap,the DME just wanted a new RX written with min/max pressure setting.

I agree with what you said here, Dori. Spartancal's insurance said they wouldn't pay for the new machine, so this may end up being paid for totally out of pocket. I probably wasn't clear (no surprise there!). What I meant is that the cost difference between CPAP and APAP machines isn't a whole lot if you're buying online, out of pocket, meaning no insurance is involved.

In theory, when insurance is involved, any CPAP or APAP should cost the same to the patient, since the insurance billing code is exactly the same for both (code E0601). As you said, the insurance company reimburses the DME the same amount for either type of machine. But I've been seeing on the forum lately that some DMEs are now charging an "upgrade fee" for the top-of-the-line CPAP/APAP machines. My DME told me that they weren't allowed to do that -- that they could get in trouble for doing that! But some DMEs may have a special agreement with the insurance company that allows the extra fee, or they just do it anyway (to increase their profits). I think that anyone who is asked to pay an "upgrade fee" should check with their insurance company before agreeing to that.

Spoke with my Doctor, she indicated that she felt that a Bilevel machine was not required and that she was changing my prescription to state to set the exhalation pressure to within 3 cm H2O of my inhalation pressure of 17 cm H2O.


So what is the best machine for me? Is the Resmed S9 worth the $400 price difference over the Phillips System One Remstar Auto CPAP mahine?

What are the advantages of the Resmed S9 Autoset over the Remstar Auto?

What advantages does the Remstar Auto have?


If I order the S9, which hose should I order the heated ClimateLine or the slimline?

Here is a thread that discusses both machines:

viewtopic.php?f=1&t=50624&st=0&sk=t&sd= ... dreamdiver

Spartancal, I'm glad you were able to get your prescription rewritten. That makes sense, now that the amount of exhalation relief is corrected.

You can find a lot of good comparison information in the thread that Katie referred to. I think that you'll find the answers to most of your questions there. As to whether the S9 is worth the extra $400, I'm not sure how to judge that. I suppose you can compare the differences between the two machines and see if any of them matter to you. I believe that they're both great machines.

The ClimateLine hose is heated and using that one you should not have any rainout because you can use the S9's Climate Control feature. Climate Control is not available with the SlimLine hose. The S9 has only been out for a few months. Some users are reporting that both ResMed S9 hoses are a bit fragile, and a few have reported tears near the rubber cuff after some use. ResMed is reportedly working on this and will probably be selling the redesigned hoses later. The SlimLine hose comes with the S9 machine. You could always try that (or any regular CPAP hose) for a while and get the ClimateLine later if you decide you need the rainout protection. The ClimateLine hose is around $55.

I hope that helps you make your decision.