Tips for Newcomers to Sleep Apnea

Peer coaching article # 4

1. You’re in the driver’s seat. Take as much control in the process as possible so that you can make informed choices. The interventions are all for your benefit. Because you are the one being sleep tested or using the PAP (Positive Airway Pressure) machine, CPAP, AutoPAP, or bilevel, you are the one who makes care and treatment successful. A well-meaning respiratory therapist who doesn’t have sleep apnea may suggest a certain mask, but he or she is not the one who needs to wear it every night. Don’t just passively follow, but actively partner and collaborate with your doctor, sleep lab technician, people at the DME (Durable Medical Equipment/Home Medical Equipment provider), and your insurance company. If your reasonable needs are not being met, be polite but assertive, persistent, and creative in pursuing what you need.

2. Whether in the sleep lab or at home with a PAP machine, no one is used to sleeping as a masked hose-head with a vacuum cleaner blowing air up their nose. Managing resistance and fear is a big part of the process. Direct your power of control inward, to manage your thoughts and feelings as well as outward, to manage treatment. Be kind and gentle with yourself, disciplined and determined when necessary. Humor helps. Get support from others. Related discussion thread: http://www.cpaptalk.com/viewtopic/t22566/Normal-to-be-angry-when-newly-diagnosed.html
Learn the Seven Stages of CPAP and What Is Feeling Good? at http://smart-sleep-apnea.blogspot.com/2008/01/seven-stages-of-cpap-and-what-is.html

3. Take notes during and after visits with healthcare professionals. There is a lot of information to absorb, remember, and evaluate, with decisions to be made. Make a list of questions between visits to ask the next time you see your doctor or respiratory therapist.

4. Control information flow to avoid being overwhelmed. Seek and absorb the information at your own pace so you can make informed choices.

First step: find out about sleep apnea, its health implications, and the sleep lab process and results. Accepting your diagnosis takes some emotional energy and wisdom. Learn that “I NEED TO DO THIS.”

Second step: find out about the various treatment options, based on the type and severity of your apnea. For mild Obstructive Sleep Apnea (OSA), treatment may include a dental appliance or the pillar technique. For most sleep apnea from mild to severe, CPAP (or APAP or bilevel) may be the best treatment. If that fails, perhaps surgery is considered. (Research long-term effects of surgery before making a decision.) Talk with a sleep doctor about options. Internet websites have easily readable descriptions of the treatments and their effectiveness. The most usual option is a PAP machine. If you have OSA and your physician prescribes CPAP, explore the various types and brands of PAP machines through your physician, sleep center, Internet, books, and DME. Partner with your physician to select a fully data-capable or smart display machine, heated humidifier, mask. Buy machine software on your own.

Third step: When you are ready, get more details. If you are getting a machine, find out about the various types of interfaces or masks – nasal masks, nasal pillows, and full face masks. Some users rotate between a nasal mask and nasal pillows, using a full face mask when they have a stuffy nose from a cold. If you breathe through the mouth, a full face mask is probably the best choice. Internet sites from manufacturers, sellers, and user groups have a lot of information and opinions on masks and related equipment. Be discerning when reading user opinions. Most people try several masks over time before they find the one that works for them.

5. Failure is not an option. Determine to succeed. You have a choice of treating your sleep apnea or having a greater risk of high blood pressure, heart disease, stroke, car crashes due to falling asleep at the wheel, lack of mental clarity, lack of energy for relationships, and lack of zest for life. The initial obstacles to successful PAP therapy are the user’s attitude and uncomfortable (occasionally unbearable) sleeping conditions due to unsuitable equipment. Gone is the illusion of a good night’s sleep. You may have temporary problems such as insomnia, bloating, and rainout (condensation in the hose). Don’t hastily give up on PAP therapy, when instead you need to give up on a particular piece of equipment or solve a problem. For the first few weeks or months of therapy, the biggest event of each day may be the night. Train for it as you would for an athletic event. Manage your mindset. Manage caffeine, alcohol, drugs, diet, exercise. Get your nose working. Do your homework on equipment options and modifications. Through a combination of ongoing experimentation with better equipment and nightly practice, you can create acceptable (even comfortable) sleeping conditions and work your way toward good sleep again, truly good sleep. Learn that “I CAN DO THIS.”

6. Make friends with your mask. If you are so inclined, use common sense, mental imagery, visualization, or prayer to build a peaceful, harmonious, and beneficial relationship with your PAP machine and equipment (masks, heated humidifier, hose or heated hose, bed pillow, machine software). The modern APAP machine with a heated humidifier, smart card, and software is a marvelous invention. In contrast, for most people, masks are problematic, but there are many options to explore, and hopefully manufacturers will improve masks in the future. Can you become friendly with your equipment? If you can’t, maybe it’s not you; maybe you have unfriendly equipment. Refit and modify it; experiment. Or replace it with equipment that is better suited to your well being.

7. Gather feedback on your progress. Consider keeping a nightly sleep log. A problem may go away one night but come back the next. With a diary or log, you can see, as well as feel, that you really are making progress over time in spite of frequent equipment struggles. If you get a machine with software tracking information, the data is enormously helpful for motivation and problem solving, for both you and your doctor. You will be well aware of problems. Remember to celebrate small victories.

8. Persist in having a positive, problem-solving attitude. Get creative ideas from an online CPAP community, local support group, and other users. Make improvements in your equipment and regimen. Give each change you make some time to work before trying another option. Learn to play the waiting game – waiting for appointments, insurance approval, equipment delivery, adapting to new equipment. Be patient, remembering it’s not always easy when you are sleep deprived. Stay with your therapy, however you need to modify it to make it work. Success is in your hands – and head.

Written from personal experience. Not written by healthcare professionals. The information and opinions offered are not intended or recommended as a substitute for professional medical advice.
© Mile High Sleeper, May 2006-2008. All rights reserved. You may make copies of this message and distribute in any media for free educational purposes, as long as you change nothing, credit the author, and include this copyright notice and the web address http://smart-sleep-apnea.blogspot.com

Building Your CPAP Support Team

Peer coaching article #5
It Takes a Village

Why is it necessary to have a support team?

1) Because it can be difficult to adjust to the cumbersome PAP (Positive Airway Pressure) treatment, whether it’s CPAP, AutoPAP, or Bilevel treatment for obstructive sleep apnea (OSA). Almost half the people in the US who start CPAP therapy fail, often because they lack good information, the right equipment, and ongoing support, especially at the start of therapy. Their PAP failure increases their risk for heart attack, stroke, car accidents, other health problems, and diminished quality of life.

2) Because selection of equipment, its set-up, and ongoing adjustments usually have some difficulties. There are many important details and variables. In addition, research is ongoing and equipment technology is rapidly changing.

3) Because for many people there are two missing pieces – good information sources and an informed person to help with frequent therapy questions. Adjusting to PAP therapy can easily take 3 months or more with close patient follow-up. The problem is finding a healthcare professional who both knows the intricacies of treatment and who provides frequent, effective follow-up. Patients are largely on their own with OSA treatment. Related link: http://www.cpaptalk.com/viewtopic/t26628/US-Gov-saysquotPatients-should-take-charge-of-their-own-he.html

Basic and detailed therapy information and ongoing assistance at a local DME (Durable Medical Equipment or Home Medical Equipment provider) are not as easy to find as you might expect, or be used to from healthcare professionals in a hospital or medical clinic. Respiratory Therapists (RTs) at many national chain DMEs, even if patient-centered and kind, may be hampered in assisting you by organization constraints (legislation, fear of litigation), misinformation, or dysfunctional organizational systems. For example, the RT is not allowed to share certain information with you such as general information about pressure settings and refers you to your doctor, who may not be an experienced sleep specialist. If you spoke to the same RT in a more neutral setting such as an AWAKE support group meeting, maybe they would share more general information from their experience. Or the DME sells equipment from only a few manufacturers, so their people only suggest those products, even though you may need better equipment from a different manufacturer. Perhaps they can get you other equipment, but they don’t volunteer that information, it may take a long time to get it, they don’t have a refund policy for special orders, and they say they can’t handle replacement parts for it. Your doctor, focusing on medicine, probably doesn’t have the time, nor anyone in his/her office, to assist with the many and frequent therapy issues better handled by a respiratory therapist or nurse. Related link: http://www.cpaptalk.com/viewtopic/t27151/What-do-you-wish-you-had-known.html

Ideal team members: a physician experienced in sleep medicine, specialist doctors as needed, psychologist or therapist offering Cognitive Behavioral Therapy (CBT) support for CPAP adaptation, sleep center/lab, local DME, online DME, online support group, community support group, others with OSA, family and friends acting as helpers or as an advocate, and OSA web sites.
CBT: http://www.eurekalert.org/pub_releases/2007-05/ra-nrh051007.php


1. Let’s say your primary care physician or family doctor is very helpful and was instrumental in suggesting a sleep study which led to the diagnosis of OSA, but is not a specialist in subsequent CPAP therapy. You may want to find a doctor experienced in sleep therapy. This may be a sleep doctor who is board certified and experienced in sleep medicine, a pulmonologist (breathing specialist) or other specialist; or a primary care physician or family doctor with sleep therapy experience. Treatment of sleep disorders is still relatively new in the medical community and sleep doctors may be overbooked. There is a body of knowledge about ever-evolving treatment techniques not known to every physician. It’s worth searching for a doctor with experience in sleep apnea. Ask your family doctor and/or local hospital sleep lab for names of sleep doctors. Prepare a few questions about their practice. Phone their offices for answers and talk to the nurse, front desk people, the doctor, your family doctor, or to other patients or sleep lab technicians in the hospital where the doctor practices.

Discussion thread on sources of finding a sleep doctor:
http://www.cpaptalk.com/viewtopic/t14872/What-is-a-sleep-doctor.html?sid=bb563d5b160be04b2a29a62356138016

Locator for finding local sleep resources: http://www.cpap.com/locator.php

Finding a sleep doctor through the American Board of Sleep Medicine:
http://www.absm.org/diplomates/listing.htm

Does this practice accept your insurance?
Is the doctor accepting new patients?
How long does it take to get an appointment; how busy or accessible is the doctor?
What is the doctor’s experience with sleep apnea?
Does the doctor ever recommend alternatives to CPAP treatment (dental devices, pillar procedure, etc.)? (Depending on your condition, if the doctor immediately suggests surgery as a first step rather than CPAP, he/she may not be up-to-date on less invasive and less risky treatment options.)
What types of CPAP treatment does the doctor use? Does he/she categorically disapprove of auto CPAP (APAP)? (The answer may give you some indication of how up-to-date the doctor is on APAP research and newer machines. APAP may not be the best choice for you, but open-mindedness is helpful.)
Does the doctor support a cooperative, collaborative relationship with the patient and advocate responsible patient self-management of their therapy? Does he/she support patient responsibility and empowerment in their therapy, or are they more “old school” and paternalistic with the doctor as the authoritarian manager of the therapy and the patient as passively obedient and compliant? Which style are you as a patient? Discussion thread on doctors and Internet patient information: http://www.cpaptalk.com/viewtopic/t16401/Doctors-vs-Internet-Information.html

If after a few visits you find that your doctor’s style and your style of handling your therapy are incompatible, find a different doctor, if you can. Related link: http://www.cpaptalk.com/viewtopic/t19426/My-Dr-is-not-happy-with-me.html

2. After the diagnosis of OSA, if suggested by your primary care physician or the sleep study report, you may want to visit an ENT (Ear/Nose/Throat) doctor, pulmonologist, cardiologist, or other specialist to learn more about your health conditions and how to improve them. Bring a copy of your sleep study report.

3. DME or HME provider. You may be assigned to a Durable Medical Equipment (DME) or Home Medical Equipment (HME) provider by your insurance company, or given a choice of several DMEs, depending on your insurance plan. Following your doctor’s prescription, a respiratory therapist (RT) may outfit you with a machine and mask, and provide training tips for use and cleaning. DMEs are a profit center store, warehouse distributor, and delivery service (except that they don’t usually deliver CPAP equipment) with a measure of therapeutic support; a valuable service if done right.

Is the DME company’s customer service knowledgeable, accurate and prompt in handling your prescription and equipment orders?
Do they return your phone calls promptly?
Do they give you phone numbers to contact your local office or always require you to go through regional customer service and then not follow up to help you?
Are there procedural conflicts and poor communication between one part of the company and another (customer service, local office, billing, regional, legal for HIPPA), so they can’t easily help you if you have problems? In other words, do you get the run-around?
Are they genuinely courteous and helpful or do they take a hard line against you and your needs and act dismissive under the guise of their procedures?
Do they offer accurate information and assistance or do they conceal information in order to push their products, or are they uninformed or misinformed?
How long does it take to get equipment?
Do they ship the right equipment? Is it easy to return incorrect equipment?
Do you have a short drive to the local office and short waits for an appointment or service? Under what circumstances do they deliver equipment?
Is the RT both knowledgeable and compassionate?
Does the RT provide safety information about the CPAP machine and masks?
Does the RT show competence and confidence in setting up (programming) your machine and set it up correctly?
Does the RT show you how the machine is set up and how to work the controls and mask, at a time and pace when you can absorb the information?
Does the RT show you a reasonable choice of masks, both types (nasal mask, nasal pillows, full face) and brands (ResMed, Respironics, AEIOMed, Fisher and Paykel, others)? The DME will probably have a contract with only a few brands or manufacturers, but you may require a different brand. Can they order another brand for you? Will getting it take an unreasonable amount of time?
Does the RT seem to know how to fit a mask? Is the mask trial and fitting done while you are lying down on your sides and back, with the CPAP machine turned on to check for leaks?
If your machine has a smart card, is the DME able to provide you with software reports on a timely basis?
With HIPPA regulations, does the organization make it easy for you to get your software reports, equipment information, and billing information?
How well do they handle equipment replacements and repairs? Billing?
Does dealing with them relieve your stress as a new PAP user or add stress?

If the service at your DME is unsatisfactory, you can ask for a different RT in the same office, or try another office of the same DME company. If your attempts at consistently getting adequate service fail, you can go up the chain of command to the branch manager and regional manager or headquarters. You can phone your insurance to see if other DME or HME providers are available on your insurance plan, in-network or out-of-network, local or online, and try them. You can try an online DME and compare pricing and service. If you have an effective local DME, you are fortunate indeed.

4. Online DME. Some people give up on hassling with the ineffective and expensive local DME office and order equipment on the Internet at a much lower price with faster delivery and good customer service and advice. At www.billmyinsurance.com you can see if your insurance plan will cover purchases through them. If you are a senior on Medicare, you can order through www.cpapforseniors.com . You can use an online DME such as www.cpap.com paying out-of-pocket. Because they don’t need to deal with insurance and maintain expensive local offices, drivers, a huge inefficient infrastructure, and play the insurance game, online prices are astonishingly low for the same high quality equipment offered at much higher prices by large national DMEs with local offices working with insurance companies. With luck and ingenuity, you can combine various options for service to get your needs met for OSA equipment. For example, first you can research machines and masks at www.cpap.com. Can you try on the specific masks that seem promising at a hospital sleep lab and buy it there? Or can your local DME order the mask and let you try it? It may be easiest and most cost effective just to order the mask through the online DME. Related link: http://www.cpaptalk.com/viewtopic/t18820/Noob-question--Why-are-DMEs-more-expensive-than-CPAPcom.html

5. The hospital sleep lab or sleep center may be a resource beyond your initial sleep study. Sleep technicians at a hospital may be less profit motivated and more patient-focused, more informed, and not hampered by a dysfunctional organization.
Does the center’s sleep technician offer mask trials (trying on various brands and types of masks under pressure)?
Does it offer mask fittings (adjustments) of your current mask, no matter where you purchased it?
Have you compared the center’s sleep tech’s skills at mask trials and mask fitting with the skills of the RT at your local DME?
Does it offer these services to people who are not former patients? Are services free or at a cost?
Does it sell equipment and how do the costs and services compare with your local DME or an online DME?
Does it have a return policy within 30 days (a rare option)?
Do other sleep centers in your region offer these services, and can you use them even if your sleep study was not done there?
Does the sleep center offer expertise (or pamphlets) not readily available elsewhere? Does it sponsor support group meetings through ASAA (American Sleep Apnea Association) AWAKE groups or another organization?

6. Online support group, forum, board. A very helpful community of PAP users is found at www.cpaptalk.com. Practical PAP tips are offered under the light bulb icon, Our Collective Wisdom, and under the question mark icon, Frequently Asked Questions. You can ask individual questions and quickly get a variety of supportive responses from other people with PAP experience. Sponsored by www.cpap.com, this forum gives back information to the CPAP community. See http://www.cpaptalk.com/viewtopic.php?t=9385 and http://www.cpaptalk.com/viewtopic.php?t=9375. If you regularly read this forum, you may quickly find that you know more about certain practical aspects of PAP therapy than your professional healthcare advisors. You may want to explore other online support groups as well. Remember, opinions and personal truths are offered, not necessarily facts or your truth, so be discerning. Related links:
http://www.cpaptalk.com/viewtopic/t19119/IM-EXCITED-AND-GRATEFUL.html
http://www.cpaptalk.com/viewtopic/t29075/New-Herejust-diagnosed-with-severe-sleep-apnea.html
http://www.cpaptalk.com/viewtopic.php?t=19904&postdays=0&postorder=asc&start=0
http://www.cpaptalk.com/viewtopic/t29612/Browsing-other-CPAP-msg-boardsICK-YUK-and-no-good.html


7. Community support group. Look for ASAA AWAKE group local meeting information at http://www.sleepapnea.org/awake/index.html. If you attend a meeting, you may find that you are able to help other PAP users with your new-found knowledge from www.cpaptalk.com. If you want to start your own support group, explore http://www.awakeinamerica.org/Groups/LaunchGroup.shtml.

8. Others with OSA, family and friends, an advocate. Personal support, both given and received, can be invaluable. Do you need reassurance? Do you need help with using technology, the machine or its software? Do you need help adjusting your mask? Do you need help with running interference with an uncooperative DME or perplexing insurance coverage? It can be quite trying to be exhausted from sleep deprivation and need to repeatedly deal with DME hassles. A friend acting as an advocate can help. Related links:
http://www.cpaptalk.com/viewtopic/t23735/I-cant-bring-myself-to-use-the-CPAP.html
http://www.cpaptalk.com/viewtopic/t29021/Hubdroid-is-jealous.html

Humor: Unofficial CPAP Glossary http://www.cpaptalk.com/viewtopic.php?t=5326

What Are You Thankful For? http://www.cpaptalk.com/viewtopic/t15282/What-are-you-thankful-for.html

Source: Based on personal experience with Obstructive Sleep Apnea.

Want more? See http://smart-sleep-apnea.blogspot.com for the peer coaching articles Introduction to Sleep Apnea, More Sleep-Related Web Sites, CPAP Machine Choices, CPAP Mask Choices.
Search www.cpaptalk.com or post a message there.

Not written by healthcare professionals. The information and opinions offered are not intended or recommended as a substitute for professional medical advice.
© Mile High Sleeper, August 2006-2008. All rights reserved. You may make copies of this message and distribute in any media for free educational purposes, as long as you change nothing, credit the author, and include this copyright notice and the web address http://smart-sleep-apnea.blogspot.com

Short List of My Best PAP Equipment

Peer coaching article # 7
Cut to the chase.

Good equipment and good information on how to use it are essential for success at life-saving CPAP therapy. Medical and equipment needs, opinions, and preferences differ. These are my opinions and what works for me. Other people will have their own best list. Many successful PAP users use a data-capable machine.

1. The right type of PAP (Positive Airway Pressure) machine with data capability for my individual needs, plugged into a surge protector. The machine must have data capability, that is, optional software to measure AHI (apnea-hypopnea index of events per hour), AHI related to pressure, leak rate, etc. The machine must be prescribed by a doctor and should be agreed upon by both doctor and patient. I have APAP (auto adjusting CPAP) with exhalation relief, which can also be used in the straight CPAP mode, so you get two machines in one; more, if you select a machine with various exhalation relief options. The auto-adjusting feature is very important because a) the initial sleep lab pressure titration may be wrong, b) pressure needs vary during the night, c) pressure needs may change over time with weight loss or gain, and another sleep lab study is expensive. http://www.cpap.com/advanced-find-cpap-products/Self-Adjusting-CPAPS

· I’m lucky to have the older “classic tank” Respironics REMstar Auto CPAP with C-Flex, no longer available. The current version is the Respironics REMstar Auto M series machine with A-Flex and C-Flex, about $580. See user comments about the M series by searching cpaptalk.com. If I had another sleep study, based on the results and working with a doctor, I might consider an auto-adjusting bilevel machine.

Those with certain medical needs requiring straight CPAP or with limited income may want a less expensive straight CPAP machine, if it costs them less than an APAP. The Medicare billing code is the same for CPAP and APAP, so with insurance, the patient’s cost for straight CPAP is not necessarily less than the cost of the superior APAP machine which also functions as a CPAP. Some people require bilevel machines with different pressures for inhalation and exhalation, or an auto-adjusting bilevel.

2. Machine software (not covered by insurance and bought online) so my doctor and I can monitor and adjust my therapy and I can succeed. http://www.cpap.com/simple-find-cpap-products/software Some people have a smart machine which displays AHI and leaks. That’s good, but not as good as a fully data capable APAP machine with software which shows apneas, hypopneas, non-responsive apneas/hypopneas (flow limitation) at various pressure settings, average pressure, minutes at various pressures, vibratory snore, and average and large leaks.

I have the older Respironics EncorePro software. The current version designed for patients is Respironics EncoreViewer software, about $140. I have the Mako Infineer DT3500 USB card reader, about $24. If I had a Puritan Bennett machine, I would get its SilverLining software. I also have the freeware MyEncore and there is the newer freeware EncorePro Analyzer.

3. A heated humidifier, stand-alone or machine-specific, depending on performance, for comfort (a key success factor), healthier airways, avoidance of nosebleeds and dry mouth. http://www.cpap.com/advanced-find-cpap-products/Humidifiers

I have the integrated heated humidifier for the older “classic tank” Respironics autopap machine that works well. If I got a new Respironics M series autopap, I would not get the integrated heated humidifier because reportedly it is hard to fill, is too small, and had a leakage problem. I would get the stand-alone Fisher and Paykel HC 150 heated humidifier, about $155, which could still be used if I change machines.

4. A SleepZone heated hose to eliminate rainout (condensation in hose) and a spare standard hose, plus a hard plastic hose connector. http://www.sleepzone.com.au/

I also use a fleece Snuggle Hose cover over the cover that comes with the heated hose, http://www.cpap.com/productSearch.php?query=Snuggle+Hose&q=1 .

5. At least two of the three main types of masks and headgear: nasal mask, nasal pillows, full face mask. Consideration of nasal prongs and other types. Finding the right mask and adjusting to it is the most difficult part of PAP therapy for most people. Try out a mask before purchase through a daytime, professional mask fitting at a sleep lab, lying down under pressure on sides and back while leaks are measured. Have a spare back-up mask and headgear. http://www.cpap.com/simple-find-cpap-products/cpap-mask Mask preference is very individual.

I have the ResMed Ultra Mirage Full Face mask and an extra for a backup. I also like the AEIOMed Headrest Nasal Pillows mask, adapted and used with the headgear from another mask. I use PadACheek mask strap pads for comfort, http://www.padacheek.com/index.html .

6. A bed pillow such as the PAPillow that works with the mask. A memory foam bed wedge for silent acid reflux. http://www.papillow.com/ Pillow preference is very individual.
I have the smaller, lower mini PAPillow, shaped like a triangular boomerang.

7. A power supply (machine-specific or stand-alone or a deep cycle battery) in case of power outage, and a DC connector. http://www.cpap.com/simple-find-cpap-products/cpap-battery-cable

I have an integrated rechargeable battery pack for my backup machine (see below), a machine-specific DC connector for each of my two machines, and an AGM battery.

8. If income allows and if the primary machine is heavy, a small, light CPAP machine with integrated heated humidifier for travel, camping, and naps on the sofa, and as a temporary spare in case the primary machine breaks. An old PAP machine may also serve as a spare http://www.cpaptalk.com/viewtopic/t31649/If-your-XPAP-breaks-at-10pm-tonight-do-you-have-a-backup.html
and http://www.cpap.com/advanced-find-cpap-products/CPAPS

I have the AEIOMed Everest travel machine with integrated heated humidifier and rechargeable battery pack, about $480. There are many good, small CPAP machines and bargains out there.

9. For those who need it: An overnight recording pulse oximeter to measure blood oxygen saturation levels, about $500 with software, bought online. One recording pulse ox does not require software. Very useful if you require supplemental oxygen at night or your oxygen saturation rate is dangerously low without PAP. I don’t have a pulse ox but borrow one occasionally to check on my treatment. It’s very handy to loan to friends who may have undetected sleep apnea, to raise their awareness and encourage them to see a physician.

Good places to research products: http://cpap.com and manufacturer web sites

Places to get PAP equipment through insurance:

· A local Durable Medical Equipment/Home Medical Equipment company that takes your private health insurance, if their service is good and what you pay out-of-pocket is reasonable, compared to online DME pricing

· Online DME, check with your insurance to see if you will be reimbursed: http://cpap.com and its two affiliated companies listed below.

· Online DME for people with insurance: http://billmyinsurance.com

· Online DME for people with Medicare: http://www.cpapforseniors.com/

Places to get PAP equipment at your own expense:

http://cpap.com

http://www.cpapauction.com Beware of used machines with a permanent tobacco or campfire smoke smell or pet or other odor, and used masks that have not been thoroughly disinfected, if the previous owner had a staph infection.

Sources: Based on personal experience with obstructive sleep apnea and gleaned from the collective wisdom of cpaptalk.com contributors.

Want more? See the blog peer coaching articles on CPAP Machine Choices, CPAP Mask Choices, and CPAP Heated Humidifiers at http://smart-sleep-apnea.blogspot.com .
Search or post a message on www.cpaptalk.com .

Not written by healthcare professionals. The information and opinions offered are not intended or recommended as a substitute for professional medical advice.
© Mile High Sleeper, February 2008. All rights reserved. You may make copies of this message and distribute in any media for free educational purposes, as long as you change nothing, credit the author, and include this copyright notice and the web address http://smart-sleep-apnea.blogspot.com

CPAP Humidifiers

Peer coaching article # 8

Why. One of the reasons that people find PAP (Positive Airway Pressure) therapy uncomfortable is that they don’t use a PAP heated humidifier. For many people, the forced air in PAP therapy (CPAP, autoPAP, or bilevel) causes the nasal passages to become blocked. Heated, humidified air helps unblock the nasal passages, keeps the nose, throat, and mouth healthier and more comfortable, reduces or eliminates nosebleeds, and makes the therapy more comfortable, contributing to successful treatment. Many people on humidified PAP find that they seldom get head colds. Many CPAP users find that they need to use the heated humidifier every night, even in warm, humid summer months and humid climates. Some turn off the heat in the summer but continue to humidify. A few people need no humidification at all, and don’t get blocked or dry nasal passages or dry mouth. People who use a full face mask because of mouth breathing require heated humidification so their mouth doesn’t get dry. Discussion thread at http://www.cpaptalk.com/viewtopic/t28636/Do-I-need-a-humidifier.html

Selection criteria. For a brief but thorough introduction to heated, passive (unheated), integrated (built-in), and stand-alone humidifiers, see Answers, Humidifiers at http://www.cpap.com/cpap-faq/Humidifiers.html#FGID-61 . If you try unheated humidification, you may find that it does little to keep your nasal passages open and isn’t comfortable, unlike heated humidification. Since a heated humidifier can be turned off and become a passive humidifier, it may make sense to get a heated humidifier for more options. To keep humidity levels high, use an Australian heated hose from http://www.sleepzone.com.au/ To save wear and tear on the end of the hose, use a hard plastic hose connector. A stand-alone humidifier such as the Fisher and Paykel HC 150 can be used with any machine, in case you need to replace your machine early in treatment or after a few years. A stand-alone machine holds more water and can deliver higher levels of humidity. A small integrated humidifier may not hold enough water for the night at a high humidity level. An integrated humidifier has the advantage of being compact and built-in, useful for travel. Depending on the angle your hose needs to make from the humidifier, consider using a hard plastic right-angle elbow connector. Discussion thread at http://www.cpaptalk.com/viewtopic/t29232/Whats-so-great-about-HC-150-Humidifier.html

Water. People may have memories of unsanitary, portable room humidifiers and vaporizers heavy with mineral deposits, growing and spreading bacteria. CPAP humidifiers are different if you use clean distilled water, emptied daily or frequently. Use only distilled water in the humidifier to avoid mineral buildup. Distilled water is condensed steam, mineral free, sold in gallon bottles for usually less than $1 at grocery stores and WalMart, for use in humidifiers and steam irons. If you are traveling or run out of distilled water, it’s okay to use tap water for a few days, but your humidifier may show mineral deposits. To remove deposits, soak the tank in a mild white household vinegar solution and rinse well. Since bacteria, molds, and mildew won’t grow on a dry surface, empty the tank every morning and let it air dry. Depending on the humidifier’s construction, you may not want to dissemble it, and taking it apart may be unnecessary. For tips on taking apart and assembling a humidifier, see the discussion thread http://www.cpaptalk.com/viewtopic.php?t=10305

After drying, replace the humidifier on the machine. Make sure the humidifier connects snuggly to the machine, to avoid air leaks. To fill, use a funnel in the opening for the hose (with the hose removed). For convenience, store the distilled water in the bedroom. For ideas on filling the humidifier, see http://www.cpaptalk.com/viewtopic.php?t=13397
Some people don’t empty the tank daily and have no problems with things growing in the humidifier. If you don’t empty the tank, consider removing or disconnecting the humidifier from the PAP machine so the inside of the machine can dry out during the day, to avoid growth of mildew inside the machine.

Don’t add anything to the clean distilled water. The air that passes over it goes directly into your lungs. It’s not aroma therapy, it’s CPAP respiratory therapy.

To protect furniture, keep the heated humidifier and machine on a waterproof surface in case you spill water or there is a leak. Some options are an inverted plastic lid from a large storage box, or a cookie sheet with a rim. See a discussion of humidifier water leaks at http://www.cpaptalk.com/viewtopic/t14183/Puddle-Underneath-CPAP-Unit.html and search cpaptalk.com for discussions on the leaks related to the integrated humidifier for the Respironics M series PAP. (As of this writing in June 2008, Respironics is taking measures to correct the leak problem.)

Usage Tips. To preheat the water, turn on the humidifier about 20 minutes before going to bed. Experiment with the various humidifier settings to find the best setting for you. Once you find an optimal heat setting, notice how much water is required nightly, and fill the tank only to that level, if you want to avoid wasting water with daily emptying. Don’t fill beyond the fill line, since overfilling may interfere with correct machine operation. Some users recommend having a spare water chamber if the cost is low, see http://www.cpap.com/simple-find-cpap-products.php?selected=HUMIDIFIERPARTS Also briefly experiment with passive humidification (don’t turn on the heating element) in case you ever need to run the CPAP on battery power during a power outage or when camping, since heated humidifiers can’t be run on DC batteries unless you use an inverter to convert to AC.


Sources: Based on personal experience with obstructive sleep apnea and gleaned from the collective wisdom of cpaptalk.com contributors.

Want more? See the blog peer coaching articles on CPAP Machine Choices and CPAP Equipment Cleaning and Replacement at http://smart-sleep-apnea.blogspot.com .
Search or post a message on www.cpaptalk.com .

Not written by healthcare professionals. The information and opinions offered are not intended or recommended as a substitute for professional medical advice.
© Mile High Sleeper, 2006-2008. All rights reserved. You may make copies of this message and distribute in any media for free educational purposes, as long as you change nothing, credit the author, and include this copyright notice and the web address http://smart-sleep-apnea.blogspot.com

CPAP Machine Choices

Peer coaching article # 9

Contents
Terminology, Contraindications, Prescription, Choice, Failure hazard, Selection criteria, Trying a machine, rental, purchase; Software, Heated humidifier, Exhalation relief, Hoses, Ramp

CPAP MACHINES (constant pressure), Advantages of straight CPAP,
Disadvantages of straight CPAP, CPAP comparison chart

APAP MACHINES (auto adjusting), APAP myths, APAP vs. CPAP research,
Reasons why your titrated pressure may be wrong, Qualifying for APAP, Advantages of APAP, Disadvantages of APAP, APAP comparison chart

BILEVEL MACHINES
Mike Moran’s humor

Terminology. CPAP (pronounced see-pap) is an acronym for Continuous Positive Airway Pressure. The term CPAP is used two ways. One way is literal, indicating a straight CPAP machine with a constant pressure. The other way is generic, indicating two other types of PAP machines as well, including bilevel PAP (with one pressure for inhalation and one for exhalation) and auto-adjusting PAP (APAP with self-adjusting pressure based on your body’s requirements , and auto-adjusting bilevel.) Other terms for a PAP machine are device, flow generator, or blower. The earliest treatment for Obstructive Sleep Apnea was a tracheostomy, cutting a permanent hole in the windpipe. The CPAP machine was invented in 1981 by Dr. Colin Sullivan, an Australian pulmonologist. Later the bilevel and AutoPAP were developed. For an interview with CPAP’s inventor, see http://www.sleepapnea.org/resources/pubs/pioneer.html .

The term PAP indicates any type of Positive Airway Pressure machine. Compared to surgery, the PAP machine is a wonderful invention, a safe, relatively noninvasive and inexpensive way to restore you to health and happiness. Machine technology is evolving quickly; here’s a comparison to illustrate. Straight CPAP is like black and white TV, APAP is like color TV, and bilevel and PAP machines not yet on the market are like flat panel, plasma, and high definition TVs. In future PAPs, patients want better sensors, patient-centered software, better auto adjusting, exhalation relief, smart displays, heated hoses, integrated power supply, and smaller footprints. One difference between TVs and PAP is that a PAP is a medical device, not a consumer product. However, PAP extra features are not frivolous “bells and whistles;” they are features to make therapy more effective and comfortable so patients don’t give up on it. See Machine Answers at http://www.cpap.com/cpap-faq/Machines.html#FGID-2

Contraindications for PAP
Your doctor will assess medical reasons which may indicate not using PAP, involving previous or recent head injury, certain respiratory conditions or lung disease, recent ear, nose, or head surgery, vomiting, stroke (inability to maintain airway), seizures, severe cardiac arrhythmias.

Possible contraindications for the variable pressure auto-adjust mode may be epilepsy, central sleep apnea, stroke, and various heart and respiratory conditions such as Cheyne-Stokes respiration. A bilevel machine prescribed by an experienced sleep doctor may be a better choice.

PAP use may be contraindicated short term with a sinus or middle ear infection, severe ear discomfort, severe nosebleed, conjunctivitis, or skin abrasions caused by the CPAP mask. Consult your physician.

Prescription. A doctor’s prescription is required by US federal law to rent or purchase a machine, whether through a Durable Medical Equipment (DME) or home medical equipment company or online, whether paid by insurance, Medicare, or bought outright by the user. Any doctor can write the prescription, your primary care physician or a sleep doctor. Get the prescription in hand so you can choose your provider, through insurance or online through insurance or online at your own expense. There are two options for prescriptions. One is to get a general prescription for a CPAP which can also be used for an APAP, since the insurance code is the same. Another option is to get a specific prescription for a certain brand and model, if you and your doctor think that will be more useful in working with your particular DME company. The DME should not refuse your doctor’s prescription for a particular brand and model in favor of a cheaper machine to increase their profit at the expense of your successful therapy. For more on prescriptions, see Answers, Prescriptions, at http://www.cpap.com/cpap-faq/Prescriptions.html#FGID-130 .

Choice. The choice of type, brand, and model of machine is both a medical decision and a patient-preference decision, best made as a collaborative decision between you and your prescribing physician. A sleep doctor will know your medical needs and should ideally, but not necessarily, have knowledge of brands and models of machines. You are the one who needs to use the machine all night, every night, for the rest of your life, so your agreement, cooperation, and comfort are essential. You can research machines at http://cpap.com and manufacturers’ web sites, and perhaps through local, unbiased sources such as a hospital sleep lab. As you learn about equipment, bring that knowledge to your doctor’s appointment. You can anticipate your machine preferences and needs for adaptability and comfort.

The choice of a machine is best not left solely to a Respiratory Therapist (RT) at a Durable Medical Equipment/home medical equipment provider. The RT may know about various machines, but their inventory (and maybe knowledge) will be limited by the brands of machine carried by their company. For example, it’s said that Apria favors Respironics machines and Lincare favors ResMed machines because of their business contracts with those manufacturers. Your patient needs are not necessarily the same as the DME’s business deal or need to move inventory. (The same is true for masks.) The DME may be able to get other brands, but not initially suggest them unless you request it. In the end, your research and trial and error are the methods for finding the best machine for you, since each person is unique.

For more, see Answers, CPAP Brands at http://www.cpap.com/cpap-faq/CPAP-Brands.html#FGID-107
The top three PAP machine manufacturers are Respironics, ResMed, and Puritan Bennett. Discussion thread on machine brands beyond the big three: http://www.cpaptalk.com/viewtopic/t4092/What-about-the-other-manufacturers.html

Failure hazard of any PAP treatment

Most people on PAP therapy use straight CPAP machines, and about half of PAP users fail at continuing the therapy. Those who give up on PAP have increased risk for stroke, heart failure, obesity, diabetes, and other serious health conditions, as well as a diminished quality of life overall, including greater risk of car crashes. If further medical treatment is necessary because of the consequences of abandoning PAP treatment, this is extra cost for both the patient and insurance company.

Three main reasons for the high failure rate of PAP compliance may be 1) poor mask selection and mask fitting resulting in leaks, 2) lack of quality information for the patient about PAP equipment and therapy and lack of support in adjusting to the therapy, and 3) lack of patient involvement in therapy equipment decisions and management of therapy. Other equipment problems are wrong pressure settings, discomfort from equipment problems (humidification, rainout/condensation in the hose, hose management, aerophagia/swallowing air, bed pillows).

Comfort in using the machine and good results from it are essential for continued use. With any PAP machine, if the machine is not preventing your apnea/hypopnea events (AHI) because your pressure settings are wrong or your mask leaks too much, or if it’s hard to exhale, or if the machine is incompatible with your breathing pattern, or if it’s so noisy it keeps you awake, or if it’s too bulky to take with you when you travel, you are risking successful therapy and a happier, longer life. This is where high quality equipment as well as good patient information can help you. Software can involve you in the therapy and give you information on correcting mask leaks and AHI related to pressure. An APAP machine and software can allow you and your doctor to fine-tune the pressure. People who take control of their therapy are those who succeed.

Discussion thread http://www.cpaptalk.com/viewtopic/t26629/Another-Anniversary-Thanks-Sorry-Long.html

Selection criteria in order of importance for many people. What are your priorities?

1. Type of machine - CPAP, APAP (auto CPAP) or bilevel, with full data capability (software that measures more than just compliance or usage). The choice is based on both your medical needs and patient needs, since you will be sleeping with it all night, every night, for the rest of your life, and your life depends on it. An APAP machine provides two-in-one, since it can be used in either the APAP or CPAP mode. All APAP and bilevel machines are data capable. Only a few CPAP machines are data capable.

2. Software showing AHI (Apnea-Hypopnea Index of events per hour, AHI related to pressure, mask leaks, etc.). Not paid by insurance. Gives you and your doctor essential information to monitor and adjust your therapy, promoting success.

3. Heated humidifier with several temperature levels and passive (unheated) humidification; integrated (built-in) or stand-alone which can be used with another PAP if you get one. Keeps nose, mouth, throat healthier, reduces nosebleeds, required for a full face mask. Humidification is more comfortable for most, but not all, people.

4. Exhalation relief (called A-flex and C-flex in Respironics machines and EPR in ResMed machines). Briefly reduces air pressure on exhalation, making it easier to exhale, a comfort factor making it easier to sleep. Comfort is not a frill; it leads to adapting to and continuing the therapy. Those who have a higher prescribed pressure or who need more exhalation relief may require a bilevel machine. Some, especially those with low pressures, don’t need or want any exhalation relief.

5. Price, factoring in private insurance coverage, co-pays and deductibles, or Medicare, and pricing of equipment sold online

6. Size – weight, dimensions, portability

7. Features – smart LCD display, mask off alert, automatic (or manual) altitude adjustment, ramp or settling (gradual startup), AC/DC/DC power cord, international voltage, battery option, etc.

8. Ergonomics, ease of use – how to change various settings, LCD display size and readability, buttons, lights not too bright or too dim

9. Noise. Not usually a problem with current machines unless you are especially sensitive to noise. Noise level in decibels is listed in the user manual specifications. Normal conversation is 60 dB. A whisper is 15 dB. Most PAP machines are around 30 dB, much quieter than snoring. Noise is related to the individual machine; some are quieter, some more whiny. You could consider a quiet PAP machine as relaxing, soothing white noise, soft waves lulling you to sleep.

Trying a machine, rental, purchase. Even if you and your doctor are convinced that a certain machine will be right for you, and even if at your first visit to the DME company they offer to let you buy it on the spot through your insurance company (after you pay a deductible), avoid buying a machine at the very start of treatment before you try it. (There’s a possibility that an unscrupulous DME is taking advantage of your being an exhausted and uninformed PAP novice by selling you a low-end or outdated CPAP machine which costs them less than $300, while billing your insurance company top dollar, the same amount they would bill insurance for a high-end APAP machine which costs them less than $600. They make twice the profit by providing you with a cheap CPAP machine.) You need time to try it out the machine to be certain it will work for you. With experience, you may change your mind about which machine is best for you.

If a machine doesn’t seem to fit your breathing patterns or is noisy or doesn’t fit your needs, work with your doctor and try out different machines through rental at your DME, at another DME on your insurance plan, or at a sleep center. If your insurance and DME are already providing a machine but you want to find a better one through a one-month trial rental, it will be at your own expense. That’s less expensive than buying a machine and then finding out it doesn’t work. Find a good local DME company by asking a hospital sleep lab for recommendations. Then inquire about a monthly rental from them, with prescription in hand.

Most insurance companies require at least a two or three month wait before they will purchase a machine for you, to make sure you are “compliant” (adapt to using the machine at least four hours nightly). When you are certain the machine is the best for your needs, then is the time to buy rather than rent. A typical approach is to let the DME rent you what seems to be the best machine from your research and your doctor’s input. If it works well, let your insurance plan buy it for you in two or three months. It’s reassuring to own the machine that you depend on. You will probably need to phone the DME to initiate the purchase, if they have been making more money by renting it than selling it. First do the math to see if purchase is more cost effective for you than continual rental. Compare the local DME price with online prices and see what your insurance company will reimburse. With purchase, you are responsible for repairs, but most machines are fairly reliable, under a two-year warranty with an anticipated life of five years or more.

Discussion threads on rental from DMEs and buying: http://www.cpaptalk.com/viewtopic.php?t=14487&postdays=0&postorder=asc&start=0
http://www.cpaptalk.com/viewtopic.php?t=15970&postdays=0&postorder=asc&start=0
http://www.cpaptalk.com/viewtopic/t28179/Is-a-basic-machine-best-or-merely-adequate.html

There are many places to buy a machine. Find out which ones are covered by your insurance. Then compare your insurance costs (deductibles, co-pays) with buying on your own, online, to find which is less expensive. Places to buy a PAP machine:

- Local branch of a large, national DME company, or small local DME company
- Sleep lab or doctor acting as a DME
- Online DME billing insurance, such as http://www.billmyinsurance.com/
- Online DME billing Medicare, such as http://www.cpapforseniors.com/
- Online DME for people paying at their own expense, which may or may not be reimbursable on their insurance http://www.cpap.com/

Discussion thread on pricing http://www.cpaptalk.com/viewtopic/t26648/My-CPAP-Journey.html
Discussion thread on Medicare http://www.cpaptalk.com/viewtopic/t24046/I-have-Medicare-should-I-use-it.html

Medicare guidelines, which most insurance companies follow, allow for machine replacement every five years. That’s a relatively long time in a market that quickly develops better new technology, so you probably want an up-to-date machine that works the best for you from the start. For more, see Answers, CPAP and Sleep Apnea Basics, Machines, at http://www.cpap.com/cpap-faq/Machines.html#FGID-2

Software
It helps enormously to have software so you can responsibly self-manage your therapy, with your doctor’s support, and monitor mask leaks and machine performance and track results. Using a PAP machine without software is like driving a car without a windshield and without an instrument panel. You may think you are on the road and getting there, but you’re really not sure; you just know you haven’t crashed yet. You may think you’re not speeding and have enough gas, but you’re not really sure. With a PAP machine with little or no feedback information, you may feel better or not feel better, but you have no other information.

If you’re not doing as well on PAP as you think you should be doing, and have no software, you and your doctor have very little information on what or how to improve. Does your mask leak? How much, acceptably or too much? Are you still having apneas (stopped breathing), hypopneas (partial breathing), and flow limitations or UARS (like small hypopneas in the nose and mouth) How many? Are you still in the severe, moderate, or mild range of the AHI (apnea-hypopnea index), or are you now in the normal range? Where in the normal range? At what pressure do you have the most and least apneas and hypopneas? When you make a mask change or adjustment, does it help or hinder? If your doctor makes a pressure change, does it help? Machine software reports can answer these questions. Without the software, there is no way to answer the questions. Some doctors may be disdainful of PAP sensors and software, since they aren’t as sophisticated as sleep lab equipment. However, the smart PAP and software provide adequate night-to-night information to monitor and adjust therapy, when a full-blown sleep study isn’t needed or possible.

With a data capable machine and software, you have data on your Apnea Hypopnea Index, AHI related to pressure, flow limitation, volume of mask leaks, snores, etc. If you are computer literate, most PAP software is easy to use, even for those who aren’t computer experts. If your machine has data capability and a smart card, you can take the card to a cooperative DME for a printout sent to your doctor, and don’t need to buy software.

Warnings: 1) Not all machines are fully data-capable, so select one that is. 2) Some software records only compliance (usage) for the DME and insurance company’s benefit only, so make sure the software also records AHI, leaks, and pressure. See software FAQ at See http://www.cpap.com/cpap-faq/Software.html#FGID-56
Insurance won’t pay for software or a smart card reader, but you may be able to deduct them as a medical expense on your income tax. You don’t need a prescription for software. Software and readers can be purchased online often for less than $200 for both. See http://www.cpap.com/simple-find-cpap-products/software

Discussion threads on software:
http://www.cpaptalk.com/viewtopic/t25965/Doc-debunked-CPAP-AHI-data.html
http://www.cpaptalk.com/viewtopic/t26806/Is-there-success-without-having-a-Datacapable-machine.html
http://www.cpaptalk.com/viewtopic/t25720/Re-controversy-over-changing-pressure.html

Heated humidifier. In normal breathing, your nose warms and moisturizes incoming air. With the large volume of air forced into your nose (or mouth) by a PAP machine, your nose can’t keep up. Use of PAP leads to congested nasal passages in many people who weren’t previously congested. The addition of a heated humidifier makes PAP healthier and more comfortable, which makes it easier for you to adapt or be compliant. It helps you avoid nosebleeds and dry nasal passages and mouth and maybe even helps ward off colds. A heated humidifier is required for a full face mask for mouth-breathers or people who are temporarily using a full face mask because of a cold or allergies. For many people, a heated humidifier is more natural, comfortable, and effective than unheated. Some people prefer passive or passover unheated humidification, so they don’t turn on the heating element. Most humidifiers are machine model-specific and fit into the machine (integrated). You might consider a stand-alone humidifier, which works with any machine, if you anticipate having more than one machine over time. Sometimes a certain model of humidifier is known for leaking or being difficult to fill. Check with other users on http://cpaptalk.com for their product opinions. Do you have a deviated septum, nasal polyps, allergies, nosebleeds, or chronic sinus congestion that may make a heated humidifier medically necessary? Discuss use of a heated humidifier with your prescribing physician to see if it should be prescribed. A humidifier prescription is not required by law, but is required for insurance reimbursement. See Answers, Humidifiers, at http://www.cpap.com/cpap-faq/Humidifiers.html#FGID-61

Exhalation relief
Some people find exhalation relief makes therapy more comfortable because it matches their natural breathing patterns and they don’t have to fight incoming air pressure to exhale. It increases their compliance. Others don’t need pressure relief. Some Respironics models (both CPAP and APAP) have A-Flex or C-Flex with three settings. The machine senses exhalation and lets the pressure drop slightly and briefly, making it easier to exhale. The Flex feature has various levels and can be easily turned off. See Respironics flex technology http://flexfamily.respironics.com/

Flex discussion threads:
http://www.cpaptalk.com/viewtopic/t20772/AFlex-a-good-thing-Or-a-sales-pitch.html
http://www.cpaptalk.com/viewtopic/t26438/Aflex-Trying-to-Self-Breathe.html
http://www.cpaptalk.com/viewtopic/t20453/Why-not-always-use-max-CFlex-setting.html

RedMed has EPR (expiratory pressure relief) available only in its straight CPAP machine. See http://www.resmed.com/en-us/clinicians/compliance_and_efficacy/epr-expiratory-pressure-relief.html?menu=clinicians

People who need a lot of exhalation relief may need a bilevel machine.

Hoses (tubing). PAP machines are dispensed with a hose to connect mask to machine. Hoses are a standard diameter to fit any machine and mask. The standard hose is 6 feet in length. Hoses also come in 10 feet and 18 inch extensions. A few machines or masks require a nonstandard hose, see http://www.cpap.com/cpap-faq/Tubing-(CPAP-Hose).html#170 People who experience rainout (condensation in the hose) or who want to maintain PAP heat and humidity levels in a cool bedroom buy the Australian SleepZone heated hose, http://www.sleepzone.com.au/ . There are hose-to-hose connectors and right-angle hose connectors.

Ramp or settling allows the user to start treatment at a lower pressure and as they fall asleep, the pressure slowly rises. This is a comfort setting and can be from 0 to 45 minutes on most PAP machines. Ramp is more appreciated by beginners. Sometimes the lower ramp pressure setting is too low to clear exhaled carbon dioxide from the mask, so it’s not comfortable unless it’s adjusted upward. Many experienced PAP users find ramp unnecessary.

CPAP MACHINES (constant pressure)
Advantages of straight CPAP

1. A straight, constant pressure setting delivers the best results for many people. (However, the versatile APAP is two machines in one and can be set to a straight CPAP mode.)

2. Except for some of the features noted below and in the www.cpap.com comparison charts, all CPAPs have a standard operation and give similar results. There are few performance variables, which makes it easier for your doctor to prescribe a machine and predict the machine’s performance. Your experience with it is another matter. Since CPAPs have been around the longest of the three types of machines, more research has been done on them and some doctors are more familiar with them than the advanced technology APAPs or bilevels, so may tend to prescribe CPAPs more frequently.

3. Some Respironics, ResMed, and Puritan Bennett machines have software to track your results (not just compliance). Other brands do not.

4. Some Respironics and one ResMed straight CPAP model have pressure relief for exhalation. Other brands do not.

5. CPAPs are the least expensive of the three main types of PAP machines. Prices start about $220 to $500, without a heated humidifier. The top end overlaps with the price of some APAPs. Depending on your insurance deductibles and co-pays for the machine and need for subsequent sleep studies because you don’t have an APAP with software, getting a less expensive CPAP machine may be to your financial advantage or not.

6. For backup when electric power fails, or for travel, camping, or armchair naps, there are choices of small and light CPAP machines with or without integrated rechargeable batteries and a DC port for DC power supply from batteries. (APAPs and bilevels also can run on DC power.)

7. If you already have a low-end or high-end CPAP machine and it’s continuing to work well for you, you feel good all day, and your blood oxygen saturation rates are good (measured with an overnight recording pulse oximeter), then you may already have the best machine for you.

Disadvantages of straight CPAP

1. You may need a different pressure to lower your AHI.
A) Your titrated pressure may be wrong or have changed. The sleep study titration (finding a pressure setting) was probably only a few hours of one night, in an unnatural setting which some people describe as the worst night of their life. See Reasons why your titrated pressure may be wrong.
B) If your weight goes up you may need a higher pressure setting; if it goes down, a lower setting. If you have CPAP and software and work with your doctor, you can work to improve your pressure setting, but not nearly as easily as if you had an APAP machine with software, which can also be used in the straight CPAP mode.
C) You may need a different pressure during the night when sleeping on your back or side, when in REM sleep, after using alcohol or sedatives, or with nasal congestion. A straight CPAP machine cannot automatically adjust to the need for pressure changes while you are sleeping. If your pressure is not correct, you will not be getting the full benefits of therapy and won’t feel as good as you would with the proper pressure setting, and you may be tempted to give up. Only an APAP machine or auto-adjust bilevel machine can match your changing pressure needs throughout the night.

2. Because most straight CPAPs don’t provide optional software data, they don’t encourage the user involvement that a smart APAP machine does. Patient involvement is essential for buy-in and commitment leading to successful continued use.

3. If your doctor is informed about CPAP but not about the newer technology and advantages of APAP and bilevel, and is not tuned in to your individual user needs and preferences, the straight CPAP they prescribe may not be the best match for you.

4. Although the initial price may be somewhat lower, if a CPAP is your sole machine, depending on your insurance and budget, price may not be the most important factor. If your insurance deductible is the same for a basic or advanced machine, and your health depends on its successful use, you may be far better off with an advanced machine. If, by having a less expensive CPAP without software, you require additional sleep studies, that may add to your overall insurance deductible cost.


CPAP comparison chart of various brands and models
http://www.cpap.com/cpap-compare-chart/all-CPAP


See the best selling CPAP machines at this online DME for self-paying customers at http://www.cpap.com/cpap-user-preference.php How many of these people already have an APAP machine at home and are buying a small CPAP as a backup or for travel?

APAP MACHINES (Auto-adjusting CPAPs also known as auto-titrating, self-adjusting, or auto CPAPs)

APAPs (pronounced A-paps) are the new generation of the original CPAP machines. They are smart machines which use sensors to automatically adjust pressure throughout the night if your body needs more or less pressure. In addition, when set in APAP mode with smart capability, the machine does a mini-sleep study on you every night, in the comfort of your own bed, helping you and your doctor adjust your therapy. Many APAP users find that the newer, adjustable technology of APAP provides better nightly therapy than straight CPAP. (If they find they do better on straight CPAP, they then switch their machine to the straight CPAP mode.)

APAP myths
APAPs have not been researched.
APAPS are only experimental.
The auto feature is unreliable and has not yet been perfected; or APAPs take too long to adjust to changing pressure needs.
APAPS are not for long term use.
With a titrated pressure below 10 cm H2O you don’t need an APAP machine.
APAPs wait for an apnea before adjusting.
Insurance companies will not pay for APAPs.
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

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/167/5/716 Quote: 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.pdf Quote: 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

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:

Respironics REMstar Auto A-Flex M series machine, $579
Fisher and Paykel HC 150 heated humidifier, $155
Respironics EncoreViewer software, $140
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.


APAP comparison chart of various brands and models
http://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 http://www.cpap.com/cpap-user-preference.php
How many of these people are replacing a basic CPAP machine with the more advanced technology of APAP?

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

Bilevel machines (Respironics terms are BiPAP, Adapt SV, VPAP, and AVAPS. A ResMed term is VPAP.)

Like CPAPs and APAPs, bilevel machines come in two flavors: fixed pressure (like straight CPAP) or auto-adjustable pressure (like APAP), plus other sophisticated features for various respiratory conditions, such as ASV devices. Bilevel positive airway pressure machines have one setting for inhalation (IPAP) and another setting for exhalation (EPAP). Bilevel machines or auto bilevels are prescribed when the patient can’t tolerate a standard CPAP or APAP machine, needs a very high pressure, has central apneas, needs extra exhalation relief, has UARS or flow limitations not corrected by CPAP or APAP, or has other medical conditions such as some heart or respiratory conditions. Some people without those medical conditions prefer bilevels or auto bilevels because of the comfort of extra exhalation relief. Bilevels are the most expensive of the three types of PAP machines, running from about $1,000 to $4,000. Again, with any type of machine, the algorithm and the setting of the timing of exhalation and inhalation needs to be compatible with your breathing patterns, or else the machine will be uncomfortable. Titration and adjusting the machine settings may best be done in a well qualified sleep lab while you are sleeping.

Here’s a technical discussion of bilevel machine settings and various health conditions. It illustrates why you need a very good sleep lab and sleep doctor if your SDB (Sleep Disordered Breathing) is not the garden variety that easily responds to CPAP or APAP: http://www.cpaptalk.com/viewtopic/t26896/BILEVEL-PAP-Therapy-Pearls-Clearing-the-First-Hurdle.html

See this informative article by a sleep doctor about flow limitation or UARS (upper airway resistance) and bilevel: http://www.cpaptalk.com/cpaptalk-articles/flow-limitation-UARS-BiPAP.html


Bilevel comparison chart of various brands and models
http://www.cpap.com/cpap-compare-chart/all-BiPAP


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

Mike Moran’s humor: Alternative AP therapies http://www.cpaptalk.com/viewtopic/t17588/Alternative-AP-Therapies-Humor.html


Sources: Based on personal experience with obstructive sleep apnea and gleaned from the collective wisdom of cpaptalk.com contributors.

Want more? See the blog peer coaching articles on Checking Your CPAP Machine Settings and Changing Your CPAP Pressure Settings at http://smart-sleep-apnea.blogspot.com .


Not written by healthcare professionals. The information and opinions offered are not intended or recommended as a substitute for professional medical advice.
© Mile High Sleeper, August 2006-2008. Permission to use for free educational purposes.

START HERE 2008 Finding all the articles in this blog

Articles in chronological order for the new CPAP user, to save scrolling through the Archives:

1-0 Are You Sleeping with the Enemy? by Scott Standage MD, http://smart-sleep-apnea.blogspot.com/2007/02/are-you-sleeping-with-enemy-by-scott.html

1A. Evaluating Your Sleep - Symptoms, http://smart-sleep-apnea.blogspot.com/2006/08/evaluating-your-sleep.html

1B. Sleep Study Tests, http://smart-sleep-apnea.blogspot.com/2006/09/sleep-study-tests.html

1C. Diagnosing Sleep Apnea without Insurance, http://smart-sleep-apnea.blogspot.com/2007/06/diagnosing-sleep-apnea-without.html

2. Intro to Sleep Apnea, Selected Resources, http://smart-sleep-apnea.blogspot.com/2006/08/introduction-to-sleep-apnea-selected.html

3. More Sleep-Related Web Sites, http://smart-sleep-apnea.blogspot.com/2006/08/more-sleep-related-web-sites.html

4. Tips for Newcomers to Sleep Apnea, http://smart-sleep-apnea.blogspot.com/2008/06/tips-for-newcomers-to-sleep-apnea.html

5. Building Your CPAP Support Team, http://smart-sleep-apnea.blogspot.com/2008/06/building-your-cpap-support-team.html

7. Short List of My Best PAP Equipment, http://smart-sleep-apnea.blogspot.com/2008/06/short-list-of-my-best-pap-equipment.html

8. CPAP Heated Humidifiers, http://smart-sleep-apnea.blogspot.com/2008/06/cpap-humidifiers-peer-coaching-article.html

9. CPAP Machine Choices, http://smart-sleep-apnea.blogspot.com/2008/02/cpap-machine-choices.html

10A. Checking Your CPAP Machine Settings, http://smart-sleep-apnea.blogspot.com/2008/01/checking-your-cpap-machine-settings.html

10B. Changing Your CPAP Pressure Settings, http://smart-sleep-apnea.blogspot.com/2008/01/changing-your-cpap-pressure-settings.html

12A. CPAP Mask Choices, http://smart-sleep-apnea.blogspot.com/2008/01/cpap-mask-choices.html

12B. Solving CPAP Mask Problems, http://smart-sleep-apnea.blogspot.com/2008/01/solving-cpap-mask-problems.html

16. Solving Common Equipment Problems, http://smart-sleep-apnea.blogspot.com/2008/01/solving-common-cpap-equipment-problems.html

17. Everyday CPAP Safety, http://smart-sleep-apnea.blogspot.com/2008/01/everyday-cpap-safety.html

17C. Preventing and Reporting Errors in Your Care, http://smart-sleep-apnea.blogspot.com/2008/01/preventing-and-reporting-errors-in-your.html

18. CPAP Equipment Cleaning and Replacement, http://smart-sleep-apnea.blogspot.com/2008/01/cpap-equipment-cleaning-and-replacement.html

19. Seven Stages of CPAP and What Is Feeling Good? http://smart-sleep-apnea.blogspot.com/2008/01/seven-stages-of-cpap-and-what-is.html

20. CPAP Adaptation Stages and Recovery, http://smart-sleep-apnea.blogspot.com/2008/01/cpap-adaptation-stages-and-recovery.html

21. Diary of Two Hoseheads, http://smart-sleep-apnea.blogspot.com/2008/01/diary-of-two-hoseheads.html

20B. Specific Health Conditions and OSA Recovery, http://smart-sleep-apnea.blogspot.com/2007/12/specific-health-conditions-and-osa.html

20C. Social and Psychological Factors in SBD Recovery, http://smart-sleep-apnea.blogspot.com/2007/12/social-and-psychological-factors-in-sbd.html

24A. Mike Moran's CPAP Humor, http://smart-sleep-apnea.blogspot.com/2007/12/mike-morans-cpap-humor.html

24B. More CPAP Humor, http://smart-sleep-apnea.blogspot.com/2007/12/more-cpap-humor.html

25. AWAKE Workshop Design/Peer Coaching, http://smart-sleep-apnea.blogspot.com/2007/02/awake-meeting-designpeer-coaching.html

Checking Your CPAP Machine Settings

Peer coaching article # 10A
Part 1 of 2 on PAP Pressure

Tips for All PAP Users

Pressure Definition. Machine air pressure is measured in centimeters of water, cm/H2O or cwp, centimeters of water pressure. A pressure of 10 cm/H2O means that if you were drinking water from a 10 centimeter (3.9 inch) straw positioned at the top of the water to your mouth, the suction you create would be 10 centimeters of water pressure. Speech is measured at about 7 cm/H2O pressure past the vocal cords. The average pressure for treating sleep apnea is 10 cm/H2O. Typical pressures for treating obstructive sleep apnea are 6 to 15 cm/H2O. Some people require higher pressures. The air pressure acts as a pneumatic splint to keep the throat open. The pressure is less than a sneeze and rarely causes the ears to pop. Source: TS Johnson MD et al, Sleep Apnea – The Phantom of the Night, p. 92.

Titration is a scientific lab term, meaning to slowly add a little bit more of something until you reach a desired effect. During the sleep study, the sleep technician slowly increases the CPAP machine pressure one centimeter/water at a time until you stop having apneic events (apneas and hypopneas). That and some more calculation lead to a titrated pressure setting. See Reasons Why Your Titrated Pressure May Be Wrong in the peer coaching article CPAP Machine Choices. Research article on the inaccuracies of a one-night titration: http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=14971878&dopt=Citation

Know your titrated pressure from the sleep study. Know the pressure your doctor prescribed. If you don’t know them, ask your doctor’s office for a copy of the sleep study report and doctor’s prescription. Some people start and continue CPAP treatment with the titrated pressure from their sleep study and have continuing good results with no problems. Others still feel tired, or feel tired again after a few months, and need to explore the correctness of their machine pressure setting and pressure prescription, as well as first solving other equipment problems.

Consequences of a wrong pressure setting
Don’t worry; unless you have other serious medical problems, your immediate life is probably not in danger! Long term is another matter if you give up on CPAP therapy. It’s important to know your titrated pressure from a sleep study (if you have been titrated) and pressure prescription, and know that your machine has been set up correctly by the Respiratory Therapist (RT). The prescribed pressure setting on your PAP machine is very important.

If the pressure is too low for you, it won’t eliminate all the apneas or hypopneas and may not clear out all the exhaled carbon dioxide from your mask. Pressure too low may be indicated by snoring, insomnia, feeling starved for air, subtle feelings of suffocation or claustrophobia while on PAP, an AHI (apnea-hypopnea index) above the normal 5 or below events per hour, or still feeling tired or sleepy during the day. Some people find that a setting of 4 or 5 cm/H2O is not high enough to clear the exhaled carbon dioxide, and need a setting of 6, 7, or 8 cm/H2O or more as their lowest setting on an APAP.

Pressure that is too high for you may be indicated by uncomfortable therapy, large mask leaks, mouth breathing, dry mouth and throat even with heated humidification, aerophagia (swallowing air), an AHI above the normal 5 or below events per hour, and still feeling tired or sleepy during the day. Some people have concerns that too high a pressure setting may lead to pressure-induced central apneas (the brain not telling the body to breathe) unless the PAP machine algorithm (operating rules) prevent runaways as in Respironics machines. Pressure settings above 15 cm/H2O are considered high for some people; for others, 18, 19, 20 cm/H2O is high.

If your autopap machine is left at the factory default setting of 4 to 20 cm/H2O, you may experience the problems of both too high and too low. In addition, the APAP machine may have difficulty responding quickly enough with this large range. With pressure too low, too high, or other wrong setting (CPAP or APAP mode, exhalation relief, ramp or settling), your AHI may not be as low as it should be, or you may be more uncomfortable, and you may think the therapy doesn’t work very well and be tempted to give it up. To know your AHI, you need a machine with a smart display or better yet, software. Your AHI should be 5 events per hour or less to be considered in the range of normal sleepers. Many people require an AHI of 2.5 or less to be truly rested and invigorated.

Two measurements of Sleep Disordered Breathing (SDB)
Apnea. The Greek word “apnea” means “without breath.” You stop breathing during sleep for ten seconds or longer.
Hypopnea. There is airflow through your throat but at a much reduced level, which leads to not getting enough oxygen. It’s abnormally shallow breathing lasting at least ten seconds.

1. AHI, Apnea-Hypopnea Index for sleep apnea:
Less than 5 events (apnea or hypopnea) per hour is considered normal.
5 or more events per hour is considered Mild sleep apnea
15+ considered Moderate
30+ considered Severe
(from T. S. Johnson MD, Sleep Apnea - The Phantom of the Night, page 211)

Flow limitation or Upper Airway Resistance Syndrome (UARS) is another important, subtle form of SBD. The airflow meets resistance in the nose or mouth, causing the brain to waken the sleeper. The American Academy of Sleep Medicine advocates counting apneas, hypopneas, and flow limitations/UARS for the Respiratory Disturbance Index, RDI.

2. RDI, Respiratory Disturbance Index for sleep apnea:
5 to 20 events per hour is Mild SDB
20 to 40 events is Moderate SDB
More than 40 events is Severe SDB
(from Barry Krakow, MD, Sound Sleep, Sound Mind, page 245)

Check the accuracy of your machine’s prescribed pressure setting. This is important.
Your doctor’s prescription was entered into the PAP machine by a Respiratory Therapist at a DME/home medical equipment company who could make a mistake. The DME company may not have procedures to detect setup errors, so if they made an error, you would never know, unless you had other means to check the settings. (Their follow-up phone call asking “how are you doing?” isn’t precise enough to detect set-up errors.) You are entitled to ask and observe to have the settings checked by a Respiratory Therapist other than the one who set it up, or by a lead respiratory therapist; or minimally, by a slow and careful walk-through demonstration by the same RT who programmed the machine originally. See the end of this article for a sample walk-through of machine set-up. The check could be done when you get the machine, or a few days later if you were overwhelmed by your diagnosis and too much information when you first picked up the machine.

If you run into resistance from the RT about checking your machine setting, is it because they are unwilling or unable? If unable because they are not competent in setting up the machine, there is a greater chance they made an error, and all the more reason to have it checked. If they are unwilling, it may be that, following company policy, they are unwilling to risk your learning how the machine is set so you don’t “tamper” with it. Nevertheless, you are entitled to see if it’s a correct prescription, just as you are entitled to see if the label on a bottled drug prescription or the pill has the right dosage. If you run into resistance, talk with the lead RT or branch manager, or if the DME insists, get a doctor’s prescription to let you observe the correct settings, or get a doctor’s prescription for the clinician’s manual from the DME and check it yourself.

Learn the patient-controlled settings. This is important.
Read the user’s manuals that come with your machine and heated humidifier to learn how to set the features you can control. For example, in a older, classic tank Respironics REMstar autopap, that would be heat/humidity level, C-Flex level, ramp pressure and duration of ramp (if in CPAP mode rather than APAP on an older machine), mask-off alert/auto-off, and button lights. Learn to read the display screens. Use a flashlight and magnifying glass if necessary. If you have trouble pushing buttons, you may want to get someone to help you. Discussion thread on a ramp (settling) pressure setting that was too low: http://www.cpaptalk.com/viewtopic.php?p=134380#134380

Using a clinician’s set-up manual to check the accuracy of your prescribed pressure setting

Personal criteria for using a set-up manual
If you aren’t good with technology, you should probably rely on the respiratory therapist at your local DME to check the prescribed pressure settings; or rely on a family member, friend, or doctor. If you can’t program your VCR, DVR, cell phone, or use most of the features of a digital camera, seek help from others. If you can handle most basic consumer technology, it should be easy for you to use a set-up manual safely and well to check the accuracy of your machine settings. Checking the set-up menu is not much more difficult than changing the time on a digital clock and takes less than a minute, once you know what you are doing.

How to get a clinician’s set-up manual
The clinician’s set-up manual is boxed with the new machine, along with the user’s manual. The local DME/HME company should give you the patient/user’s manual but, fearing liability, will probably withhold the clinician’s manual unless you have a doctor’s prescription for it. When you ask your doctor for a prescription for the manual (before or after you get your machine), tell him/her that without it you can’t check the correctness of your machine settings made by the DME. Discuss your ability to scroll through a menu with your doctor, show him/her the sample dialog at the end of this article if he/she isn’t familiar with a machine’s setup, and show him/her the user’s manual if you already have one. The clinician’s manual isn’t much different; if you can follow the user’s manual, you can follow the clinician’s manual.

If you buy your machine online at www.cpap.com, all manuals will be included. Some people buy clinician’s manuals online, but be sure that you get the one for your machine, not another model. Some people ask other experienced users for the simple directions on how to use the buttons to access the set-up menu in the display; you really don’t need the hardcopy set-up manual. For example, see
http://www.cpaptalk.com/viewtopic/t15421/How-to-change-settings-on-RemStar-Plus.html and http://www.cpaptalk.com/viewtopic.php?t=11376 and http://www.cpaptalk.com/viewtopic.php?t=10055 . Don’t expect support from your local DME in using a set-up manual or machine software.

You do not need machine software to use a set-up manual or instructions to check whether the DME RT set your machine correctly. As you scroll through the settings, write them down for later reference. If you find that the DME set up the machine wrong, not following your doctor’s prescription, inform your doctor and take the machine into your DME for correction by the lead RT or correct it yourself. Report the error to the local DME supervisor/lead respiratory therapist or branch or regional manager, and consider reporting it to the DME branch or regional manager and filing a complaint with The Joint Commission of Accreditation of Healthcare Organizations http://www.jointcommission.org/GeneralPublic/Complaint/oqm.htm so other patients won’t be harmed. The DME needs feedback to improve their quality of service to other patients. See the article on Preventing and Reporting Errors in Your Care.

With a clinician’s manual, you will be able to change the pressure settings beyond the original prescription, but it is inadvisable to do that unless you have supervision from your doctor and software to give you feedback on the results of changes.

To get the machine pressure changed by your doctor and DME, you need to get an appointment or phone your doctor, explain why you think a change is needed, make sure that a prescription was sent to the DME and received, make sure that the DME processed the prescription internally so your local office can make the change, make an appointment at the DME, drive to the local office, wait, have the respiratory therapist make the change, which literally takes about 30 seconds, and drive home. Before you leave, request that another RT check the accuracy of the setting, or get a careful walk-though demonstration from your machine showing correct settings.

An alternative is to team with your doctor to correct or adjust the pressure settings yourself, if you are a suitable candidate for this team effort. See the next article on Changing Your CPAP Pressure Setting.

After you have mastered hose, mask, leaks, comfort, humidity, ramp/settling, exhalation relief, and been stable on PAP for a few weeks or months, borrow an overnight recording pulse oximeter from your doctor or RT, or buy one online. Use it to check your blood oxygen saturation levels at night as another indicator that your PAP is working well.

Even better, get a machine with software to more precisely show how well your therapy is working.


Appendix I
Check the machine accuracy with a manometer

New users, don’t let this scare you. This is rare but important: http://www.cpaptalk.com/viewtopic/t15002/cpap-machine-gone-crazy.html

Rarely, the pressure reading on the machine’s LCD display and actual pressure may be different. You may want to check the actual pressure every six months or annually. An instrument called a manometer will give an accurate reading. A free manometer check may easily be done by your local DME, perhaps before and after AWAKE support group meetings at a sleep lab, or you can make or buy a manometer online. See http://www.cpap.com/ and search. If the pressure is off, some machines have an internal reset feature. If there is no reset, you can change the machine’s pressure setting to match the actual pressure. For example, if you are seeking a prescribed pressure of 9 cm H2O but 9 on your machine isn’t really a pressure of 9, you can bump it up to 10 to get an actual pressure of 9. If you don’t have a manometer and the pressure is off, what really matters is how you feel and your AHI at the actual pressure you do have.


Appendix II
Sample walk-through to check settings on an older Respironics REMstar Auto with C-Flex CPAP (the “classic tank” model)

It takes less than a minute to scroll through the menu, using the buttons on the machine. The respiratory therapist should demonstrate competence and confidence in working with the machine settings. This is a sample dialog that you should hear from the respiratory therapist to confirm correct settings. The dialog for your machine will be different, but the RT should explain each screen.

“Screen 1. Nights at more than 4 hours means the number of nights you used the machine for more than 4 hours. Stop me and ask if you have questions about any of these settings.

Screen 2. AFLE means that the therapy mode is set to Auto CPAP with C-Flex pressure relief, what your doctor prescribed.

Screen 3. Min 9.0 means that your lower pressure is set to 9.0 cm H2O pressure, what your doctor prescribed.

Screen 4. Max. 11.5 means that your higher pressure is set to 11.5 cm H2O. Your machine will automatically adjust up and down between 9 and 11.5 cm H2O, what your doctor prescribed.

Screen 5. C Flex 3 means that your exhalation relief is set to 3, the highest setting offering the most relief. You can change this setting on your own, following the instructions in the user’s manual.

Screen 6. 0:00 ramp means that your ramp (startup) time is set to 0. This means there is no ramp in the APAP mode. Your machine will start at your lowest setting, 9 cm H2O, and adjust upward to 11.5 as you need it. For older REMstar auto machines, the ramp time must be set to zero in the auto mode. If the ramp is set to anything other than 0:00, the machine is set for a split night sleep test, remaining at the lowest pressure for the set number of hours, so you are not getting a full night of therapy. (If your doctor had prescribed CPAP mode instead of APAP, ramp time from 5 to 45 minutes would be available on this older machine. Respironics newer M series autopaps can use ramp while operating in auto mode.)

Screen 7. Alert 1 means that your mask-off alarm beep is turned on. If your hose disconnects or your mask comes off, the machine will beep. It also means that the machine auto-off feature is turned on. You can change this setting on your own.

Screen 8. LED 0 means that the button lights are turned off while the machine is on. You can change this setting on your own.

Screen 1 again means that this is where we came in; we’ve gone through the whole menu and it’s correct.”


Sources: Based on personal experience with obstructive sleep apnea and gleaned from the collective wisdom of cpaptalk.com contributors.

Want more?
Discussion thread on pressure vs. leaks: http://www.cpaptalk.com/viewtopic/t15360/pressure-versus-leaks.html

See the blog peer coaching articles on Changing Your CPAP Pressure Setting, CPAP Machine Choices, Everyday CPAP Safety, Preventing and Reporting Incidents on http://smart-sleep-apnea.blogspot.com .

Search or post a message on www.cpaptalk.com .

Not written by healthcare professionals. The information and opinions offered are not intended or recommended as a substitute for professional medical advice.
© Mile High Sleeper, August 2006-2008. Permission to use for free educational purposes.

Changing Your CPAP Pressure Settings

Peer coaching article # 10B
Part 2 of 2 on PAP Pressure

This is the second of two articles. See the first article on Checking Your CPAP Machine Setting, sections on Pressure Definition, Titration, and Consequences of a wrong pressure setting.

For Those Who Need and Want to Be More Involved with Their PAP Therapy

Why responsible self-management of PAP therapy? This is important.
Most people find that useful information on their optimal pressure settings and PAP therapy in general is elusive. As a result, some people seek information online, buy machine software, and by necessity start to manage their own therapy, because no one else is managing it on a nightly basis. If the quality of information they are able to access is good, if they are discerning, and if they have good medical backup and supervision, this can work well. These people are committed and actively working toward success in a difficult therapy.

Responsible self-management does not mean sole management. Working with a doctor does not have to be an “either-or” process where either the doctor is completely responsible or the patient is completely responsible. Working with a doctor can be a “both-and” process of collaboration. Both the doctor and the patient are managing the therapy. The doctor is managing the medical side and some aspects of the therapy, and the patient is managing his/her nightly therapy and equipment, seeking advice and support from the doctor. The patient is closest to the therapy and best able to notice problems, observe results, and take action to make the treatment work. This may include making gradual changes in pressure settings, in collaboration with the doctor, and trying them long enough to observe results.

Similar to responsible patients with diabetes who test and moderate their blood sugar levels, responsible patients on PAP can be trusted to adjust the many variables of their PAP equipment. CPAP is a safe and live-saving therapy. Not only can the capable PAP user manage the equipment variables; they must manage the variables to be successful.

Know the original pressure setting resulting from your sleep study titration, if you had one. Know the original pressure setting your doctor prescribed. If you have already mastered problems with the hose, mask, leaks, comfort, humidity, ramp/settling, and exhalation relief, and you’ve been on the therapy for several weeks or months and are still not feeling as good as you think you should, or still experiencing sleep apnea symptoms such as nocturia (nighttime urination), you may have a wrong pressure setting. Discussion thread of the inaccuracies of sleep lab titrations and patient at-home experimentation: http://www.cpaptalk.com/viewtopic.php?t=19947&postdays=0&postorder=asc&start=0
Discussion thread on changing your pressure settings: http://www.cpaptalk.com/viewtopic/t25586/New-here--Do-you-change-your-own-pressures.html
Discussion thread on why it’s important: http://www.cpaptalk.com/viewtopic/t27856/Why-taking-your-treatment-into-your-own-hands-is-important.html


For people without serious health problems who use machine software in working with their doctor to adjust pressure settings

This is moving up a notch in terms of responsible self management of your therapy. Are you free of serious health conditions such as heart or respiratory trouble, central or complex/mixed sleep apnea, mental health problems, problems with mental acuity, or any other condition that would make your working with pressure settings inadvisable? Are you capable and confident about working with the machine settings and software? Is your physician open to working with you on pressure settings in this manner? See the discussion thread on working with a helpful doctor at http://www.cpaptalk.com/viewtopic/t14847/A-GOOD-doctor-story-for-a-change.html .

It is illegal for a DME to change your pressure setting without a doctor’s prescription. It is not illegal for you to work with your doctor in changing your own pressure setting.

Don’t try this at home without software! If you attempt to change pressure settings without software, it’s like shooting at an archery target with your eyes closed. You don’t have enough information to know if your arrow is getting close to the bulls eye. You need to have a machine that is fully data capable, and buy the software (and perhaps a card reader) online at your own expense. Although most software is designed and labeled for the clinician, it is not illegal for you to have it as a patient. One manufacturer, Respironics, wisely offers software designed for the patient. Be aware that your machine’s sensors and software are crude, compared to the sophisticated equipment in a sleep lab. However, they are good enough to be helpful in monitoring and adjusting therapy. Scroll down to see the post by Sleepy-in-AL showing an older Respironics Encore Pro software Daily Details report: http://www.cpaptalk.com/viewtopic.php?t=10245&highlight=puffy Once you have the software, collect some reports to show your doctor, showing your leaks are under control but your AHI (apnea hypopnea index) is still too high. Again visit your doctor and get a written prescription for a new safe pressure or range of pressure, based on your sleep study.

Write down your original pressure and each change you make. Most important, monitor and keep a daily log of how you feel each day, related to the pressure setting and other variables such as mask leak. How you feel is the best indicator of a good pressure setting.

Monitor the software for AHI, flow limitation or UARS, daily events per hour at various pressures, mask leaks, and any other useful data. It’s tempting to overly rely on the software data’s numbers, since they look so precise, but how you feel is more important. It’s necessary to know how to read graphs and charts. If you can’t understand them, get a helper or ask your physician. You will probably need help from a doctor, sleep technician, or other software users to read the first report, if the software doesn’t include definitions of measurements. Although you can ask, your DME RT will probably be prohibited from helping you interpret software reports.

Two measurements of Sleep Disordered Breathing (SDB)
Apnea. The Greek word “apnea” means “without breath.” You stop breathing during sleep for ten seconds or longer.
Hypopnea. There is airflow through your throat but at a much reduced level, which leads to not getting enough oxygen. It’s abnormally shallow breathing lasting at least ten seconds.

1. AHI, Apnea-Hypopnea Index for sleep apnea:
Less than 5 events (apnea or hypopnea) per hour is considered normal.
5 or more events per hour is considered Mild sleep apnea
15+ considered Moderate
30+ considered Severe
(from T. S. Johnson MD, Sleep Apnea - The Phantom of the Night, page 211)

Flow limitation or Upper Airway Resistance Syndrome (UARS) is another important, subtle form of SBD. The airflow meets resistance in the nose or mouth, causing the brain to waken the sleeper. The American Academy of Sleep Medicine advocates counting apneas, hypopneas, and flow limitations/UARS for the Respiratory Disturbance Index, RDI, which is more comprehensive than the Apnea-Hypopnea Index.

2. RDI, Respiratory Disturbance Index for sleep apnea:
5 to 20 events per hour is Mild SDB
20 to 40 events is Moderate SDB
More than 40 events is Severe SDB
(from Barry Krakow, MD, Sound Sleep,Sound Mind, page 245)

Partner with your physician. Show him/her your weekly software printouts and sleep log or diary of how you feel. Use them to plan the next pressure adjustment. For those who were never titrated in a sleep lab, it may take weeks or months to find your optimal pressure or pressure range, but meanwhile, you should be feeling better with each incremental improvement in pressure.

There are no single formulas for success. Try a prescribed setting long enough to know if it works. For most small pressure change adjustments, give them at least week or two. Study your software full details report daily if experiencing any problems, or at least weekly to track and analyze each adjustment. Make small, incremental changes. Change one thing at a time to track the effect and not confuse it with other changes. For example, change only one of the following at a time: mask, mask fitting, humidity level, exhalation relief level (if applicable), ramp time (if applicable), pressure. That’s why it may take months to experiment with all the variables. Most people get their masks and leaks under control, and humidification and exhalation relief, before adjusting pressure settings. (Exception: people who haven’t been titrated and have an APAP initial prescription of 4 to 20 cm/H2O.) For example, you may experiment with masks for a month, getting comfort and leaks under control, while leaving the pressure setting as is. Then you may change the humidifier setting for three days, and then the exhalation relief for four days, leaving the mask and pressure setting unchanged. The following week or two, you may try a new pressure, not changing the mask or other settings. The next week, more refining of the pressure adjustments. Keep a written record of all changes and how you feel, so you don’t get confused and can analyze it later. Discussion thread: http://www.cpaptalk.com/viewtopic/t25791/General-protocol-for-self-pressure-adjustment--Comments.html

Continue to use the detailed software reports and how you feel to track and confirm therapy progress. After you have a correct pressure or range, over time you may want to monitor only monthly or every few months or when you have a problem. When you have a change in masks or weight change, you may want to monitor your software reports and adjust pressures again.

If needed, seek advice from other CPAP users such as
http://www.cpaptalk.com/viewtopic.php?t=10357
http://www.cpaptalk.com/viewtopic.php?t=10426 and
http://www.cpaptalk.com/viewtopic.php?t=16391&postdays=0&postorder=asc&start=0

Once you have a plan, try if for a week or two, and then, based on your software report and the way you feel, adjust it gradually, narrowing or widening the range or moving it up or down. An AHI of 10 events per hour, which is mild sleep apnea, may mean that your heart is still susceptible to damage. Continue to strive for feeling clear-headed and energized all your waking hours and an AHI of 5 or less. Some people report that an AHI of 2.5 seems to be a marker. With an AHI from 2.5 to 5 they feel tired by the late afternoon or evening, or feel not as good that day. With an AHI under 2.5, they feel great all their waking hours. By comparing how you feel and your AHI figures, you can gauge what your body needs from its PAP therapy. Repeat a pressure or range to be certain that it’s the best for you or a different pressure is needed.

After you have been stable on the same pressure or pressure range for a few weeks or months, borrow an overnight recording pulse oximeter from your doctor or DME, or buy one online. Use it to check your blood oxygen saturation levels at night as another indicator that your PAP is working well.

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.

Ideas for straight CPAP users to discuss with their doctors

At some point when they have detected a potentially optimal pressure setting, some people try switching to the straight CPAP mode on their APAP machine, to see if they get better results. Some use their titrated pressure, or 90% pressure, as a straight CPAP setting. If you use the daily events per hour data to find the pressure that gives you the lowest AHI and use that as a straight CPAP setting, it may be too low for events that require a higher pressure setting, and the 90% pressure may be better. Or the opposite, if a 90% pressure is too high and leads to aerophagia or central apneas.

For straight CPAP or autopap users in the CPAP mode, if all this seems too complicated, some start with their titrated pressure or a number just above or below it. For example, with a titrated pressure of 10 cm/H2O, they try that for a week and note how they feel, then try 9 cm/H2O for a week, then try 11 cm/H2O for a week, etc. Once a pressure is found that seems to work, they can fine-tune by going up and down half a cm/H2O from that pressure to see if there is an improvement in the way they feel. For example, trying both 10 and 10.5 cm/H2O.

Sources: Based on personal experience with obstructive sleep apnea and gleaned from the collective wisdom of cpaptalk.com contributors.

Want more?
Discussion thread on the safety, legality, and merit of the patient changing their own pressure settings at http://www.cpaptalk.com/viewtopic.php?t=3366&postdays=0&postorder=asc&start=0

Discussion thread on CPAP vs. APAP and the complexity of adjusting your own pressure settings:
http://www.cpaptalk.com/viewtopic.php?t=18054&postdays=0&postorder=asc&start=0

See the blog peer coaching articles on Checking Your CPAP Machine Settings, CPAP Machine Choices, Everyday CPAP Safety, Preventing and Reporting Incidents on http://smart-sleep-apnea.blogspot.com .

Search or post a message on www.cpaptalk.com .

Not written by healthcare professionals. The information and opinions offered are not intended or recommended as a substitute for professional medical advice.
© Mile High Sleeper, August 2006-2008. Permission to use for free educational purposes.

CPAP Mask Choices

Peer coaching article # 12A
So many masks, so little time.

PAP (CPAP, APAP, or BiPAP) treatment works wonders in many people’s lives. Usually the most difficult part of the therapy is finding the right mask and adjusting to it. Here are some tips for being a smart mask shopper and user. You are the one who needs to sleep with the mask all night, every night. You are the one, not your doctor or respiratory therapist, who needs to discover which mask is best for you.

The problem with masks
Most PAP (Positive Airway Pressure) users have no problems with their machine if it was an informed choice based on their needs and preferences. A CPAP heated humidifier easily makes air passages comfortable and helps keep nasal passages open. Daily nasal irrigation helps reduce congestion in nasal passages. Hose management is easy to do. A PAPillow or other good pillow can be found to use with a mask. Rainout (condensation) in the hose can be easily eliminated with an Australian heated hose from www.SleepZone.com.au/ .

But masks, also called interfaces, are problematic for most PAP users because of their design and fit. Most masks come in only three to five sizes. It’s as if all the men and women in the world were expected to fit into only three unisex shoe sizes, but worse. Manufacturers make custom eyeglasses, dentures, clothes, orthotics (shoe insoles), shoes, but generally not custom CPAP masks. Despite each person’s unique facial contours, facial hair, and unique muscle relaxation in deep sleep, despite the force of air pressure and humidified air and sweat, masks are expected to fit everyone comfortably and not leak. That doesn’t happen readily. Common mask problems are fit and discomfort at pressure points on the nose and face, uncomfortable and noisy leakage of air from the mask, noise from the air vents, discomfort with the headgear to hold the mask in place, and air blowing from the mask vents onto your hand, arm, or your bed partner. All these mask problems affect the quality of sleep, number of apneaic events, likelihood of adherence or compliance with the treatment, and resulting health and longevity.

Mask evolution lags far behind machine evolution. With so many people yet undiagnosed with sleep apnea, there is a huge potential market which may funnel dollars into better mask design and production in the future.

It’s not “just” comfort
It’s important that your mask (and everything else) be comfortable. With sleep therapy, comfort is not just a luxury, it’s a necessity for successful treatment. In the daytime, when you are awake and not exhausted, you could tough it out and handle a difficult physical therapy for a few hours. But at night, when you are exhausted, vulnerable, extra sensitive, and need to sleep, your mask needs to be compatible with sleep all night long. In other words, comfortable. Although people have great capacity to adjust and “sleep though anything,” there is a limit.

To make a mask more comfortable, consider Pad-A-Cheek strap covers http://www.padacheek.com/ , a mask-compatible pillow such as PAPillow http://www.papillow.com/ to reduce leaks, proper hose management so there is no drag on the mask causing leaks; a PAP heated humidifier, fleece hose cover, Australian SleepZone heated hose http://www.sleepzone.com.au/index.html , and hose connectors. See the articles on Solving CPAP Mask Problems and Solving Common Equipment Problems.

To minimize mask leaks, go to bed with a clean face, avoid facial moisturizers at night, and wash facial oils off your mask each morning. See the article on Equipment Cleaning.

Mask prescriptions
By law, CPAP masks do not require a doctor’s prescription for purchase. However, if you get a mask through a DME (Durable Medical Equipment or Home Medical Equipment) provider which will be paid by insurance, a prescription is required for insurance reimbursement billing purposes. The prescription can be generic, allowing you to make your own choice. If you want a specific brand and model from a DME, it’s better if the prescription is specific for that mask, so you get exactly what you want. If a mask is bought online, no prescription is required, but it may be helpful to inform your doctor of your mask choice. Check in advance to see if your insurance company will reimburse you for online purchases, unless you decide to pay for it yourself.

Mask types
Three main types are nasal masks which cover the nose, nasal pillows which snug against the openings of the nostrils, and full face masks which cover the nose and mouth. Additional useful types are a hybrid mask that combines nasal pillows and a mouth mask, nasal prongs or cannula which fit into the nostrils, nose cushions which fit under the nose, a nasal pillow interface that is held in place by a mouth piece, and an oral mask that blows air into the mouth only. On cpap.com see Answers, Masks at http://www.cpap.com/cpap-faq/Masks.html#52 .

There are many brands and models of masks in each category. Any type of mask generally works with any type of PAP machine. One manufacturer’s brand of nasal mask may not work for you; another manufacturer’s may work well; and the same for nasal pillows, full face masks, and all the other types.

How to minimize mask discomfort
1. Good mask selection
2. Good mask fitting
3. Get two different types of mask near the start of treatment

There are a lucky few who experience no mask discomfort or leakage from the start. If you find that your first mask works, you may not want to explore another until your insurance will pay for it in six months. More common is the need to try several masks before finding one that works. Ask about a 30-day return policy.
With any mask, do what you can to make sure the respiratory therapist fits it properly at the start and shows you how to adjust the fit yourself. In addition, you will probably have to do your own repeated fitting and tweaking to make it work, tested over many nights. Once you get a good fit, if it’s possible with your mask, don’t change the headgear adjustments. Undo a clip or two to remove the mask, and leave the headgear as is.

There is a time incompatibility. Your working unit of time for mask-success is nightly. The timeframe of your doctor, insurance, and DME to approve and get you another mask is probably in weeks. If your first mask doesn’t work, this means weeks of nightly discomfort and frustration while waiting for your next mask and the temptation to give up on PAP. Discuss with your physician the option of getting two types of masks (nasal mask, nasal pillows, full face mask, etc.) near the start of your therapy. For example, if you start with a nasal mask and discover after two weeks that you have a chronically congested nose on PAP, you may have a medical necessity for a full face mask.

Advantages to having more than one type of mask near the start: you can continue your nightly PAP therapy if one mask doesn’t work or it breaks. If the nasal pillows make your nostrils sore, you can switch to a nasal mask the next night; or if a nasal mask makes your face sore at pressure points, you can switch to nasal pillows. Or, if your nose is stuffy or you have seasonal allergies, you can switch to a full face mask. If you want to take a daytime nap but your mask is still wet from morning cleaning, you have a dry back-up mask.

Disadvantages: insurance may pay for only one mask at the start or may pay for medically necessary masks only over a period of months. The usual insurance schedule for a new mask due to wear, usually based on Medicare guidelines, is every six months. Mask cushions and nasal pillows are replaced more frequently. See Medicare replacement guidelines at http://www.billmyinsurance.com/cpap-faq/Medicare.html#14
You may need to buy the less expensive second mask on your own. Your successful therapy and health are worth it, if your budget allows.

At the start, it may seem overwhelming to research and adapt to two types of masks instead of one. You may not be psychologically ready to try a type of mask you are resistant to, such as a full face, until you have become accustomed to another type, such as a nasal mask, and found that it too has limitations. A remedy is to balance the level of your confusion and resistance with the convenience of having a back-up option on hand. You may be tempted to not give each type and brand of mask a fair trial. A remedy is to stick with one (for example, nasal mask) until it works or you give up on trying to make it work; then switch to the other type (nasal pillows), while you then continue to explore other brands of nasal masks or types of masks, and so on. Exception: if you know in advance that you must breathe through your mouth, you will need only a full face mask. You might try just one, since they are the most costly of the mask types.

Strike a balance between suffering with a badly matched mask for six months, or trying too many masks too fast. If your first mask isn’t working, research other masks online for ideas and revisit your doctor and/or respiratory therapist. Your relationship with your mask and other CPAP equipment is important. Like any other relationship, it requires patience and work and brings its own rewards.

Mask trials and choices
The choice of a mask is best not left solely to your doctor or a respiratory therapist (RT) at a DME. Consider their advice, but make your own choice, since you have to live with it. The RT may be informed only about the masks in their inventory, which is limited by the manufacturers they represent, and uninformed or misinformed about other masks. For example, it’s said that Apria favors Respironics masks and Lincare favors ResMed masks because of their contracts with those manufacturers. Your patient needs are not necessarily the same as the DME’s business contract or need to move inventory. Beware of a DME that carries only Respironics masks and says that they have found that ResMed masks don’t work very well, and vice versa, because they may be putting their profit motive ahead of your best health option. The DME may be able to special order brands they don’t normally stock, but not initially suggest them unless you request it or have a prescription for a specific mask. Even professional and ethical respiratory therapists may have knowledge gaps and be biased about masks they have experience with, but they aren’t the one who needs to wear it. Sometimes it’s difficult to sort out biased opinions from sound professional advice. Keep searching in your region or online until you find someone whose judgment you can trust. A good source of professional help may be a hospital sleep lab supervisor or sleep technician, since they work with different brands and models of masks nightly, and are usually not selling any one product line.

Trial and error is the only way to discover the best mask for you, but you can maximize your chance of success. Because mask selection is so individual and difficult, some people have a collection of masks they’ve bought on their own, many of them expensive failures. To minimize this problem, try before you buy, if at all possible. Research masks on the Internet at online CPAP stores and manufacturers’ web sites. Make a list of masks that look promising. Then try to find a local source for getting those masks for you to try in your size.

An excellent place to try masks, if you can find one, is a hospital sleep lab, morning or early evening when they aren’t doing sleep tests. A sleep lab can sterilize masks, so they are able to have demo masks for trials. The sleep lab may have a supervisor or sleep technicians who are expert mask fitters and advisors, who can suggest a mask size (which varies by brand and model) and can test your mask under your prescribed pressure, checking for leaks with their equipment, while you are lying down on your back and sides. They may do this for free, charge a small fee, combine it with other medical services, or act as a DME. If they also sell masks, do they have a 30 day return policy if the mask doesn’t work?

If you are buying at your own expense and there is a small price difference between the local source and online DME, perhaps it’s worth the difference to pay more locally for high quality service. If it’s two or three times or more the cost of buying online, your income and sense of fairness may be the deciding factors. Masks are also sold on online auctions. If you buy a used mask, there is a risk if the previous owner had a staph infection and the mask has not been sterilized.

Will your local DME get the masks you want and let you try them before buying? Are there other DMES on your insurance plan? Or another DME not on your insurance plan who will let you try masks? How long will it take them to get the masks you want to try? To find the better DME companies, ask for recommendations from a hospital sleep lab or a sleep doctor. Many people get frustrated with repeated inferior service from the only large national DME on their insurance plan, and just order online for more accurate information, better service, faster delivery, and lower prices. For CPAP users comments on using a DME, see the discussion thread http://www.cpaptalk.com/viewtopic.php?t=11021 .

Mask sizing and fitting
Wherever you try on a mask, it should first be expertly sized and fitted by a technician while you are sitting up, then tried under your prescribed pressure and checked for leaks (by equipment at a sleep lab or by feel at a DME) while you are lying down on your back and sides. Sitting up in a chair with a mask on does not reflect what the mask will do when you are in bed and your facial features adjust to gravity while laying down. If you run into resistance from the DME to trying masks lying down under machine pressure, know that they are pretending to fit the mask, not actually doing it. A few people actually come to the DME with a pillow and insist upon lying on the floor to get their mask fitted and checked for leaks in various positions. If the RT does little more than take the mask out of the box, put it on your head and say “there,” you aren’t getting a real mask fitting.

Does the respiratory therapist have enough expertise to fit the mask properly and advise you about how well a given mask will work for you? If not, ask for a different RT who knows how to fit masks, or go to another office of the same DME that does fittings lying down, find another DME company for mask fitting, or better yet, go to a sleep lab or center. See the post by rested gal at http://www.cpaptalk.com/viewtopic/t25335/CPAP-Should-I-turn-it-into-flower-vase.html

People go to optical shops to get their eyeglasses fitted and periodically adjusted. Mask fitting is even more complex. Once you have a mask, you may need help with the initial mask fitting and maybe follow-up. Each mask and each person is different, but the RT or sleep technician should be able to give you some general principles of fitting a particular mask, a show-and-tell. “Keep this part firm, this part looser. Adjust this part first, then this part. Watch for this and that. To take it off, do this.” Remember the tips or take notes and keep them with the mask.

People are sometimes forced to “lab rat” and experiment to customize the fit and comfort, but find the effort worthwhile. They ask for help and share their many ideas on www.cpaptalk.com.

Nasal masks
A nasal mask covers just the nose. In terms of bulkiness the nasal mask is midway between the full face mask and nasal pillows. As such, it may be a good starter mask, to try out moderate bulkiness and see how you adjust to it. Some people prefer to have just their nose covered; others don’t like it.

Examples of popular nasal masks are the ResMed Mirage Activa, ResMed Ultra Mirage II, Puritan Bennett DreamFit, Fisher & Paykel HC FlexFit 406 Petite and FlexFit 407, Respironics ComfortGel, Respironics Profile Lite Gel, Respironics ComfortClassic.

See nasal mask selections by manufacturer at http://www.cpap.com/simple-find-cpap-products/cpap-mask
Scroll down to see Nasal Mask Brands Line Preference and comments at http://www.cpap.com/cpap-user-preference.php

Nasal pillows masks
Myths about nasal pillows:
Nasal pillows are a last resort when all other masks fail.
Nasal pillows make your nose all sore and crusty.
Nasal pillows are not for use every night.
Nasal pillows can’t be used with autopap machines.
Nasal pillows can’t be used with high pressures.
All untrue.

Nasal pillows nestle up against the nostrils. They are the least bulky of the three mask types and may be good for people with mask claustrophobia. Since they deliver air directly into the nostrils, they may work well along with heated humidification to help clear nasal congestion or for people with a deviated septum. Users find nasal pillows light and comfortable. There is a difference in the comfort level (softness vs. stiffness), shape, and size of the pillows from one brand to another. A larger size nasal pillow than expected may be the right size for you. Some brands have vents that are quieter, some noisier. Nasal pillows should work with all autopap (APAP) machines; if in doubt, phone the mask manufacturer’s customer service number.

One noteworthy nasal pillows mask is Invacare’s Twilight NP nasal pillows, formerly called the Aura, because it has soft, squishy pillows, vents straight upward like a chimney rather than on your arm or bed partner, is light weight with quiet vents, and has headgear that fits like a baseball cap. For people with very large nares (nostril openings), the two pillow sizes may be too small. For small heads, the large headgear requires reconstruction or removal. The Twilight is susceptible to rainout (condensation) in the mask itself and may require its own hose cover and wrapping. Because of its advantages, fans of this mask find it worthwhile to modify it.

With nasal pillows, a light gel nasal moisturizer made for use with nasal cannula is recommended as nightly lubricant and protection, found at medical supply stores or online. One product used in hospitals is Cann-Ease Nasal Moisturizer with aloe vera, phone 1-888-443-3031. Another product is water-based KY jelly or its generic version. To avoid any ingredient that will break down the mask silicone over time, use products made for nasal cannula.

Some people find a nasal gel with saline irritating over time. Avoid the widely used preservative benzalkonium chloride in the nose because it can cause a rebound effect over time. Avoid mercury preservatives (thimerosol). Although some people use All Natural Chapstick lip balm, bag balm, or other skin salves, others advise against use of any of these oily products because of the rare but potential hazard of lipoid pneumonia in the lungs. This hazard can be avoided by using water-based products made for nasal cannula. Avoid products with mint, lavender, and other fragrances that you don’t want to smell so intensely. If you are using oxygen with CPAP, avoid Vaseline and petroleum-based products because of hazard to the lungs. See http://www.cpaptalk.com/viewtopic/t14588/Mask-gone-Pillows-hurt-frustration-and-other-delights.html .

Examples of popular nasal pillows are the Puritan Bennett Breeze, Respironics ComfortLite 2, Invacare Twilight NP (formerly called the Aura), ResMed Swift.

See nasal pillows selections at http://www.cpap.com/simple-find-cpap-products/simple-find-cpap-products.php?selected=NASALPILLOWMASKSYSTEMS
Scroll down to see Nasal Pillows Brands Line Preference and comments at http://www.cpap.com/cpap-user-preference.php
For a typical user discussion of nasal pillows and similar masks, see http://www.cpaptalk.com/viewtopic.php?t=10728

Warning against mouth leakage
Whether you use a nasal mask or nasal pillows (or any other kind of mask except a full face), if air leaks out through your mouth, the PAP therapy will not work. There are two safe options. The first is to learn to keep your mouth closed while sleeping. Since the feel of pressurized air exiting your mouth is an unpleasant sensation, PAP aids in this. Some people position the tongue behind the top teeth and let it spread out in back to cover the throat opening and make a seal so the PAP works. The second option is to use a full face mask. If you are a mouth breather, breathing in through your mouth instead of your nose, a full face mask is required. An alternative practice for mouth leaks, mouth taping or sealing, is understandable but not advisable, and is not safe if your nose gets stuffy at night, you have acid reflux, need to regurgitate; or you have a hose disconnect or lose machine power and need to breathe through your mouth.

Full face masks
Full face masks don’t really cover the full face, but cover both nose and mouth, so you have a choice of breathing through one or both. It seems rather counterintuitive, but a full face mask may be more comfortable for some than a nasal mask; perhaps because it’s more like the feeling of the edge of your hand cupping the nose and mouth. Full face masks work well for people who breathe through their mouth out of habit or because of congested nasal passages. It’s handy to have a full face mask on hand in case of head colds, allergies, or sore nares from nasal pillows. Full face masks require a heated humidifier so your mouth and throat don’t get dry. If you also have a heated hose, the additional warmth helps keep the humidity level up.

Full face masks have more facial contours to fit and so tend to leak more than other masks. They are the bulkiest of the masks, have confining headgear, and don’t work well for people with mask claustrophobia, unless they overcome it through desensitization techniques. If you are worried about what would happen in case of a power outage while wearing a full face mask, the manufacturers have designed vents so you can continue to get air. The Food and Drug Administration approves all masks before they can be sold in the US.

A version of a less bulky full face mask is the RespCare Hybrid Universal Full Face CPAP Mask with Nasal Pillows at http://www.cpap.com/productpage-advanced.php?PNum=2204 . Use the Search on cpaptalk.com to find discussion about fitting and customizing the mask.

Examples of popular full face masks are the ResMed Ultra Mirage Full Face, Respironics ComfortFull 2, Fisher & Paykel HC Flexfit 431, and the Teleflex Medical Hybrid.

See full face mask selections by manufacturer at http://www.cpap.com/simple-find-cpap-products/cpap-mask
Scroll down to see Full Face Mask Brands Line Preference at http://www.cpap.com/cpap-user-preference.php

More mask types

For nasal prongs or cannula, see http://www.cpap.com/simple-find-cpap-products/simple-find-cpap-products.php?selected=INNOMED . An example of a popular nasal prong is the NasalAire II.

For nose cushions, see the Respironics ComfortLite2 at http://www.cpap.com/productpage/Comfort-Lite-2-Nasal-Interface-CPAP-Mask.html and the Respironics ComfortCurve at http://www.cpap.com/productpage.php?PNum=1842&PAID=209

There are two interfaces using the mouth. Both require that you keep your mouth closed or they will leak. Before considering one, talk with a sleep dentist (one experienced in working with dental devices for obstructive sleep apnea patients) or prostodontist about potential effects of misalignment of teeth and jaw and TMJ because of using such devices. For CPAP PRO nasal pillows that use an oral interface (boil-and-bite mouth piece), see http://www.nomask.com/. For the Fisher and Paykel Oracle 452 Oral Mask, see http://www.cpap.com/productpage/fisherandpaykel-fisher-paykel-oracle-452-nasal-cpap-mask.html .

For most people, masks are the most difficult part of CPAP therapy. With much prolonged problem-solving, patience, and persistence, you can achieve mask success for a good night’s sleep. See the articles on CPAP Mask Problems, CPAP Adaptation and Recovery and Seven Stages of CPAP and What Is Feeling Good? at http://smart-sleep-apnea.blogspot.com

Mike Moran’s humor – Confession of an Interface Junkie, http://www.cpaptalk.com/viewtopic.php?t=4700

Sources: Based on personal experience with obstructive sleep apnea, gleaned from the collective wisdom of cpaptalk.com contributors, and TS Johnson MD et al, Sleep Apnea – The Phantom of the Night

Want more? See manufacturer interviews and user reviews at http://www.cpaptalk.com/archived-cpap-interviews.php

Discussion thread on mask satisfaction http://www.cpaptalk.com/viewtopic/t15365/TroubleFree-Masks.html?sid=8d651dae0ba3b7882cfbdfdb9da29d50

Fisher and Paykel mask discussion links, http://www.cpaptalk.com/viewtopic/t14594/LINKS-to-FampP-FlexiFit-nasal-mask-and-431432-FF-topics.html

Australian customized mask, http://www.cpaptalk.com/viewtopic.php?t=19232&postdays=0&postorder=asc&start=0

See the peer coaching articles on Tips for Newcomers to Sleep Apnea, CPAP Pressure Settings, Ready to Give Up at http://smart-sleep-apnea.blogspot.com . Search or post a message on www.cpaptalk.com .

Not written by healthcare professionals. The information and opinions offered are not intended or recommended as a substitute for professional medical advice.
© Mile High Sleeper, August 2006-2008. Permission to use for free educational purposes.

Solving CPAP Mask Problems

Peer coaching article # 12B
One man’s meat is another man’s poison, especially when it comes to masks.

Mask comfort
As Good As It Gets

Use a CPAP heated humidifier to make the air more comfortable and keep air passages moisturized and healthier. Get an integrated or stand-alone CPAP humidifier. Experiment with settings from low to high humidity. Dry nasal passages can become irritated, crusty, and bleed. Use an additional nasal moisturizer or spray if you experience dryness.

A mask needs to fit the way you breathe – nose breathing or mouth breathing. If you breathe through your nose, use a nasal mask or nasal pillows. If you breathe through your mouth, or go from a clear to clogged nose during the night, use a full face mask.

Often, adjusting the headgear and mask too tight will make leaks worse. If a mask leaves marks on your face in the morning that don’t go away for a long time, it’s too tight. A mask and headgear that are too tight may cause puffy, baggy eyes, misaligned teeth, dental pain, headaches, neck aches, and pressure sores on the bridge of the nose or other parts of the face.

To make a mask more comfortable, consider Pad-A-Cheek strap covers http://www.padacheek.com/ , a mask-compatible pillow such as PAPillow http://www.papillow.com/ to reduce leaks, proper hose management so there is no drag on the mask causing leaks; a fleece hose cover, an Australian SleepZone heated hose http://www.sleepzone.com.au/index.html , and hose connectors. See the article on Solving Common Equipment Problems.

Claustrophobia or fear of suffocation may have three causes. One is machine air pressure that is too low, leading to not enough incoming air and insufficient venting of exhaled carbon dioxide. The easy remedy is to increase the machine pressure. A second cause is nasal obstruction, a blocked nose because of nasal congestion, a severely deviated septum, nasal polyps or large nasal turbinates (bony structure). Remedies may be daily nasal irrigation, a CPAP heated humidifier, or nasal surgery. A third cause is mask claustrophobia. A remedy is to overcome fear through desensitization techniques, such as reading or watching TV with the mask and machine on, gradually increasing the time; or through a few therapy sessions. A book with much good body-mind and mental imagery advice is Sound Sleep, Sound Mind by Dr. Barry Krakow, http://sleeptreatment.com/
Dr. Krakow pioneered a mask adaptation technique called PAP-NAP. An abstract is at www.aasmnet.org/jcsm/JCSMAcceptedPapers.aspx. Perhaps you can work with your local sleep doctor and sleep lab using a similar adaptation technique.

Nasal pillows, nasal prongs, or nose cushions may be good choices for someone with mask claustrophobia, rather than a nasal or full face mask. Discussion thread on mask claustrophobia: http://www.cpaptalk.com/viewtopic.php?t=13970&highlight=claustrophobia

It’s easier to prevent skin breakdowns from mask pressure points than to heal them. If you can’t adjust the mask to get rid of the pressure points, such as the bridge of the nose, then switch to another mask for a few nights, or replace the mask with a better one. If your alternate mask also hits the sore area, put a Band-Aid blister bandage on the sore. Try padding the offending mask with Dr. Scholl's moleskin or moleskin foam, found in the foot section of the drug store. Apply the moleskin to the mask, not your face.If you experience a sore nostril from nasal pillows, inspect the pillows to see if they are damaged. Nasal pillows (not the whole mask) should be replaced every three months or when worn out. Wear another type mask while your nostril heals.

If you have APAP or BiPAP, adjust the mask for leaks at your highest pressure. If it doesn’t leak at the highest pressure, it won’t leak at the lower pressure (unless there is a reason other than pressure for the leak). If possible, remove the mask by undoing a lower clip without readjusting the headgear each time. To get up at night, disconnect the mask from the hose and breathe through your mouth while wearing the mask.

Mask Vent Blowing Air on Your Arm, Hand, Bed Partner
Strangers in the Night

It’s very important that a mask have a vent to clear exhaled carbon dioxide. Never cover the mask vent with bed covers. Allow it to vent. When you get the mask, ask the technician to show you the vent. Vents may be hard to see. If you don’t know where the vent is, put on the mask, turn on the machine, and feel where air is coming out. Unfortunately, almost all vents are placed to vent forward from your face so air blows on your hand, arm, or bed partner. You can learn to sleep with your arm under a cover or pillow and barricade your partner. You can wear long sleeves and even gloves, if you don’t mind looking like Mickey or Minnie Mouse. Most pharmacies sell soft white cotton gloves, worn for hand ointment, behind the counter. If you have a tolerant and resilient bed partner, you need to find creative options so they don’t get caught in nightly windstorms.

One well designed mask vents straight upward, like a chimney, towards the headboard. It doesn’t vent on your forehead, arm, or partner. It’s a nasal pillow mask, the Headrest Twilight NP. See http://www.cpap.com/productpage/aeiomed-aura-nasal-cpap-interface.html As time goes on, more mask manufacturers may learn to make masks vent less violently.

Leaks are good and bad. A good leak is called the vent flow rate or flush rate, airflow through the vents, purposely designed to flush away exhaled carbon dioxide. Leakage above that rate is a bad leak from a poorly selected, sized, or fitted mask, leaking because it doesn’t rest securely on your face or nostrils. The higher the pressure, the higher the vent flow rate and bad leak rate. Wash your face to remove facial oils before using a mask, and avoid skin moisturizer on your face at night. The mask shouldn’t leak into your eyes (causing conjunctivitis) or anywhere else around its seal. For subtle leaks with nasal pillows, you may not be able to detect leaks by how they feel on your face. Use your hand to feel around the mask for leaks. Another way to detect leaks is by sound. If your mask turns into a sonar device, echoing a new sound off of bed pillows, you have a leak. If your full face mask makes a rude raspberry noise or turns into a wind instrument, you have a large leak.

Some masks are made to “hydroplane” on the face, floating on air for a seal. To adjust it, pull the mask away from your face momentarily so it can inflate and float again. Use sound and hand to detect loose hose connections in your machine around the humidifier connection. If your mask leaks, a very common occurrence, keep experimenting with adjusting it and improvise ways to get a custom fit. If you’ve had the mask for a while and then it begins leaking, check the age of the silicone cushion or nasal pillow. The cushion or pillow (not the whole mask) should be replaced every three months or when worn out. Insurance companies start with Medicare guidelines to design their replacement schedule. See Medicare replacement guidelines at http://www.billmyinsurance.com/cpap-faq/Medicare.html#14

For a discussion thread on interpreting leak rates, see http://www.cpaptalk.com/viewtopic/t14536/Meaning-of-System-Leak-Numbers.html

For a table of vent flow rates of various masks compiled by cpaptalker dsm from other users quoting the manufacturers’ published vent flow rates, see http://www.internetage.com/cpapinfo/leak-rates-1.html . The numbers along the top line of the chart are machine pressure in cm/H2O. This table is useful if you want to compare the necessary vent flow rate with the leak rate shown by your machine software. The difference allows you to assess how badly your mask is leaking due to a poor fit.

It may take several weeks or months of fiddling with your mask and learning to sleep with it, using a data-capable PAP machine with software to track results, before you achieve a satisfactory low level of leaks and AHI (apnea hypopnea index) with a particular mask. You may need to adjust machine pressure up or down for each mask. Learning when to give up, and when to keep trying, only comes from experience. If you give up on a mask, try it again several months later to see if now you can make it work.

Mouth breathing and mouth leaks
Mouth breathing and mouth leaks are closely related, but not necessarily the same thing.

Mouth breathing must occur when the nasal passages are blocked, so the only way for any air to get into the lungs is through the mouth. People with blocked noses breathe through their mouth, not through their nose. The solution to mouth breathing is to use a full face mask. Some effort and time may be required to find the best full face mask, fit it, and adjust to it. Use of nasal irrigation and humidified CPAP, especially with nasal pillows, may open nasal passages that were previously chronically blocked. The person can then learn to breathe through the nose.

Mouth leaks may occur if the person is breathing through their nose, but opens their mouth during sleep. If leakage through the mouth is a persistent problem, CPAP treatment can be rendered completely ineffective. CPAP air detouring out the mouth does nothing to keep the airway open. Either mouth breathing or mouth leakage can also cause feelings of suffocation from apneas still happening and/or just the choking feeling of air rushing out the mouth unexpectedly. The safest solution to mouth leakage is to use a full face mask. See http://www.cpaptalk.com/viewtopic/t23863/Why-dont-more-people-use-a-full-face-mask.html

Other remedies including using a homemade or commercial chinstrap in hopes that the tongue will maintain an airtight seal inside the mouth if the jaw is kept up. Many people find that chinstraps don’t work to prevent mouth leakage.

Another remedy is to use the tongue to maintain an airtight seal inside the mouth. Some people train the tongue by positioning the tip of the tongue behind the upper front teeth or on the roof of the mouth, and let the tongue spread out in back to seal the throat air passage, even if the lips open. Others use a dental splint, custom made by a dentist, or a do-it-yourself mouth guard to help the tongue maintain an airtight seal.

“The safety of taping the mouth shut has not been proven and there are potential risks of regurgitation and aspiration of food and of suffocation.” TS Johnson MD et al, Sleep Apnea – The Phantom of the Night, p. 167. Mouth taping is especially dangerous for anyone who ever gets blocked nasal passages during the night. If air can’t get in through the nose, it needs to get in through the mouth. Mouth taping is also risky in case of a hose disconnect or power outage.

For most people, masks are the most difficult part of CPAP therapy. With much prolonged problem-solving, patience, and persistence, you can achieve mask success for a good night’s sleep. See the articles on CPAP Mask Choices, CPAP Adaptation and Recovery and Seven Stages of CPAP and What Is Feeling Good? at http://smart-sleep-apnea.blogspot.com

Mike Moran’s humor –The Incredible Growing Mask, http://www.cpaptalk.com/viewtopic.php?p=63381

Sources: Based on personal experience with obstructive sleep apnea, gleaned from the collective wisdom of cpaptalk.com contributors, and TS Johnson MD et al, Sleep Apnea – The Phantom of the Night

Want more? See the peer coaching articles on Tips for Newcomers to Sleep Apnea, Solving Common Equipment Problems, CPAP Pressure Settings, Ready to Give Up?, Cleaning Equipment at http://smart-sleep-apnea.blogspot.com . Search or post a message on www.cpaptalk.com .

Not written by healthcare professionals. The information and opinions offered are not intended or recommended as a substitute for professional medical advice.
© Mile High Sleeper, August 2006-2008. Permission to use for free educational purposes.