The day before the DME delivers my first machine

Yep! My top choice at the moment is the PR System One REMstar Auto CPAP Machine with A-Flex. I don't think that'll be a far reach, since apparently the sleep doc is hell bent on PR machines. It's either an under-the-table deal, or they lost the CDs for the other manufacturers' software.

I'll admit it though... the S9 is just so cool. Resmed knows how to tempt a geek who's bad a breathing

You're well prepared for a conversation with the elusive Dr. "Sandman", Kilgore.

Don't be surprised if he says he will not prescribe an autopap. Some "sleep doctors" are simply knee-jerk anti-autopap.
This link is to a very old thread, but the mentality is still out there:

Feb 19, 2005 subject: "Sleep Doctor" doesn't like autopaps
viewtopic.php?t=1461

And then there are some doctors who have such an ego that makes them instantly anti-anything-the-patient-suggests.

Sounds like you have a great PCP. She can write the autopap Rx for you if the big doc won't.

With a little luck, the "Sandman" will see that you understand what you're doing and are perfectly capable of taking up the reins of your own therapy at home...and he'll write the Rx. Do let us know how it goes.

Kilgore Trout wrote:I'll admit it though... the S9 is just so cool.

de lure of de machine, it calls to me.
It's shiny and glows, like baubles and beads.
All silver and blue, it calls out,
"I'm better....I'm new."

I have all my reasons, in order, of course:
I need to be first,
it fits my scene,
it's a much better scheme,
it will tell me all of the things,
that I need to know, while I sleep.
This....this is the one.

As I lie here and ponder, wonder and wake,
it gnaws at me....

it's a much more primal need.

It's not de lure of de machine,
that calls to me.....
it's not the glow of baubles and beads,
that beckon to me....

On the edge of the desperate, black inky night, it lurks,
it's the burning eyes of the beast....

it's de lure of sleep.

Yep! My top choice at the moment is the PR System One REMstar Auto CPAP Machine with A-Flex. I don't think that'll be a far reach, since apparently the sleep doc is hell bent on PR machines. It's either an under-the-table deal, or they lost the CDs for the other manufacturers' software.

Kilgore, the software is hefty and expensive (even though we have our ways ) so most sleep clinics tend to be either ResMed or Philips Respironics, not both.

The question to ask Sandman, if you intend to stick with him as your sleep doc, is whether or not he will actually do regular follow-up with you where he will actually download your card and collaborate with you to adjust your treatment based on the efficacy data. If the answer is yes, then there is some value in getting the brand of machine he prefers and has the software for. He'll be more comfortable and confident reading the data and working with you (and can also make annoying changes to your card and machine ).

IF, on the other hand, he's not intending to see you more than once a year, if that, and doesn't really care about efficacy data other than satisfying the DME of your compliance so the DME can get paid (this is the more common scenario among sleep doctors), then get whatever brand you want. ResMed bells and whistles, particularly the on board data, makes it probably the best machine choice, although the PR S1 is also an excellent machine.

As far as the EPR vs. Flex algorithms, you won’t really know until you’ve experienced it. The differences are subtle and only some people have a decided preference for one over the other. I’m not sure I would even notice a difference. Most of us don’t get to experience both brands of machines, anyway—we get used to whatever we get. Both deliver great therapy.

rested gal wrote: . . . Don't be surprised if he says he will not prescribe an autopap. Some "sleep doctors" are simply knee-jerk anti-autopap. This link is to a very old thread, but the mentality is still out there: . . .

True, and I understand a doctor's anti-litigious nature and let mine know that I had asthma and needed the exhalation relief of the AFLEX. I did not want to have a hard time exhaling and more importantly didn't want the wrong machine to worsen my asthma.

Keep in mind even those claustrophic to XPAP therapy can benefit from the feeling that air isn't being pushed down their nose/throat. The exhalation relief of the APAP (A-FLex) helps relieve the claustrophobic syndrome.

Interpret this for your health needs.

ResMed's EPR is the same basic idea as PR's Flex.

gasp wrote:...and let mine know that I had asthma and needed the exhalation relief of the AFLEX...

Good call, I actually have asmtha too! Time to use it as a bargaining chip

Kilgore Trout wrote:

gasp wrote:...and let mine know that I had asthma and needed the exhalation relief of the AFLEX...

Good call, I actually have asmtha too! Time to use it as a bargaining chip

Well there ya go! Nice to have it payoff in some way after all the 'irritation' it causes

ResMed's EPR is the same basic idea as PR's Flex.

True, they both provide relief of pressure on exhalation, but they do differ in the timing of when the pressure comes back to the normal pressure (at what point in the breath cycle). I can't remember the specifics at the moment, but I'm sure someone will chime in. Some people are more comfortable with the point at which one machine or the other increases the pressure again, but for most of us it doesn't matter.

Also, people who experiences long periods of very slow or shallow breathing tend to complain more about the PR S1 because it will send out "test puffs" of air to make sure your airway is open. Some people are really disturbed by these puffs of air. If you hold your breath for about 15 seconds you can perceive them. I can hear them, but I can't feel them, so they don't bother me at all. If you know you tend to breathe very shallowly or slowly, then the ResMed might be a better choice for you.

Janknitz wrote:

ResMed's EPR is the same basic idea as PR's Flex.

True, they both provide relief of pressure on exhalation, but they do differ in the timing of when the pressure comes back to the normal pressure (at what point in the breath cycle). I can't remember the specifics at the moment, but I'm sure someone will chime in. Some people are more comfortable with the point at which one machine or the other increases the pressure again, but for most of us it doesn't matter.

The short answers:

How much is the pressure reduced during exhalation?

• Resmed's EPR provides a FIXED amount of pressure relief on every single breath---EPR=1, 2, and 3 provide a 1cm, 2cm, and 3cm drop in pressure respectively.
• PR's Flex systems provide a VARYING amount of pressure relief on each breath---the stronger the exhale, the more the pressure is reduced. The Flex setting itself (1, 2, or 3) somehow controls how deeply the pressure will be reduced overall---in other words, given the same exhalation rate, a Flex setting of 3 drops the pressure MORE than a Flex setting of 2 does.

When does the pressure start to increase back up to full therapeutic setting?

• Resmed's EPR starts to increase the pressure back up rather late in the exhalation stage---so late that some people claim it feels like a poor man's version of bi-level. (Bi-level machines wait until inhalation has started to before starting to increase the pressure to IPAP)
• PR's Flex systems start to increase the pressure back up right after the rate of exhalation has started to decline---in other words, the increase in pressure typically starts about one-third to one-half of the way through the exhalation.

I agree with Janknitz that for most of us, it really doesn't matter that much.

Also, people who experiences long periods of very slow or shallow breathing tend to complain more about the PR S1 because it will send out "test puffs" of air to make sure your airway is open. Some people are really disturbed by these puffs of air. If you hold your breath for about 15 seconds you can perceive them.

And some folks can feel the forced oscillation technique (FOT) made up of lots of very frequent mini pressure changes that the Resmed S9 uses to determine whether your airway is open. Back when I had the S9, I could certainly feel them if I held my breath for even as little as 7 or 8 seconds since the S9 starts doing the forced oscillations about 6 seconds after it detects no air movement in or out of the lungs. But oddly enough, I don't seem to have the same problem with the S1's "test puffs"---maybe cause they don't keep repeating---at high frequency--for the duration of "test" which on the S9 lasts for several seconds. Or maybe because my silly old highly sensitive body is finally beginning to acclimate itself to air being shoved down my throat

But I have to be honest: I don't think most people would notice either system very much when they are awake and I don't think most people would be awoken by either system. However, SOME people WILL. And in that subset of sensitives, the preference for one of the systems over the other will likely be very STRONG and very PERSONAL.

So if you are someone who tends to have long periods of very slow or shallow breathing, it may be critical to see if you can talk the DME into actually letting you breathe with each machine for at least 5 or 10 minutes while you do some experimenting with holding your breath and breathing really, really slowly.

I think tomorrow's going to be the big day (post subject became relevant again!) and I'm ready to make this happen... and to look elsewhere if I don't get what I need.

1. Exhalation relief: since I have asmtha, I'll need this for comfort during nights where exhaling's already stressed so I don't have to fight the positive pressure.

2. Data: So I can monitor my progress closely and manage my own health. And because I'm a geek who's been known to track video game progress with spreadsheets (what? pivot tables tell me things the game doesn't )

3. APAP rather than CPAP: Hat tip to a comment cflame1 made on this one... I hadn't thought about it yet. I'm on pain mends for my back and knees, and one of them is a heavy sedative. I don't always take it, but the pressure I need will have to be different for the nights I have to drug myself (3-4 nights a week). Additionally, I'm a social drinker on the weekends, and during the week days, I might have a scotch or two on the night of a stressful day... again affecting my sleep and breathing (I'm very careful not to "drug up" on nights when I've had a few drinks).

4. I want to have some trial time before I take anything home, so if the mask or machine's a problem, it can be dealt with.

Hopefully I can go from the doc to the DME, they already have my reports and insurance information. If not, no big deal, I can wait a little longer.

Keep in mind that the billing code for APAP is the same as CPAP. Both you and your insurance will pay exactly the same. The DME will pay a little more at wholesale. The only variable is if the DME is willing to give up a few bucks of profit to get your long-term business. If not, you're better off with someone else.

Also, your DME can dispense an APAP on a 'script that says "CPAP" (the doc does NOT have to specify APAP for you to get what you want.)

Update! I just got back from a meeting with Dr. Sandman, who was surprisingly helpful. He showed me all of the data from both sleep studies, explained everything thoroughly, and was pretty sympathetic to my concerns and condition, while still being straight forward with the severity of sleep apnea and low O2 saturation. When we talked equipment, he surprised me again... the people at the front desk wouldn't talk anything but Respironics, but he suggested a Resmed S9 Autoset, and wrote it on my order. He agreed with my thoughts about asmtha and exhalation relief, and wouldn't dream of letting someone use a machine without full data capability.

He was happy to order me an APAP, although he said he thinks I should try it in CPAP mode first, and if I'm having trouble tolerating the pressure, or the data is showing problems, he'd have the DME set it to APAP mode. But, he told me the choice is mine, and he'll back me up. He wrote down some masks for me to try (and specified 2 masks, like I wanted) and suggested I try on several different ones, and try them out hooked up to a machine at my pressure setting (13).

He told me to call him if I'm having any problems, and he'll help me out. Wow, I wasn't expecting that at all! Sounds like I might have lucked out with this guy.

I'm off to the DME at 2 p.m., hopefully there are no surprises. Yesterday was an awful low-energy day, and I've gone from dreading using one of these things to seeing them as my salvation. Hope my next post isn't about how I left the DME spewing obscenity and still without equipment!

Kilgore Trout wrote:Hope my next post isn't about how I left the DME spewing obscenity and still without equipment!

Just make sure that the ResMed S9 Autoset does NOT have the word Escape on it. They do make one and it offers very minimal data according to ResMed website. Other than that, they pretty much have to follow the written RX.

You know I will! S9 Autoset = good, S9 Escape Auto = bad. I checked out the names for the whole series so I can't be bait and switched. Bait and annoyed outside calling my doctor, maybe, but not switched.