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AutoPAP - also known as "auto-titrating CPAP", "auto-adjusting CPAP", or "self-adjusting CPAP."

CPAP is set for one continuous pressure. An AutoPAP can be set to deliver a range of low/high pressures, customizable within 4 - 20 cm H2O.

An AutoPAP differs from a CPAP in that an AutoPAP uses algorithms to sense subtle changes in the user's breathing and deliver only the amount of pressure necessary to keep the airway open.

An AutoPAP automatically varies the pressure to prevent and/or correct sleep disordered breathing events - apneas, hypopneas, air flow restrictions, and snores.

Computer software is available for AutoPAP machines, which will allow a user or clinician to download the recorded data into a PC. This data can be put in report form to track treatment results.

APAP myths

1. APAPs have not been researched.

2. APAPS are only experimental.

3. The auto feature is unreliable and has not yet been perfected; or APAPs take too long to adjust to changing pressure needs.

4. APAPS are not for long term use.

5. With a titrated pressure below 10 cm H2O you don’t need an APAP machine.

6. APAPs wait for an apnea before adjusting.

7. Insurance companies will not pay for APAPs.

8. APAPs are just for places that don’t have sleep labs.

All of the above myths are not true, perpetuated by the uninformed, or by those trying to convince you to get a cheaper straight CPAP so they make more profit. Discussion thread on APAPs, DMEs, and insurance: http://www.cpaptalk.com/viewtopic.php?t=13326

APAP versus CPAP research

Link to research references on obstructive sleep apnea articles on auto titration devices: http://reimbursement.respironics.com/TitrationTherapy.asp

Google APAP vs. CPAP studies. A research article: http://thorax.bmjjournals.com/cgi/content/full/53/suppl_3/S49

Reasons why your titrated pressure may be wrong

The CPAP pressure setting determined in the sleep study may be too high once you settle into therapy. 1. In the sleep lab, you may have experienced more REM sleep (dreaming) for the first time in years, a REM rebound effect requiring a higher pressure. On PAP therapy after your sleep patterns return to a normal amount of dreaming, your pressure may be too high. 2. Untreated sleep apnea may cause swelling in the mouth and throat, requiring a higher pressure setting in the lab. After PAP treatment, the swelling may go down, requiring a lower setting. 3. If you had nasal congestion the night of your study due to allergies, a cold, chemical sensitivity, cool air, or air flow from the CPAP machine, a higher pressure setting would be required in the lab than your usual requirements. Source: TS Johnson MD et al, Sleep Apnea – The Phantom of the Night, pages 168 – 169

REM (dream) sleep and sleeping on your back require higher pressure settings because of more apneaic events. If you slept poorly and didn’t experience REM or sleep on your back, the technician had to guess what settings you might need. The technician may estimate a pressure that is actually too high or too low.

It’s true that your current titrated setting, if accurate, may not require an APAP. But what about next month or next year? If your weight goes up, you will probably require a higher setting; if it goes down, a lower one. If you start feeling tired again, you may need a different pressure setting. Another sleep study is an expensive way to fine-tune pressure requirements, and has the risk of your not sleeping normally in a lab setting. With an auto-titrating machine and software in the comfort of your own home, you can determine whether the lab’s titrated pressure is indeed your best pressure, or experiment to find your best single pressure setting (for CPAP mode) or range (for APAP mode), working with your doctor.

Insurance companies will pay for an APAP just as they would pay for a CPAP, if it’s a prescribed medical necessity. Insurance companies use the same billing code for CPAP and APAP and cover up to the maximum allowable charge for that billing code, regardless of whether it is CPAP with or without C-Flex or EPR, or APAP with or without A-Flex or C-Flex. The DME company does care about the cost of the machine, since they make more profit on the allowable charge by selling you the cheaper CPAP machine rather than a costlier APAP machine. You may need to pay a larger co-pay for a more expensive machine, or not, depending on your insurance plan.

Qualifying for APAP

This is a matter for your physician. Get a copy of your sleep study report to help you understand your condition. Does your prescribing physician think that an APAP is a medical necessity? From your sleep study report, what is your AHI level – mild (5 or more events per hour), moderate (15 or more events per hour), or severe (30 or more events per hour)? You might check the accuracy of this with your physician: Medicare guidelines, which most insurance companies follow, require that the patient have at least 20 events per hour to qualify for an APAP machine, but this number is related to your oxygen saturation rate as well. What is your oxygen saturation rate? Does your AHI exceed 20 events per hour when you sleep on your back? How long are your apneas and hypopneas? Do you have daytime drowsiness which may also qualify you for an APAP? Do you have other related health conditions making successful PAP treatment (compliance) all the more critically necessary? Do you have the skills and willingness to cooperate with your doctor in managing your sleep therapy, or family or a friend to help you?

Advantages of APAP

APAP is super!

1. An APAP machine offers two machines in one. It can be set to a straight CPAP mode, giving the advantages of a constant pressure plus the other advantages of APAP, adjustable pressures and home titration. There are two considerations: your best MACHINE and your best THERAPY (use of the machine). Your best MACHINE may be APAP, since APAP with software allows you to try out both the straight CPAP and APAP therapy modes, as well as check your initial sleep lab titration and make any needed pressure adjustments in the future without repeating a sleep study. By trying both, you can find the best THERAPY, either CPAP or APAP.

2. In the APAP mode, the machine automatically adjusts pressure to meet increased pressure needs when you change positions from side to back, are in the REM dream sleep stage, have a blocked nose due to a cold or allergy, or have taken alcohol or sedatives. (A straight CPAP pressure setting to handle these situations may be too high for comfortable continued use, or may lead to problems like more mask leaks or aerophagia, swallowing air.)

3. Without changing the comfort of the baseline lower pressure, the upper range of the APAP pressure setting will respond to the upper range of apnea/hypopnea events described above (requiring higher pressure) making APAP therapy more effective. A titrated fixed pressure that is too low may miss a sizable number of events on straight CPAP, labeling them as non-responsive, leading to poorer therapy results.

4. APAP automatically adjusts pressure when you change masks, develop a mask leak, or experiment nightly with various mask fitting adjustments. With APAP or some CPAP and software, the patient can detect and assess the volume of mask leak and test his/her mask adjustments. The same holds for the patient’s new mask trials.

5. Studies have shown that often a user needs a lower overall pressure on APAP than the original titrated pressure. A lower pressure may be more comfortable for the patient.

6. Studies have shown that there is better compliance with APAP than with CPAP. Possible reasons may be more comfortable treatment from a lower pressure setting or range, and (with machine display or software) immediate feedback on treatment leading to higher levels of satisfaction and improved treatment.

7. Self-titration. If the patient has a smart card and optional software (or ready access to a DME for printouts) and the requisite skills, willingness, and ability (or a helper), he/she can monitor the pressure settings and results, and find the optimal pressure setting for straight CPAP, or range of settings for APAP, in consultation with the physician. Research:

American Journal of Respiratory and Critical Care Medicine, Can Patients with Obstructive Sleep Apnea Titrate Their Own Continuous Positive Airway Pressure? http://ajrccm.atsjournals.org/cgi/content/full/167/5/716Quote: Home self-titration of CPAP is as effective as in-laboratory manual titration in the management of patients with OSA.

Nonattended home automated continuous positive airway pressure titration: Comparison with polysomnography http://www.sleepsolutions.com/clinical_library/Unattended_auto-CPAP.pdfQuote: Nasal APAP titration in this study correctly identified residual apnea equivalent to the use of PSG. This correct identification allows the physician to accurately access the efficacy of treatment.

8. Once optimal pressure settings are found, with software the patient can monitor his/her progress. Software reports provide specific data for the doctor’s analysis.

9. Use of an APAP and software may reduce the need for doctor visits and DME visits if the patient is responsibly managing their own therapy.

10. Use of an APAP may reduce the need for subsequent expensive sleep tests since the patient is auto-titrating. Working with a doctor and periodically using an overnight recording pulse oximeter (borrowed, rented, or purchased), the patient can test for oxygen levels at home with the report interpreted by the doctor.

11. Lower APAP pressure settings may do a better job of reducing or eliminating aerophagia (swallowing air) than constant higher CPAP pressure settings. Or, straight CPAP may do better than APAP at eliminating aerophagia.

12. Some of the Respironics APAP machines have exhalation relief, called A-Flex and C-Flex, for patient comfort and resulting better compliance. (The current ResMed machine does not have EPR exhalation relief in the APAP mode.) Respironics Flex provides some degree of exhalation relief at a lower cost than a bilevel machine, although a bilivel provides a greater degree of relief for those who require it. By turning on and off the Flex settings, the Respironics APAP actually provides the options of several machines in one.

Discussion thread http://www.cpaptalk.com/viewtopic/t23494/APAP-Success-Story.html

Reasons to Use an APAP

by Mile High Sleeper

1. An APAP machine offers a “two-fer.” It can be set to a straight CPAP mode, giving the advantages of a constant pressure plus the other advantages of APAP (such as home titration and a range of pressures), without the disadvantages of CPAP (such as a wrong pressure setting that isn't machine reported or lack of range of pressures to meet various sleep conditions). CPAP therapy needs may differ at various stages of treatment, such as start-up or after other health changes. Some people do better on straight CPAP. Some people do better on APAP. Some people, working with their doctor, use APAP and software to confirm or find their ideal straight CPAP pressure setting.

2. In the APAP mode, the machine automatically adjusts pressure to meet changing pressure needs when you change positions from side to back, are in various sleep stages, are extra tired, have a blocked nose due to a cold or allergy, or have taken alcohol or sedatives. A fixed CPAP setting to handle some of these situations might be too high for comfortable continued use.

For the full article visit the page devoted to Reasons to use an APAP

For APAP machine listings and pricing see: https://www.cpap.com/find-cpap-products/AUTOCPAP

Disadvantages of APAP

1. The algorithm, or a set of rules for adjusting pressure, varies from one manufacturer to another. This means that each brand gives different results for a given patient, so machines are not as standardized and predictable for the doctor to prescribe as straight CPAP. For the user, one brand may work better than another, so some experimentation with another brand may be necessary if the first machine tried isn’t comfortable. This is a good reason to rent before buying. With user research online, from professionals at a trusted hospital sleep lab, and from an experienced sleep doctor who is informed about APAP technology, a carefully selected first machine may work without further machine trials.

2. Sometimes the machine may react too slowly to the body’s changing pressure needs. This can be overcome by using the APAP machine and software to find your sweet spot, single optimal pressure (for example, 9 cm H2O) and using the straight CPAP mode, or optimal narrow range of pressure (for example, 9 to 12 cm H2O), and then using the narrower pressure range in the APAP mode.

3. APAPs cost somewhat more than CPAPs, starting at about $480 to $580 without a heated humidifier. Medicare allows machine replacement every 5 years, and most insurance companies follow the Medicare guidelines. (A machine may last much longer, but new technology may offer better machines, so you may want an updated one in five years.) Here’s a cost example from a fair priced online DME, if you bought the equipment at your own expense without insurance:

  a. Respironics REMstar Auto A-Flex M series machine, $579
  b. Fisher and Paykel HC 150 heated humidifier, $155
  c. Respironics EncoreViewer software, $140
  d. Mako Infineer DT3500 USB card reader, $24 

This totals about $900 without shipping. If you used this life-saving equipment for 5 years, that’s about that’s about 50 cents a night; less if you used it longer. If insurance reimburses you for the machine and humidifier, your cost is even less.

A Rebuttal - reasons to Use APAP

by CPAPtalk member sleepinginseattle

This rebuttal is offered as a counter-point to the article "Reasons to Use Auto CPAP or APAP". It is my belief that the author's advocacy of auto-adjusting CPAP (APAP) is primarily anecdotal. As such, the author's "Reasons" are a collection to observations drawn from personal experiences and the experiences of others. While this is helpful, it does not provide a thorough investigation of APAP equipment or an accurate picture of its role in the treatment of OSA.

Here is a collection of facts regarding APAP equipment:

1) Some users have reported that an APAP machine may be more comfortable than a conventional CPAP in the treatment of OSA but there is no research that supports this finding conclusively. Compliance is the most important part of the successful treatment of OSA. Research has not shown that you are more (or less) likely to stay compliant with APAP therapy.

2) APAP may offer a two-fer (they can be set to a fixed pressure mode as well as auto-adjusting mode) but the use of auto-adjusting pressure in the treatment of OSA has not been shown to be advantageous.

3) There is no evidence to support a conclusion that wrong pressure settings are or should be a concern for users of conventional CPAP equipment.

4) Many conventional (fixed-pressure) CPAPs offer the same data reporting capability that some APAP machines offer. Data reporting CPAP machines give the same advantages without the added cost or complexity of similar APAP machines.

5) There is no evidence that supports the conclusion that OSA treatment is more effective if the pressure is adjusted based on body position, sleep stage, nasal congestion, fatigue, etc.

6) Disruptors, such as alcohol and sedatives, will mitigate the successful treatment of OSA regardless of your equipment choice.

7) APAP equipment is not intended to be a tool in the fit and sizing of masks. Furthermore, APAP equipment has not been shown to offer any advantages in this area.

8) There is no evidence to suggest that patients, in general, may need a lower pressure than was determined in the PSG titration or that there might be a long-term therapeutic benefit to lower pressure.

9) Self-titration has only been shown to be as effective as conventional sleep lab titration when combined with educational instruction in a laboratory setting.

10) There is no reason to believe that APAP-based therapy will reduce (or should) reduce the number of office visits a patient has. Self-diagnosis, as an approach for managing treatment, has not been proven to be more effective than traditional physician-based treatment. Furthermore, the software available for event reporting is not designed (or intended) to be tool for self-diagnosis.

11) Aerophagia has not been found to be less (or more) likely with APAP equipment.

The author's comments: Reasons why your titrated pressure may be wrong.

The author's comments are a broad advocacy of self-titration versus PSG titration and should be clearly identified as such. There is no evidence to support the author's conclusion that self-titration is more effective than PSG titration.

I suggest that readers do their own research on the subject of self-titration and talk with their doctor.

APAP Comparison Chart

APAP comparison chart of various brands and models https://www.cpap.com/cpap-compare-chart/all-Self-Adjusting-CPAP

See the best selling APAP machines at this online DME for self-paying customers at https://www.cpap.com/cpap-user-preference.php

Fully data capable autoPAPs

a] Resmed S8 II AutoSet b] Resmed S8 AutoSet Vantage c] Respironics M Series Auto w/A-Flex d] Respironics M Series Auto w/C-Flex e] Puritan Bennett GoodKnight 420E

You will get just as good therapy w/the CPAPs as you will w/the autoPAPs - but the autoPAPs are like two in one as they can be used in CPAP mode as well as auto mode. The DATA CAPABILITY is THE important issue, more so than auto or not.

When shopping the local DME suppliers they most likely are going to whip out a bare bone, compliance data capable only device. You can counter by asking for one of the autos. Most likely they aren't gonna wanna provide one. But if you mention the importance of the data capabilities to you that gives them the negotiating room to offer you a fully data capable CPAP. Voila! You should both be happy!

Understand that most all insurances pay by HCPCS code, NOT by brand or model. And when insurances contract w/local DME suppliers they agree on one set reimbursement fee for that HCPCS code E0601 CPAP. AND autoPAPs are coded as HCPCS E0601 (as well as the CPAPs). The catch is that, of course, the bare bone, compliance data only CPAP "costs" the DME supplier less to buy than the fully data capable autoPAPs. So most protect their profit margin by foisting off as many bare bones, compliance data only CPAPs as they can on unsuspecting new CPAP clients.

When shopping the local DME suppliers be sure to inquire about their mask exchange policy. You will want one that has a lenient mask exchange policy.

And another little secret most local DME suppliers would prefer you not know: Resmed, Respironics and Fisher & Paykel all provide FREE mask exchanges to the local DME suppliers most all of their masks that a client has tried and not been successful w/IF the DME fills out a form and returns that mask W/IN 30 DAYS.

Now, just because so many of us in the forums have encountered lousy local DME suppliers (the reason many of us are here), there ARE GOOD local DME suppliers out there. DON'T go in w/a chip on your shoulder EXPECTING them to try to take advantage of you. Keep an open mind, but be prepared.

Be FIRM, be DIPLOMATIC, be TACTFUL, but be FIRM. YOU are the one paying for this equipment, whether thru insurance OR out of pocket. No difference. W/o YOU they miss out on a lucrative sale. YOU are going to be sleeping w/this device for the next 5 years.

If you have problems getting the machine you want and/or you are trying to upgrade your machine and/or your doctor isn't interested in your therapy:

There IS the possibility that your insurance is only contracted w/this one local DME supplier and your sleep lab MAY have checked w/your insurance and THAT is why your equipment order was sent to that particular DME supplier.

When - and IF - you see this doctor again be sure to diplomatically express your disappointment that she isn't interested enough in your therapy to want that data from a fully data capable CPAP to assist her in monitoring your CPAP therapy.

Meanwhile, call your insurance company and ask THEM what local DME CPAP suppliers they are contracted with. Hopefully, you have the option of more than just this one. And ask what local sleep labs/clinics they are contracted with. Again, hopefully you will have the option of more than just this one.

Ideas for APAP users to discuss with their doctors

With your doctor, discuss a safe range for pressure adjustments in your treatment based on your sleep study, especially the higher pressure. For example, if your titrated pressure is 10 cm/H2O and you have an APAP, how suitable is a range from 7 to 15 cm/H2O for starters? Or does your doctor recommend 9 to 12 cm/H2O? If you haven’t been titrated, is a range from 6 to 16 cm/H2O appropriate for starters or not?

Next, for APAP, some people find a pressure to use as a central number for a range of pressure. If they have a titrated pressure, they use that number. Some people use the median or mean pressure as the central number.

Continuing the above about APAP, some people use their central number and add three points above and below it for a range. For example, if the titrated pressure is 10 cm/H2O, the range is 7 to 13 cm/H2O. Some people start with their titrated setting and go 3 cm/H2O under and 2 cm/H2O above the titrated pressure; for example, 7 to 12 cm/H2O. Some people benefit from an even narrower range, since that may help the machine to respond faster to events; for example, 9 to 11 cm/H2O. Remember, this is tricky business related to your health, throat anatomy, and the capabilities of each machine, so consult a doctor. For example, if you go 2 or 3 above your titrated pressure, is this likely to lead to a pressure-induced central apnea?

Some people on APAP use their titrated pressure as their lowest setting and go up 2 or 3 cm/H2O to catch events. For example, if the titrated pressure is 10 cm/H2O, the range is 10 to 12 or 13 cm/H2O. Again, work with your doctor, based on your titration study and health conditions.

Discussion threads on switching from CPAP to APAP

http://www.cpaptalk.com/viewtopic/t27646/Is-APAP-really-quotbetterquot-than-CPAP.html

http://www.cpaptalk.com/viewtopic/t15292/Thank-You-For-Suggesting-an-Auto.html

http://www.cpaptalk.com/viewtopic/t13498/why-go-to-a-autopap.html

http://www.cpaptalk.com/viewtopic/t25834/Switching-to-an-Auto-Adjusting-Machine--No-help-from-DME.html