Obstructive Sleep Apnea CPAP get smart fast

Disclaimer: These peer coaching articles describe what some savvy, successful CPAP users have done to make their treatment successful. Not written by healthcare professionals. The information and opinions may not necessarily be correct or helpful for you and your unique needs. Rely on sound, well informed medical advice from your doctors and other healthcare professionals well versed in treatment of obstructive sleep apnea.

Location: United States

IF I ONLY KNEW THEN WHAT I KNOW NOW! Blog Purpose: To help you with your CPAP therapy for Obstructive Sleep Apnea (OSA). For those with OSA, family, friends, physicians, nurses, respiratory therapists, sleep technicians. Why This Came to Be: I didn’t have the information I needed for successful CPAP treatment when I needed it. A kind sleep lab technician with OSA told me about a web site he had heard about from another patient, www.cpaptalk.com. The rest is history. It took me months of reading hundreds of posts to gather the information I needed while suffering through equipment struggles. Not everyone has that time or wants to struggle needlessly. I wrote up my own experience and advice from the collective wisdom of experienced CPAP users on cpaptalk.com. Thanks to them, my treatment is working. I’m not sure I could have done it without them. The online CPAP equipment store www.cpap.com created cpaptalk.com. I appreciate what they are giving back to the CPAP community through their website forum, as well as their fair prices. NOBODY IS AS SMART AS EVERYBODY! To email me, send a private message to Mile High Sleeper at www.cpaptalk.com.

Friday, December 09, 2011

CPAP Machine Choices

For people with sleep apnea and for their healthcare professionals, peer coaching article #12, updated 25 November 2011

Section 1. Terminology, Contraindications, Prescription, Choice, Failure hazard, Selection criteria, Trying a machine, rental, purchase; Software, Heated humidifier, Exhalation relief, Hoses, Ramp

Section 2. 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 link

Section 3.
CPAP MACHINES (constant pressure), Advantages of straight CPAP,
Disadvantages of straight CPAP, CPAP comparison chart link

Section 4. BiPAP MACHINES and link to Mike Moran’s humor about machines

Section 1
Terminology. CPAP (pronounced see-pap) is an acronym for Continuous Positive Airway Pressure. The term CPAP is used two ways. One way is specific, indicating a straight CPAP machine with one constant air pressure. The other way is general, indicating two other types of PAP machines as well, including auto-adjusting PAP or APAP (with self-adjusting pressure based on your body’s requirements) and Bi-Level PAP or BiPAP (with one pressure for inhalation and one for exhalation) Most people, including physicians, use the general term “CPAP” even if they mean APAP or BiPAP. Or they may be uninformed that APAP and BiPAP exist. 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.

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, older APAP and older BiPAP are like color TV, and new APAP and BiPAP are like flat panel and high definition TVs. PAP machines not yet on the market are like 3D TV. In future PAPs, patients want better sensors, patient-centered smart display capability or software, better auto adjusting, exhalation relief, heated hoses, integrated power supply, and smaller footprints. One obvious difference between TVs and PAP is that a PAP is a medical device, not a consumer entertainment 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 and so get and stay healthier. See Machine FAQ Answers at

Contraindications for PAP
Most people are able to use PAP. Your physician 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 physician’s prescription is required by US federal law to rent or purchase a machine (for insurance, also a mask and humidifier), 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. A primary care physician or specialist can write the prescription. 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. 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 was 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, and may balk at taking back the special-order machine if there is a problem. In the end, your own research and trial and error are the methods for finding the best machine for you, since each person is unique.

hree large PAP machine manufacturers are Respironics, ResMed, and Puritan Bennett. There are other PAP manufacturers as well. For machine comparisons, see at http://www.cpap.com/cpap-faq/CPAP-Brands.html#FGID-107

Failure hazard of any PAP treatment
Most people on PAP therapy are prescribed straight CPAP machines, whether through physician and patient lack of knowledge about APAP machines or the gaining of a wider profit margin by the DME though selling cheaper CPAP machines compared with more expensive APAP machines, yet getting reimbursed the same amount from insurance. 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 (stopped breathing or partial breathing) events 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. A smart display or software can involve you in the therapy and give you information on correcting mask leaks and AHI related to pressure. An APAP machine and smart display or 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

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

1. Type of machine - CPAP, APAP (auto CPAP) or BiPAP, with a smart display (of AHI, Apnea/Hypopnea Index and mask fit) or 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. Most APAP machines provide two-in-one, since they can be used in either the APAP or CPAP mode. All APAP and BiPAP machines are data capable. Only a few CPAP machines are data capable. Straight CPAP machines have only one pressure setting, the highest pressure you will ever need, so you’re always getting the highest pressure, whether you need it or not. APAP machines provide a range of pressures on a breath-by-breath basis, so you get only the pressure you need to keep your airways open.

2. Smart display showing AHI (Apnea/Hypopnea Index of events per hour, mask fit, pressure and humidity settings) or software (also showing AHI related to pressure, 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 BiPAP 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 whiney. 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


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 for people paying at their own expense, which may or may not be reimbursable on their insurance

Discussion thread on pricing
Discussion thread on Medicare

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

Smart display or software
It helps enormously to have a smart display or 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 data capability 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 data capability, 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
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.
Discussion threads on software:

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 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 machines have several settings of exhalation relief, or it can be turned off. The machine senses exhalation and lets the pressure drop slightly and briefly, making it easier to exhale.  People who need a lot of exhalation relief may need a BiPAP machine.

Flex discussion threads:

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 and come with their own hose. People who experience rainout (condensation in the hose) or who want to maintain PAP heat and humidity levels in a cool bedroom can buy the Australian SleepZone heated hose,
http://www.sleepzone.com.au/ . There are hose-to-hose connectors and right-angle hose connectors, to save wear and tear on the hose.

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.

Section 2
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 breath-by-breath throughout the night, if your body needs more or less pressure. You are getting the lowest pressure needed to keep your airways open. If you need a higher pressure, it’s there. 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:

APAP versus CPAP research
Google APAP vs. CPAP studies. One research article:

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 again 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 may 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 exhalation relief, or APAP with or without exhalation relief. 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 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 APAP machines have exhalation relief for patient comfort and resulting better compliance. These machines provide some degree of exhalation relief at a lower cost than a BiPAP machine, although a BiPAP provides a greater degree of relief for those who require it.
Discussion thread

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 APAP 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. 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. Add up the cost of a smart APAP machine and humidifier (and software if so inclined). Tally 365 nights a year times 5 years and divide into equipment cost. If you used this life-saving equipment for 5 years, cost may be 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

See the best selling APAP machines at this online DME for self-paying customers at
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:

Section 3
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 BiPAPs, 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 may not.

4. Some Respironics and one ResMed straight CPAP model have pressure relief for exhalation. Other brands may 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 BiPAPa can also 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. Above in this article, 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 BiPAP 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 BiPAP, 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

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?

Section 4
BiPAP machines

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. 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 $5,000. 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:

See this informative article by a sleep doctor about flow limitation or UARS (upper airway resistance) and bilevel:

BiPAP comparison chart of various brands and models

Mike Moran’s humor: Alternative AP therapies

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

Want more? See the peer coaching articles at http://smart-sleep-apnea.blogspot.com , http://www.cpap.com FAQ Learning Center, or search http://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 - 2011. All rights reserved. You may make copies of this message and distribute in any media for free educational purposes, as long as you credit the author and include this copyright notice and the web address smart-sleep-apnea dot blogspot dot com

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