Obstructive Sleep Apnea CPAP get smart fast

If an intruder tried to suffocate you with a pillow hundreds of times a night, you’d call the police. In the case of sleep apnea, the airway blocks off and breathing will stop for up to several minutes--but the victim has no idea it's even happening. According to Ralph Downey III, PhD, of the Sleep Disorders Center at Loma Linda University Medical Center in Loma Linda, California, “The body, in essence, is being assaulted by the damage done from intermittent lack of oxygen to the heart, brain and other important organ systems, and yet such an assault goes unreported. That is, patients who have these symptoms don't always have their sleep apnea corrected. Perhaps in the light of a metaphor such as the one of being assaulted by our own sleep disorder, people would take more care of their sleep. Their hearts will thank them.”

Truth be told, sleep apnea may well be the most significant, costly, easily treated, and least understood public health issue facing our nation. The most recent studies predict that between 50 and 60 million Americans are “at high risk” for having sleep apnea. And very few of them have the slightest idea what sleep apnea is, much less that it may be affecting their lives in profound ways.

The Basics Apnea is the medical term for “stopping breathing.” Sleep apnea is the temporary cessation of breathing during sleep, for intervals of 10 seconds up to minutes in length, depriving the body of oxygen. At some point the body arouses just enough to resume breathing and disrupt sleep, but usually not enough to awaken the individual. As a result, most people suffering from sleep apnea are not aware of their condition. In the most common type, obstructive sleep apnea (OSA), the airway blocks off when the tongue and/or other soft tissues in the throat relax and the individual simply stops breathing, sometimes for several minutes. This sequence can be repeated hundreds of times a night.

Apart from disrupting normal sleep patterns, sleep apnea wreaks havoc on the victim's body due to oxygen deprivation and physiological response patterns that occur during apnea events. There is no physiological signal stronger than oxygen deprivation to the brain. When blood oxygen levels are low, the body shunts blood from any and all organs, including the heart, to be sure the brain gets all available oxygen. On top of that, the sympathetic nervous system kicks in and releases a tremendous flood of stimulants and stress hormones, such as epinephrine (adrenaline) and cortisol, resulting in the well-known "fight or flight" response to danger.

Suppose somebody were to sneak up on you in the dark and lunge at you when you least expect it. Your heart races, the endocrine system instantly pumps out inordinately powerful stimulants. Sleep apnea victims are constantly confronted with a similar phenomenon and the accompanying red alert, each time their oxygen levels drop to a critical point. Another cruel twist happens when blood oxygen levels hover just above the critical desaturation level, getting just enough oxygen on board to avoid the arousal but not enough to provide the oxygenation that the body needs to stay healthy. The desaturation graph is remarkable for a very precipitous drop around the mid-to-upper 80% range for most people with sleep apnea.

Repetitive apneic events disrupt the normal physiological interactions between sleep and the cardiovascular system. Sleep fragmentation, with its accompanying increased sympathetic activation, triggers vascular endothelial dysfunction, increased oxidative stress, inflammation, increased platelet aggregability, metabolic dysregulation; in addition, it undoubtedly helps initiate and accelerate the progression of cardiac and vascular disease. Persuasive data implicate sleep apnea in the development of hypertension, and sleep apnea also contributes to cardiac ischemia, congestive heart failure, cardiac arrhythmias, and cerebrovascular disease and stroke.

At least if you’ve been attacked by a mugger you know to avoid ever going down that dark alley again. Sleep apnea, conversely, does not tip its hand. The victim’s conscious mind has virtually no recollection of the hundreds of assaults occurring during sleep every night.

It should not be surprising that common symptoms of sleep apnea include things like loud snoring and a gasping or snorting sound, high levels of daytime fatigue, irritability, depression, malaise, loss of productivity and work performance, extreme mental and physical exhaustion, loss of judgment, short-term memory dysfunction, and a number of other symptoms.

The Astounding Prevalence of Sleep Apnea in America The numbers are shocking. The most recent studies have shown that one in four adults in the United States (31% of all men and 21% of all women over 18) is “at high risk” for OSA, based on analysis of the National Sleep Foundation’s 2005 Sleep in America survey. Another study showed that one third of all people over 18 (who visit a primary care doctor) are at “high risk” for sleep apnea. Based on the 2000 Census, that means that between 50 and 60 million Americans likely suffer from sleep apnea. This is far higher that previous estimates that projected that between 10 and 18 million Americans have sleep apnea. Increasing awareness of sleep apnea and improved survey screening tools, along with an aging U.S. population, seem to be factors in the increase in OSA prevalence estimates. No longer should sleep apnea be thought of as an affliction of middle-aged, overweight men. The disorder is dependent on a number of factors (including, in particular, anatomy) and afflicts untold millions of otherwise young and fit women and men.

The Unacceptable Human and Economic Toll According to the National Commission on Sleep Disorders Research, 38,000 cardiovascular deaths a year in the United States are directly attributable to sleep apnea. On top of that, sleep apnea is associated with a large number of serious, co-morbid medical and psychological conditions, such as hypertension, abnormal heart rhythm, sleep deprivation, stroke, heart disease, diabetes, depression, memory loss, poor judgment, and change in personality. As a result, undiagnosed and untreated sleep apnea victims are significant consumers of healthcare services.

In Canada, sleep apnea victims were shown to consume 23 to 50% more medical services in the five years prior to diagnosis than control subjects, with hypertension and cardiovascular disease accounting for the majority of increased costs. A recent study from Israel showed that healthcare utilization was 1.7-fold higher by sleep apnea patients compared to the control group, with 25% of the sleep apnea patients who consumed the most resources accounting for 70% of the total healthcare expenditures. Other studies have demonstrated that successful sleep apnea treatment results in significant improvement in co-morbid conditions, including, specifically, cardiovascular disease, hypertension, diabetes, stroke, and depression.

Cardiovascular disease is the most significant killer in the United States, resulting in over 685,000 fatalities and $40.4 billion in healthcare costs annually. Hypertension healthcare costs in the United States are approximately $19 billion. While it is not known what percentage of all cardiovascular and hypertension healthcare costs is attributable to untreated sleep apnea, in light of the fact that between 50 and 65 million Americans are at high risk for the disease, it stands to reason that undiagnosed and untreated sleep apnea no doubt account for billions of healthcare dollars spent treating conditions that could be more effectively and far more economically treated as a sleep disorder. The human value in savings of physical pain and mental anguish associated with invasive procedures, surgeries, and chronic disease and death cannot be quantified.

Collateral Impacts Collateral impacts arising from 50 to 60 million clinically sleep-deprived people in the United States are certainly incalculable. One report focusing on highway safety impacts from sleep apnea concluded that more than 800,000 sleep apnea-related highway accidents occurred in 2000, resulting in 1,400 fatalities and costing nearly $16 billion. If the same analysis were performed today using the new, much higher sleep apnea prevalence rates, the highway safety impacts would probably be twofold higher. Because extreme daytime exhaustion is prevalent among OSA victims, sleep apnea-related losses due to reduced worker productivity, industrial accidents, clerical mistakes, and so forth would be almost impossible to estimate, but, given the numbers, would no doubt amount to the billions of dollars annually. On top of this, the personal quality of life impacts—depression, personality changes, lack of judgment, irritability, utter exhaustion—cannot possibly be measured in economic terms.

Simple, Economic Treatment The best news in sleep apnea is that it is a condition that is easily and economically treated. Continuous positive airway pressure (CPAP) therapy is the treatment of choice for obstructive sleep apnea and has been proven to be highly effective in treating sleep apnea and improving a number of co-morbid conditions. CPAP therapy consists of a ventilatory device that applies positive airway pressure at a constant, continuous pressure to help keep the airway open, allowing the patient to breathe normally during sleep. A number of other treatment options are also employed, such as surgery and dental appliances but questions remain as to the effectiveness of these treatment alternatives.

Where To Go from Here Perhaps the biggest challenge in addressing the sleep apnea health crisis is lack of public awareness (including many doctors). Just to put this into context, 13,658 Americans died from AIDS in 2003 while at least 38,000 died from cardiovascular disease related directly to sleep apnea. Yet while virtually everyone over 14 knows about AIDS, precious few of the 50 to 60 million Americans plagued by sleep apnea have any idea that a treatable sleep disorder is impacting every aspect of their lives. At the same time, a little awareness on the part of the patient or his or her doctor is all that it takes for treatment to start and, hopefully, for the suffering to end.

Unfortunately, a large number of doctors are still not very familiar with sleep apnea or its treatment. Primary care physicians are in an excellent position to screen people for sleep apnea, as one in every three adults they see, on average, will be “at high risk” for the condition. An excellent place to start (both for doctors and for individuals) is to fill out a one-page, ten-question survey called the “Berlin Questionnaire” that is widely available on the Internet http://www.pur-sleep.com/uploads/BerlinQuestionnaire.pdf . This questionnaire is simple and fast, and is highly predictive of sleep apnea—the positive predictive value of the survey for people scoring as “high risk” is 89%. Sleep apnea victims often have to work hard to convince their doctor (or insurance company) to refer them for a sleep study, so a "high risk" showing on the Berlin Questionnaire might be enough to convince them to move forward with further tests. If people are not satisfied with their medical care they should get a second opinion, preferably from a sleep disorder specialist. A number of overnight screening assessment tools are also available. A formal sleep study is necessary, however, to diagnose sleep apnea and obtain CPAP treatment.

Evaluating Your Sleep, Denial and Awareness

2011-12-11T17:17:00.000-07:00

For people exploring sleep apnea and for their healthcare professionals, peer coaching article #2, updated 21 November 2011

The symptoms of sleep apnea (stopped or reduced breathing during sleep) can be very subtle and easily attributed to other factors. How can you tell what you do while you’re sleeping? It’s not unusual to be unaware of having sleep apnea, a nighttime respiratory disorder. You may think you are sleeping well. You may be in denial of the condition and unaware of its serious health risks. Your bed partner or family may be more aware of a potential problem than you are. Fifty percent or more of people with sleep-disordered breathing (SBD) remain undiagnosed. (Carl E Hunt MD p. xi in Johnson’s Sleep Apnea – The Phantom of the Night).

The Boiled Frog Analogy. Maybe you’ve heard this story. If you put a healthy frog into a pot of hot water, it will quickly jump out. If you put a frog into a pot of lukewarm water, and very gradually increase the temperature, it will stay in the pot until boiled. In the hot water, the frog noticed instant discomfort and danger and took action. In the tepid water, it was lulled into complacency until unaware or unable to take action. How does this translate to sleep apnea? Have you unconsciously adapted to fatigue and eventually daytime sleepiness because its progression was so long and gradual? Have you found other reasons for fatigue, while making the best of circumstances? Are those reasons valid? You can find out by consulting a physician, taking informal sleep quizzes and, if indicated, getting a sleep study in a sleep lab. When you find the real reason for your fatigue, you can crawl out of the pot to change, improve, or reverse the condition.

Untreated sleep apnea can lead to high blood pressure, stroke, heart attack, congestive heart failure, cardiac arrhythmia, depression. Other risks are driver fatigue, poor judgment, poor memory, and sleepiness leading to car crashes, wrongful death and injury.

Possible Symptoms of Sleep Apnea

· loud and frequent snoring (in most people, but not in everyone)

· periods of not breathing (apnea) during sleep, snorting, gasping, or choking during sleep

· need to urinate at night

· awakening tired in the morning, morning headaches, daytime or evening fatigue or lethargy

· daytime or evening sleepiness when sitting or inactive, drowsy driving or falling asleep while driving

· performing actions automatically or by rote, limited attention, memory loss

· poor judgment, personality changes

· weight gain, early onset of high blood pressure, severe leg swelling

· especially in children, hyperactive behavior.

Possible risk factors:

· overweight with a body mass index (BMI) of 25 or more

· neck size for a man of 17 inches or more or for a woman of 16 inches or more

· male gender, being a menopausal or postmenopausal woman

· family history of sleep apnea, large adenoids or large tongue, short lower jaw which causes the tongue to position itself further back in the throat

· smoking and use of alcohol or sedatives.

Sources: adapted from the journal Sleep, National Institutes of Health, and James C. O’Brien MD.

More possible hints of sleep apnea:

· COPD (chronic obstructive pulmonary disease), asthma

· heart abnormalities, stroke

· high blood pressure that doesn’t respond to medication

· acid reflux or GERD

· diabetes

· deviated septum (cartilage separating the nostrils going off midline)

· bruxism (teeth grinding)

· adult bed wetting

· irritability, mood changes, anxiety, depression

· procrastination, difficulty acting on plans or finishing projects, diminished work performance

· social withdrawal, neglected relationships

· less interest in sex, sexual dysfunction

· persistent recurring dreams of struggle and failure

· the ability to fall asleep two or three hours after getting up in the morning, and/or very long naps in the afternoon, and/or sleeping nine or more hours a night

Assessment Quizzes

If you suspect a sleep problem, take some of these quizzes. They are designed to build awareness and create dialog with your doctor, not to diagnose. Discuss the quiz results and your symptoms with your primary care physician, or a sleep doctor, pulmonologist (breathing specialist), cardiologist, ENT (Ear/Nose/Throat) doctor, or other specialist. If indicated by symptoms, the doctor may suggest a sleep study to rule out sleep apnea or other diagnostic procedures.

In print, an excellent quiz to help detect sleep apnea is in the appendix of Sleep Apnea – The Phantom of the Night , a book by T. Scott Johnson MD, William A. Broughton MD, Jerry Halberstadt, a patient. An online version is at

http://www.healthyresources.com/sleep/apnea/phantom/orders/quiz.html

Epworth Sleepiness Scale and Scores widely used by sleep doctors

http://www.stanford.edu/~dement/epworth.html

American Academy of Family Physicians, Berlin Questionnaire, http://www.swclab.com/images/PDFS/Berlin-Questionnaire.pdf

Online sleep evaluation

http://yoursleep.aasmnet.org/SleepEval.aspx

Early Warning from an Overnight Recording Pulse Oximeter

When you have a routine visit to your physician, along with taking your temperature, the nurse may use a pulse oximeter on your finger tip to measure the oxygen in your blood. The device measures oxygen levels in your blood by noting the color. Oxygenated blood is bright red, blood with hemoglobin desaturation is darker red. It’s painless and noninvasive. Can you get access to not just an ordinary pulse ox, but one that records oxygen levels over time, from your doctor, a friend, rental, or purchase? It’s easy to wear a recording pulse ox overnight in the comfort of your own bed. If the reading in the morning shows a drop in oxygen level beyond a certain percentage, consult a physician, showing him/her the record. This may be an early warning that you have sleep apnea, since most people don’t notice any symptoms. A pulse oximeter alone may detect severe sleep apnea, but is not reliable in less severe cases.

Sleep Study Information

An overnight sleep study in a sleep lab is the gold standard of diagnosis. It’s a very sophisticated way of testing for sleep apnea – obstructive (the most common kind), central (more rare), or mixed – by checking airflow in your nose or mouth, snoring, and the effort your chest makes to breathe in various positions and in different stages of sleep. A lab study will also check for Restless Leg Syndrome, the amount of oxygen in your blood, and your heart rate and rhythm. If your doctor orders a sleep study, insurance or Medicare should pay for it. A split night sleep study may cost $4,000 or more.

1. In the most common, one-night “split study,” half the night is spent measuring your sleep, creating a polysomnogram (PSG) which is later interpreted by a physician. If you seem to have Obstructive Sleep Apnea (OSA), the second half of the night is spent using a CPAP (Continuous Positive Airway Pressure) machine to find the best airflow pressure setting for you.

KNOW YOUR NUMBERS. Know your AHI, Apnea Hypopnea Index. This is a key number resulting from the sleep study, like knowing your height, weight, blood pressure, or cholesterol level. Sleep apnea treatment (a dental device, pillar technique, CPAP machine) may differ depending on the severity of the sleep apnea. Three simple definitions are useful:

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)

The AHI doesn’t tell the whole story. A person may have a low AHI but severe sleep apnea. The duration of events and degree of oxygen desaturation are also important.

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

Sleep Study and Alternatives

2011-12-11T17:11:00.000-07:00

For people exploring sleep apnea and for their healthcare professionals, peer coaching article #3, updated 22 November 2011

Sleep Study Options
An overnight sleep study in a sleep lab is the gold standard of diagnosis. It’s a very sophisticated way of testing for sleep apnea – obstructive (the most common kind), central (more rare), or mixed or complex (both kinds) – by checking airflow in your throat, snoring, and the effort your chest makes to breathe in various positions and in different stages of sleep. A lab study may also check for Restless Leg Syndrome, the amount of oxygen in your blood, and your heart rate and rhythm. If your doctor orders a sleep study, insurance or Medicare should pay for it. A split night sleep study may cost between $1,500 and $5,000. Check your insurance coverage and whether pre-approval is necessary..

1. In the most common, one-night “split study,” half the night is spent measuring your sleep, creating a polysomnogram (PSG) which is later interpreted by a physician. If you seem to have Obstructive Sleep Apnea (OSA), the second half of the night is spent using a CPAP (Continuous Positive Airway Pressure) machine to find the best airflow pressure setting for you.

Advantages of a split study: lower cost, since it’s only one night. If the sleep technician gives you a mask, you get fast feedback in the middle of the night that you most likely have OSA. Later, upon receiving the report, you have a pressure setting for a doctor’s prescription for a CPAP machine.

Disadvantages: if you have concerns about falling asleep in a lab setting, or worry about wearing a respiratory mask for the first time, you may not fall asleep or have poor quality sleep, resulting in an inconclusive outcome or poor study. The sleep technician has less time to record your sleep cycles to do the sleep study and less time to find an effective titration setting, a slow trial-and-error process which requires your sleep.

2. A second option is a two-night study. It’s the same process as a split study, but a full night is used for each part. The first night is a baseline study of your sleep. The second night is a titration study to establish a CPAP pressure setting.

Advantages of a two-night study: Alleviates mask fear on the first night since no mask is needed, supporting better sleep and a better study. The technician has plenty of time to record sleep cycles and on the second night, plenty of time to try various pressure settings during the titration.

Disadvantages: may be twice the cost of a split study. It will take additional time to schedule the second study and get a pressure setting, which could delay the start of treatment.

3. An unusual alternative third option is a single baseline study and use of an APAP machine instead of a titration study to determine pressure settings. After a baseline study report of OSA (the first night), if CPAP seems to be the best treatment, and if you are a candidate for an APAP (an Auto-titrating Positive Airway Pressure) machine, you can get a prescription and machine long before a second night study. In fact, with an APAP machine and software and helpful doctor, it may not be necessary to have a second titration study. The APAP machine can be used to determine pressure settings instead of sleep lab titration.

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-laboratorymanual titration in the management of patients with OSA.

Advantages of a baseline study and APAP: lower cost, since it’s only one night. Alleviates mask fear during the study since no mask is needed, supporting better sleep and a better study. The technician has plenty of time to record your sleep cycles. If you do require a second night titration study, it can still be done later. Requirements: 1) the physician’s decision about the efficacy of APAP machine auto-titration settings instead of sleep lab titration. 2) use of an APAP machine able to record daily details, machine setup manual, and software. 3) physician and patient experimentation to find optimal pressure settings. 4) frequent software downloads by the patient (or a cooperative Durable Medical Equipment provider, DME). Remember, the sleep lab results are the gold standard, held to be the most effective means of determining CPAP machine pressure settings. The questionable trade-off may be better sleep lab equipment versus better patient comfort and resultant sleep in their own bed, and the ability to trial various pressure settings over several nights.

The deciding factors among the sleep study options may be a combination of your medical and psychological needs, your physician’s advice and support, and your insurance or Medicare coverage or your ability to pay out-of-pocket for APAP machine software. Discuss your needs with your physician and find out what your insurance company or Medicare supports and requires. Insurance companies tend to pay for a sleep study and CPAP equipment, because it’s more cost effective than paying for treatment of heart failure or stroke, treatment of car wreck injuries, and other serious health conditions resulting from untreated sleep apnea. Medicare usually requires a sleep study before paying for CPAP equipment. Does your insurance company have the same requirement? What impact do your deductible and co-pay have on your costs for various options? If possible, it may be more expedient to avoid scheduling your sleep study during the last quarter of the year, since the sleep lab may be overly busy then because people wait to schedule testing until they have reached their calendar year insurance deductible. However, if sleep apnea is suspected, it’s best to be tested and get your equipment as soon as possible.

Sleep Study Results

Know these three simple definitions from the sleep study report:

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.

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)

The AHI doesn’t tell the whole story. A person may have a low AHI but severe sleep apnea. The duration of events and degree of oxygen desaturation are also important.

A sleep study uses a pulse oximeter, a device with a red light that clips on your finger. It measures oxygen levels in your blood by noting the color; oxygenated blood is bright red, blood with hemoglobin desaturation is darker red. A pulse oximeter alone may detect severe sleep apnea, but is not reliable in less severe cases.

Get a copy of your sleep study report. You can refer to it from time to time as you manage your treatment. If you visit a specialist (sleep doctor, Ear/Nose/Throat doctor, pulmonologist, cardiologist, eye specialist, allergist, surgeon, dentist, etc.), give them a copy of your sleep study.

KNOW YOUR NUMBERS. Know your AHI, Apnea Hypopnea Index. This is a key number, like knowing your height, weight, blood pressure, or cholesterol level. Sleep apnea treatment (a dental device, pillar technique, CPAP machine) may differ depending on the severity of the sleep apnea.
Comprehensive Sleep Lab Orientation in Print
There are two chapters on sleep testing and understanding your report in the book Sleep Apnea – The Phantom of the Night by TS Johnson MD et al.

Short Sleep Lab Orientation Online Video
View a video and learn more at http://www.cpap.com/cpap-faq/Sleep-Study.html

Tips for Wearing a Mask for the First Time During the Sleep Study
Expect elaborate headgear, face straps, and stiff, bulky plastic nose pieces that make you look like an astronaut. While the sleep technician puts the mask on you, breathe through your mouth. Before you are hooked up to the CPAP machine, ask the technician to let you feel the airflow from the hose on your hand. It’s surprisingly breezy. It will feel much less breezy when felt through a mask. You won’t need it, but to make you more comfortable psychologically, ask the technician to show you how to quickly remove the mask and how to disconnect the mask from the hose or CPAP machine. The technician will show you how to call him or her during the night. While sitting up, spend a few moments “practice breathing” through the mask with CPAP turned on. It works! You can do it. You can even fall asleep while wearing it.

Other Laboratory Sleep Evaluations

For a brief description of the Maintenance of Wakefulness Test and Nap Study, see http://yoursleep.aasmnet.org/Studies.aspx

Alternatives to a Laboratory Sleep Study

In-home test though a physician. Some physicians and insurance companies suggest an in-home test. The patient wears various sensors and belts through the night. The results are monitored and reported. Sleep stages and brain waves cannot be measured as they are in a laboratory sleep study. One in-home process used by Kaiser measures apneas and hypopneas per hour, heart rate, respiratory effort, nasal-oral airflow, oxygen saturation using a pulse oximeter, body position, and snoring intensity and frequency. A simpler device is the Accutest SleepStrip, http://www.accutest.net/products/sleepstrip.php . If you explore these alternatives, discuss with your physician the need and ways to detect OSA (obstructive sleep apnea) vs. central apnea (brain not giving a signal to breathe) and mixed sleep apnea (combination of OSA and central), since treatment is different for the three types, as well as detecting other sleep disorders such as Restless Leg Syndrome. Also determine whether your insurance or Medicare will pay for subsequent treatment based on testing that is not the standard sleep study.

Diagnosis based on symptoms and perceived need may be an option for non-insured patients or patients with highly suspected obstructive sleep apnea (OSA) based on symptoms. Not Every Patient Needs to Go to the Sleep Lab is a thought-provoking Powerpoint presentation by a well respected board certified sleep doctor/pulmonologist, Dr. Barbara Phillips, at a meeting of the American Lung Association of the Central Coast in November 2004. Dr. Phillips is a professor of medicine at the University of Kentucky and is on the board of directors of the National Sleep Foundation. This approach would not detect central sleep apnea or mixed sleep apnea. Treatment differs depending on the diagnosis. If eligible, find out whether Medicare or Medicaid would pay for subsequent treatment without an overnight laboratory sleep study.

Humor by Mike Moran: Oct 13, 2005 A CPAP Failure and http://www.cpaptalk.com/viewtopic/t23827/Sermon-on-The-Mask-Humor.html and Dec 05, 2005 Twas Months After Sleep Study

Sources: Based on personal experience with obstructive sleep apnea.

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.

Diagnosing Sleep Apnea without Insurance

2011-12-11T17:08:00.000-07:00

For people with Obstructive Sleep Apnea and their healthcare professionals, peer coaching article #4, updated 21 November 2011

These suggestions are written for people with a low income who don’t have healthcare insurance (or who have extremely high deductibles), and who are not eligible for Medicare or Medicaid.

Only a doctor can make a diagnosis. First, do your homework about sleep apnea. Second, find a doctor who is informed about sleep disorders.

1. Realize that if you do have sleep apnea, your judgment may be somewhat impaired due to the toll that oxygen deprivation takes on your brain, energy levels, life perspective, and initiative. Consider asking a family member or friend to help you take the steps below, especially if you are fatigued, confused, or depressed.

2. Become informed about sleep apnea. If you don’t have a computer, use a friend’s computer or library computer. Read about the consequences of untreated sleep apnea in the article “Are You Sleeping with the Enemy?” at smart-sleep-apnea dot blogspot dot com. Read “Evaluating Your Sleep” at the same web site.

3. Take online quizzes and print the quizzes and results for your doctor. The Berlin Questionnaire and Epworth Sleepiness Scale have the most credibility with doctors. Find the Berlin Questionnaire at http://www.swclab.com/images/PDFS/Berlin-Questionnaire.pdf Find the Epworth Scale at http://www.stanford.edu/~dement/epworth.html An excellent quiz from the book Sleep Apnea – The Phantom of the Night lists symptoms at http://www.healthyresources.com/sleep/apnea/phantom/orders/quiz.html Do not rely on these quizzes for a diagnosis. They are designed to raise awareness (yours and your doctor’s), not to diagnose.

4. If your energy levels, behaviors, symptoms, and quiz results raise a concern that you may have sleep apnea, realize that you need diagnosis. It may seem difficult or impossible to pay for a sleep study test and subsequent treatment. However, if you have untreated sleep apnea and it leads to heart disease, stroke, diabetes, a car wreck or some other serious condition affecting your work, it will be far more difficult to pay for treatment of that resulting condition. “An ounce of prevention is worth a pound of cure.” An upfront investment in seeing a doctor could save you untold costs of a more serious disease. A doctor may be able to prescribe a CPAP machine without a hospital lab sleep study. An overnight sleep study in a hospital can cost $1500 and up. If diagnosed, a low-end CPAP machine for treatment costs around $300 bought new online.

5. Become informed about sleep tests by reading “Sleep Study Tests” at smart-sleep-apnea dot blogspot dot com. See the sections about these important options: an overnight recording pulse oximeter, an at-home test, a presentation for doctors, Not Every Patient Needs to Go to the Sleep Lab, and a split-night study.

6. Find a doctor. If you have a regular doctor or clinic, are they actively aware of sleep disorders and their consequences? An option may be a sleep doctor, a doctor who specializes in sleep disorders. Here are three ways to find one. Phone a local hospital sleep lab, and ask if they can suggest a sleep doctor. Or find local services at http://www.cpaptalk.com/sleep-apnea-services-locator.php Or find a sleep doctor through the American Board of Sleep Medicine.

7. Show the doctor your quiz results and discuss your symptoms. Explain your lack of insurance and financial circumstances and discuss options. Be aware that private healthcare insurance and Medicare may require a sleep study before paying for CPAP equipment. If an overnight sleep study seems unaffordable, does the doctor ever use at-home screening? Some automatic CPAP machines with a display or smart card and software can be used for a split night study and titration (finding your CPAP pressure setting) at home. Does the doctor ever use an auto PAP for these purposes? Read these articles below and ask your doctor’s opinion:

A. 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.

B. 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. If you and your doctor decide on a sleep study or CPAP machine, get costs upfront. A doctor’s prescription is necessary for purchase of a CPAP machine. Internet CPAP sellers such as www.cpap.com are usually able to sell new machines at a much lower price than local Durable Medical Equipment suppliers, and provide advice as well. For information on CPAP machines, see http://www.cpap.com/cpap-machines.php

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.

Social and Psychological Factors in Sleep Disorder Recovery

2011-12-11T17:03:00.000-07:00

For people with Obstructive Sleep Apnea and their healthcare professionals, peer coaching article #5, updated 21 November 2011

“I realized that I had a handicap rather than a moral defect. Finally, I could stop criticizing myself for not meeting social and personal standards of behavior.” Sleep apnea patient Jerry Halberstadt, Sleep Apnea – The Phantom of the Night, p. 154

Just as we’re all different in our physical conditions, we’re all unique in our psychological nature and approach to life. Listed below are a few personal issues related to sleep disordered breathing (SDB) and CPAP treatment that can come up, not even including equipment issues. If you have a family member or friend who is not very supportive of your condition and CPAP therapy, perhaps discussing some of these items will increase their awareness and understanding.

“Have I accepted that I have a serious medical condition, or am I still in some stage of denial? What emotional impact has this diagnosis had on me? How am I dealing with it? Am I making the best decisions in this weary and sleep-impaired condition? How good is my judgment? If I haven’t denied having sleep apnea, have I adopted the harmful and false belief that I can’t get used to CPAP?

This is the first time I’ve had a serious medical condition. Is it really life-threatening? It brings up issues of vulnerability, infirmity, aging, and mortality that I haven’t experienced before. How do I feel about that? Or, now I have this condition on top of other serious conditions. How do they affect each other? How do I deal with them all?

Why don’t more people understand sleep apnea? Why did my doctors not diagnose my sleep apnea for so many years? Did they misdiagnose and mistreat my other health problems when they were really sleep apnea? Did undiagnosed sleep apnea cause my other health problems? How do I feel about that?

Is untreated sleep apnea an affliction, a chronic disability, a handicap? If it’s effectively treated, is it still a handicap or impairment? Will I ever feel as good as before? How does this affect my image and self-concept? What will others think of me at home, at work, in the world?

How difficult is the therapy? How do I face my fears? Can I succeed? Can I do this long term; do I want to? What kind of support do I need and can I get?

I don’t like being dependent or an addict. How do I deal with being tethered to a machine every night for the rest of my life? How do I deal with being dependent upon a machine for my health and well being?

How does this affect my spouse, family, friends, co-workers? How can they deal with these changes? How do they support me? What blocks are other people putting up? What blocks am I putting up? How well do I support myself? How do I get around these blocks?

How does using CPAP equipment at night affect the comfort of my bed partner and sexual relations or dating? My libido is still low. Will that improve? Or, my libido is much better now that I’m on CPAP. Either way, it’s affecting my relationship.

Before now, I haven’t needed to deal with the healthcare system very much - doctors, specialists, insurance, hospital sleep labs, local or online Durable Medical Equipment (DME) or Home Medical Equipment providers. Who does what? How good are they? How do they interact? How do I make it all work for me?

Where is the best place to get equipment (CPAP machine, heated humidifier, masks, software, etc.), at the doctor or sleep lab acting as a DME, at a local large national DME or local small DME or online DME, or some combination? Which DMEs does my insurance authorize? What does the DME charge and what percentage does insurance pay; what are the deductibles? Where can I get the best value, prices, and service? Is it sometimes more cost effective to pay out-of-pocket and shop online instead of using insurance and the local DME with its pricing and insurance deductibles? If I shop online, what about service; can I still get mask trials and fittings somewhere locally?

What are the costs that I need to pay on my own? What can I afford? Are costs mainly start-up, and how much is ongoing? What equipment is worth spending more on? Are there places where it’s okay to be economical, or will that hinder effective treatment in the long term? What’s the overall effect on my health and quality of life, the cost-benefit ratio?

What do I do when part of the healthcare system doesn’t work? What do I do when I run into inadequate treatment or lack of integrity? Why do I need to deal with incompetent people or dysfunctional organizations when I’m already challenged enough by my condition and with making the therapy work for me? Is there hope for large national Durable Medical Equipment providers’ improvement or is it hopeless trying to deal with them? Is it worth the emotional distress to deal with them? What are the issues? What is my moral obligation to bring attention to the situation so other people aren’t harmed by lack of information, misinformation, incompetence, or unethical treatment of patients and questionable business practices? Where and how can I help and be effective?

I still don’t feel as good as I used to feel before. The results vary a lot. Sometimes I’m up, sometimes I’m down. I haven’t achieved stability or consistency. I still get tired or depressed. I have more mental energy to accomplish things, but not the physical energy. Or, I feel a lot more physical energy but don’t know what to do with it anymore. I feel new levels of energy but don’t know how to handle it, how to integrate it into my daily life.

Have I achieved success with my CPAP therapy – is this as good as it gets? Or will my standard of success change, will the bar be raised, after I’ve been on CPAP for a while? How long does it take to feel optimal? What is optimal?

Was it me or was it sleep apnea? What past actions, performance, and psychological state was the impairment of sleep apnea, and how much was me or my character? Who was I? Does it matter? Even more important, now that my energy is returning, who am I now, at this age, with this condition? Do I need to reinvent myself? How?

What things were hidden from me because of fatigue and lack of attention? I’ve been neglecting things for years. What things have been harmed or have self-destructed because I didn’t have the energy to deal with them? What do I do about them now? What do I do about my health? Weight? Fitness? Relationships? Family? Friends? Work? Finances? Dreams and goals? Fun parts of my life? What have been the costs of this unknown, untreated ailment? What losses do I need to mourn? How do I get my life back? How do I play catch-up? What is possible? How long will it take?”

These are important life issues about loss, change, and rebuilding. Dr. Elizabeth Kubler-Ross studied death and dying and came up with five stages that apply to any loss, not just death. The stages aren’t always sequential; they overlap or people go backward as well as forward. The point is to not get permanently stuck in one stage, but to eventually reach the acceptance stage. It’s natural to be going through these stages in dealing with the many physical, psychological, quality-of-life effects of Obstructive Sleep Apnea (OSA); not only what happened to your body and mind while untreated, but to other aspects of your life:

Denial. Isolation. “This is not happening/did not happen to me.”

Anger. Blame. “How dare they do this to me!” “How did I let this happen?”

Bargaining. Unrealistic attempts to fix. “If I just do this, that will happen.”

Depression. Regret. “I’m so sad about what happened to (some aspect of my life). ” “I can’t bear to face going through this adjustment, or putting my family through this.”

Acceptance. Gaining a realistic perspective. This doesn’t mean you like it, but you do accept that it’s happening or that it did happen. “I’m ready to face it. I don’t want to struggle or deny it anymore.”

Maybe the next interim stage is mourning or grieving the deterioration or death of parts of your life, before you move on to adaptation or rebuilding.

Psychologist William Bridges in The Way of Transition describes three sequential stages of psychological transition during any change, which can be applied to adapting to CPAP and the consequences of OSA. Getting stuck in the first two stages is a block to successful transition. See http://www.wmbridges.com/

Endings or Saying Goodbye. Letting go of the way things were. Maybe mourning.

Chaos or Wilderness Zone or Shifting into Neutral. Uncertainty, confusion. Not knowing what’s what. There is lots of this in getting used to CPAP therapy.

New Beginnings or Moving Forward. Behaving in a new way.

If you think you might benefit from it, seek understanding help from a psychiatrist, psychologist, therapist, religious or spiritual leader, or healer. Patiently rebuild your new life. Take heart that you now are gaining energy to find out who you are and who you want to become. Successful CPAP users seem to be practical and pragmatic. The CPAP therapy proves itself through results, health, well being, improved quality-of-life. Their gratitude for the results of CPAP treatment overcomes their concerns about dependency on the machine.

Look for recent additions to these discussion threads on http://www.cpaptalk.com :

Singles and OSA (Obstructive Sleep Apnea):

http://www.cpaptalk.com/viewtopic/t16860/Singles-XPAP-obvious-at-night.html

http://www.cpaptalk.com/viewtopic.php?t=19913&postdays=0&postorder=asc&start=0

Emotions and OSA:

http://www.cpaptalk.com/viewtopic/t25336/Sleep-Deprivation-and-your-quotRun-Amokquot-Emotions.html

Insomnia, Anxiety, Trauma, PTSD, Nightmares, Sleeping Pills

http://sleeptreatment.com/ and the book Sound Sleep, Sound Mind by Barry Krakow, MD

http://www.cpaptalk.com/viewtopic.php?t=20756&postdays=0&postorder=asc&start=0

Depression and OSA:

http://www.cpaptalk.com/viewtopic/t20790/Initially-misdiagnosed.html

http://www.cpaptalk.com/viewtopic/t25139/CPAP-for-Sleep-Apnea-Improves-Depression.html

http://www.cpaptalk.com/viewtopic.php?t=22015&postdays=0&postorder=asc&start=0

http://www.cpaptalk.com/viewtopic.php?t=10601&postdays=0&postorder=asc&start=0

http://www.cpaptalk.com/viewtopic/t18172/Depression-and-CPAP.html

http://www.cpaptalk.com/viewtopic.php?t=5156

http://www.cpaptalk.com/viewtopic.php?t=6348

http://www.cpaptalk.com/viewtopic.php?t=10601

Escaping from the sick role and OSA:

http://www.cpaptalk.com/viewtopic/t25371/Escaping-from-the-quotsick-rolequot.html

Humor by Mike Moran: Aug 01, 2006 CPAP Stand Up (Humor)

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.

Resources for Learning about Sleep Apnea

2011-12-10T10:26:00.000-07:00

For people with Obstructive Sleep Apnea and their healthcare professionals, peer coaching article #6, updated 8 December 2011

Recommended Book
Sleep Apnea – The Phantom of the Night, by T. Scott Johnson MD, William A. Broughton MD, Jerry Halberstadt, a patient. 2003. Comprehensive, user-friendly, loaded with practical information and written with emotional intelligence. Explains types of sleep apnea syndrome and sleep study reports. Comparisons of therapies and equipment. Frequently asked questions. Sleep log form, medical information form for your wallet, doctors, and dentist. Available at www.amazon.com and other book sellers.

Web Sites for Sleep-Related General Information and Health
From the American Academy of Sleep Medicine, a very informative web site
http://yoursleep.aasmnet.org/index.aspx

A manufacturer’s web site for fast, basic information. http://www.myresmed.com/MyResMedUS/page.do

US National Library of Medicine and National Institutes of Health offer MEDLINE Plus Medical Encyclopedia. http://www.nlm.nih.gov/medlineplus/ency/article/000811.htm Lots of links to related information such as Obstructive Sleep Apnea, snoring, obesity and health, urination at night, nasal congestion, heart failure, stroke.
Link to NIH Senior Health
http://nihseniorhealth.gov/listoftopics.html

National Sleep Foundation, scroll down to Drowsy Driving
http://www.sleepfoundation.org/articles/sleep-topics

Sleep Net, Everything you wanted to know about sleep but were too tired to ask ™, http://www.sleepnet.com/

Online Support for People with Obstructive Sleep Apnea
www.CPAPtalk.com A forum and community for all things CPAP. Excellent site. Forum members share informative, supportive information and opinions based on their experience. Includes a CPAP Wiki and CPAP Definitions. Online resource for personalized questions and answers from CPAP users.

Local Support Groups
American Sleep Apnea Association (ASAA), Washington, DC and local support groups. Phone 202.293.3650. http://www.sleepapnea.org/ Local AWAKE Network support groups meet in sleep centers or hospitals, with speakers, vendor fair.

Equipment Web Sites
www.cpap.com An online xPAP (CPAP, AutoPAP, BiPAP) store. Equipment descriptions are easier to navigate and read and more informative than many manufacturers’ web sites. Excellent product comparisons. Has manufacturers’ videos about equipment and fitting, printable price list, and lists best selling equipment. Low prices and good service. Has a practical Answers section.

Machine and mask manufacturers’ websites, such as Respironics http://www.healthcare.philips.com/us_en/homehealth/respironics.wpd , ResMed http://resmed.com , Fisher and Paykel, www.fphcare.com

National Center for Sleep Disorders Research, National Institutes of Health, http://www.nhlbi.nih.gov/about/ncsdr/index.htm

Stanford University Center for Human Sleep Research, Links, http://www.med.stanford.edu/school/psychiatry/humansleep/

Professional Journal
Journal Sleep, sponsored by the American Academy of Sleep Medicine and the Sleep Research Society, http://www.journalsleep.org/

Source: Based on personal experience with Obstructive Sleep Apnea and Exempla Lutheran Medical Center Sleep Disorders Lab patient information, Wheat Ridge, CO.

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.

CPAP Adaptation Stages and Recovery

2011-12-10T10:21:00.002-07:00

For people with Obstructive Sleep Apnea and their healthcare professionals, peer coaching article #7, updated 21 November 2011

“I can’t stand this mask. I can’t sleep with this equipment.
I’m not feeling any better. I still feel tired. How long does it take? “

Stages of recovery and timeframes “I look to the future because that's where I'm going to spend the rest of my life.” - George Burns

The person with Obstructive Sleep Apnea (OSA) has unknowingly suffered from this stealth respiratory disorder for years, perhaps decades or a lifetime, with it getting progressively worse. Fortunately, with good treatment, recovery is much faster, measured not in decades or many years, but in months up to a few years, depending on the person’s physical condition, quality of treatment, and other health issues. Recovery time is very individual. Just as everyone’s age, health, fitness, weight, and severity of OSA differ, progress on CPAP differs as well. There is no one right way to become healthier. Getting healthier is not a race. What is fast for one is slow for another.

There are two sensitive and compassionate concepts of recovery from two experienced CPAP users. Mike Moran lists seven stages of CPAP: denial, realization, diagnosis, frustration, immersion (obsession), ownership, and inflation (successful treatment). Perry Holzman lists four definitions of what is feeling good? – walking dead, basic treatment, advanced treatment, and mental zest. See the peer coaching article The Seven Stages of CPAP and What Is Feeling Good? The rare person starts to feel better during their split night sleep study when first using a CPAP mask and getting their first few hours of good sleep in years. More people feel a sense of energy and euphoria sometime during the first few days or weeks of CPAP treatment, because the body is thrilled to finally get some good sleep. Often, this honeymoon period doesn’t last, as the person continues to struggle with equipment and the body demands ever more satisfying levels of oxygenation and rest.

The speed and quality of recovery depend on:
1) how good the CPAP equipment is and how able the person is at equipment problem-solving, which depends upon their accessing knowledgeable sources of therapy information.

2) how sensible, sensitive, and adaptive the person is; or their psychological, mental and emotional states. Are they able and willing to stay the course and be successful?

3) the person’s physical condition. Are there conditions that help or hinder CPAP therapy?

Many people experience four stages of adjusting to CPAP therapy and equipment: intolerable, uncomfortable, tolerable, comfortable.

1. A lucky few, with good equipment and a no-nonsense or carefree attitude, skip the intolerable and uncomfortable stages. For most people, it may take weeks or months to go through all four stages. Sleep specialist Dr. Barry Krakow in the book Sound Sleep, Sound Mind http://sleeptreatment.com/ says it takes most people one to three months to adjust to CPAP therapy, and sometimes longer. For many people, the first few weeks of CPAP therapy can be miserable. The mask and other side effects (noise, machine feel and air pressure, mask leaks, venting on arms, rainout/condensation, aerophagia or swallowing air etc.) may be intolerable at first for far too many nights. It’s normal to sleep much worse than before treatment, because not only are they now aware of having obstructive sleep apnea and being extremely tired, but the equipment is unpleasant and keeping them awake. Wearing the mask for even an hour is an accomplishment. Then getting an hour of sleep on the equipment is an accomplishment. Gone is the illusion of a good night’s sleep, now that sleep apnea is acknowledged and because equipment struggles are all night long, every night. Although the quality of sleep is much worse, the healing process is slowly beginning. This stage is a real challenge, and may feel like it will last forever.

2. With determination, persistence, and equipment help from knowledgeable sources, in a few days or weeks they reach the stage where the therapy is merely uncomfortable. The therapy is definitely not fun. They are able to snatch a few more hours of sleep even with the equipment. A few improvements in energy and health begin to emerge. At this long stage, it may be hard to believe that the therapy will ever be truly comfortable. The body is used getting along with little sleep from untreated sleep apnea, even though before CPAP the person may have slept many hours a night (with poor quality of sleep and poor sleep efficiency). When the person starts getting a few hours of quality sleep using the machine, with a better sleep efficiency than when untreated, they may awaken after a few hours because their body thinks that they have had a full night’s sleep. It may take a few weeks for the body to get out of its deprived state and realize that it can enjoy a real full night’s sleep again. The process is akin to a starving person not being able to eat too much all at once when first offered food.

3. With time, continuous gaining of helpful knowledge, replacement of uncomfortable equipment, and nightly tweaking of equipment, as well as more practice, the therapy becomes tolerable or acceptable in a few weeks or months, especially as more and more good results begin to show. It takes many new users at least 4 to 6 weeks, along with trial, experimentation, and problem-solving, to get used to sleeping comfortably with their first mask. Getting used to a second mask usually is much faster, since the user has gained experience. Gradually, the struggles aren’t every night, and there are far more good nights than bad. At this stage and the next, some people begin to make up their sleep deficit, sleeping longer while the body catches up on years of lost sleep and heals. Tracking “compliance,” or wearing the mask to make the insurance company happy, isn’t really for the insurance company’s or DME’s benefit. If your compliance is 100% of your sleep time, including naps, you are benefiting your body, mind, and quality of life, avoiding new damage and healing old damage.

4. Eventually, in a few months, the therapy is even comfortable as good results are achieved almost every night. Many people, if they have good equipment and good advice, reach comfort in three to four months, most of the time, in most aspects of their therapy; some people sooner than that, some later. They are finally able to sleep comfortably through the night, most nights. If they awaken briefly to adjust equipment, they quickly fall back to sleep. There will probably be lingering aspects of therapy that are problematic, such as finding a better mask or reaching a plateau or backsliding, and it may take many months to find better options and equipment, but overall, the therapy is working and every day the person feels much better than before starting the therapy, or notices some improvement in energy, health, or lifestyle. There may be discouraging setbacks and progress may feel slow, but the overall results of therapy are good. It may take more months or years of tweaking and improvements in equipment and therapy practices to feel satisfied with the treatment and its results.

If the CPAP user notices signs of falling back into old symptoms after one or two bad nights of sleep, such as inefficiency, getting tired early during the day, automatic behavior, inertia, depression; then they need to isolate the therapy problem and solve it; or just wait another night for better results, since sometimes causes are hard to determine.

Discussion threads – don’t get discouraged, read the threads in the next section, too!
Welcome to CPAP Land http://www.cpaptalk.com/viewtopic.php?t=14748&postdays=0&postorder=asc&start=0
After a week, http://www.cpaptalk.com/viewtopic/t13508/Waking-up-too-many-times.html
Getting started, http://www.cpaptalk.com/viewtopic/t13684/How-long-does-it-take-to-see-results.html
After 2 weeks, http://www.cpaptalk.com/viewtopic.php?t=16810&postdays=0&postorder=asc&start=0
After 3 weeks, http://www.cpaptalk.com/viewtopic/t14637/New-user-getting-little-rest.html

Sticking with it, http://www.cpaptalk.com/viewtopic/t14561/So-what-does-quotstick-with-itquot-really-mean.html
Eureka and plateau, http://www.cpaptalk.com/viewtopic.php?t=10047
Ups and downs, http://www.cpaptalk.com/viewtopic/t14294/Why-are-things-going-this-way.html
Stages and timing, http://www.cpaptalk.com/viewtopic/t14432/Still-feel-tired.html

Still tired and problem solving, http://www.cpaptalk.com/viewtopic/t14094/Still-tired.html
Relapse, http://www.cpaptalk.com/viewtopic/t3179/Getting-tired-again-am-I-rebounding.html
It takes a while, http://www.cpaptalk.com/viewtopic/t14296/Glad-to-hear-people-are-feeling-a-change-is-it-normal-not-to.html
Normal or satisfied, http://www.cpaptalk.com/viewtopic.php?p=111910#111910

Naps, http://www.cpaptalk.com/viewtopic/t13973/Am-I-alone-on-this-one.html

Tracking your success
You will be well aware of equipment struggles. It helps to track them in a sleep log, so you can problem solve more effectively and see that you are making progress, because it might not always feel like it. A useful form for a sleep log is in the Appendix of the book Sleep Apnea – The Phantom of the Night by TS Johnson MD et al. It’s also heartening to track successes, to avoid becoming discouraged. Motivate and coach yourself. Celebrate small victories!

Your Victory List
"When you can't get a compliment any other way, pay yourself one." Mark Twain

At first, measure success by how long you wear the mask (hooked up to the machine) – one hour, two hours, etc. Next, measure success by how long you slept with the mask on. Simultaneously, track and celebrate each equipment victory you have – overcoming rainout condensation, adjusting a mask better, not giving up on dealing with insomnia, solving the numerous problems that come up. Soon you will also be able to measure success by health improvements and the way you feel. Make a list of your symptoms (ideas below) that may be caused or worsened by untreated sleep apnea. Then observe how they improve on CPAP. See the peer coaching article Diary of Two Hoseheads for others’ victory lists.

Some sleep apnea physical symptoms that may disappear: snoring, gaps in breathing during sleep, morning headaches, daytime fatigue, easily falling asleep during the day, ability to take long morning or afternoon naps, heartburn during sleep, tossing or turning, insomnia, nighttime bathroom trips (nocturia), awakening tired, brain fog, difficulty concentrating, high blood pressure, overweight, heart abnormalities and disease, pains in bones and joints, congested nasal passages, teeth grinding (bruxism), less interest in sex or sexual dysfunction, types of glaucoma. What else gets better on CPAP?

Some sleep apnea mental and social symptoms that may disappear:: procrastination, difficulty concentrating, memory loss, difficulty completing tasks, lack of initiative, doing routine tasks in a daze, arriving home without remembering the trip from work, persistent recurring dreams of struggle and failure, relationship problems, feeling out of touch, not acting like yourself, anxiety, depression, lack of interest, irritability and anger, social withdrawal. What else gets better on CPAP?

These links are inspiring reading!

Can’t wait to get on the hose, http://www.cpaptalk.com/viewtopic/t16692/I-cant-wait-to-get-on-the-hose.html

Newbie with nose to the hose would like to hear success stories, http://www.cpaptalk.com/viewtopic.php?t=14494&postdays=0&postorder=asc&start=0

Exercising, http://www.cpaptalk.com/viewtopic/t17323/I-felt-like-going-to-the-gym-today.html

Humor by Mike Moran:
Ten Reasons to Love CPAP Sep 07, 2006 Ten Reasons to Love CPAP (Humor)

A CPAP Diet-tribe http://www.cpaptalk.com/viewtopic.php?t=7286
A Year of Blowing My Brains Out http://www.cpaptalk.com/viewtopic.php?t=9071

Do You PAP When You Nap? http://www.cpaptalk.com/viewtopic.php?t=5122

Source: 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.

Seven Stages and What Is Feeling Good?

2011-12-10T10:16:00.000-07:00

For people with obstructive sleep apnea and their healthcare professionals, peer coaching article #8, reviewed 21 November 2011

The Seven Stages of CPAP © by Mike Moran. Used with permission.

Posted to www.cpaptalk.com on Wed. Dec. 14, 2005

Since many are new to this therapy I thought I should put together some of the common threads of what we all go through for ourselves and our loved ones. This is also something you might share with your family or friends so they might gain an understanding of what you are dealing with.

1. Denial – This is something we are very good at because we have been practicing it for years. If asked if you snore most will deny it and maybe point their finger at their bed partner. It appears that the louder you snore, the louder your protests. It is embarrassing and no one wants to admit they have problems doing the simple task of sleeping. Images of the Three Stooges and the cartoon characterizations of snoring we grew up with don’t help us in facing a life limiting problem.

2. Realization – For some of us it is when our spouses tell us how scared they get at night when we stop breathing for periods of time. They have gotten used to our rumbling but are now are awakened by our silences and the thought we might not wake up. For others it’s the moments of drowsiness at our desks or even worse at the wheel of our car. Why are we so tired all the time, we know we got plenty of sleep? Whatever got us there, we finally realize something is wrong with us and ask our Doctor about it.

3. Diagnosis – If you get to this stage you should be grateful to have a Doctor that listens. Quite a few of us are battling other complication, such as obesity and diabetes, and diet is often considered before sleep habits. The cost of diagnosis associated with Obstructive Sleep Apnea (OSA), in this world of HMOs and increasing health care cost, is often the impetus to pursue other avenues of treatment. Fortunately, awareness is growing in the medical community. While not the cause, OSA is being viewed as a contributing factor to many other disorders.

Once you are referred to a specialist, you are then pre-screened to see if an investment should be made in the not so trivial expense of a Sleep Study. It finally hits you, as you step into the Sleep Lab, that you are not just dealing with the latest fad disorder. The procedures the staff employ and the equipment utilized tell you that major research dollars have been expended to address sleep disorders. Being wired for the monitors and the discomfort of trying to sleep in an unfamiliar environment also gives a glimpse that sleep will no longer be the simple act of closing your eyes. As you struggle for unconsciousness you have mixed hopes that nothing will be found or you will have the answer to why you have been living your life in a fog.

If you have a split study you get your answer in the middle of the night, when they come in and give you your first taste of Constant Positive Airway Pressure (CPAP). For others it’s a few days or weeks until they can sit down with their Doctor and go over the results. Yes you have been sleeping, but you are constantly waking up throughout the night without knowing it. There is relief in knowing what you have is very real and is treatable.

4. Frustration – The causes of this are varied and the reason this is called therapy instead of fun. It may start during the period between your study and actual diagnosis. Even though you have been avoiding taking any action for years it is hard to wait for answers once you started on the path for potential recovery. Then it might be the wait until you get your equipment and start treatment. Often feeling more tired than you have ever been, caused by the depression of knowing there is help but you don’t have access to it.

This in turn builds up some expectations that may not jive with reality. Therapy does produce drastic improvement for some immediately, for others improvement is gradual and the benefits are realized over time. We all want an instant cure but the effectiveness is a function of so many things. Ignoring the condition for years and difficulty adjusting to sleeping with a mask are just a couple of things that can play a significant part in our progress.

It is not easy to strap a mask to your face with air pumping up your nose while you are trying to sleep. You wake up during the night and the only difference between that and OSA is you are fully aware of the cause. Sleep is disturbed in either case. Then you have to take into account the necessary humidity of the air being delivered and condensation developing in the hose (Rain Out). Who can be blamed for asking if it worth the struggle?

Then there is the issue where healthcare meets business. Interfaces are developed to the greatest common denominator as the cost of customization is prohibitive. Durable Medical Equipment (DME) providers limit the potential selections to reduce the cost of extensive inventories. Insurances only reimburse for the minimal level of equipment that can provide the necessary therapy to limit their expenses. This all translates down to coping with the least comfortable therapy delivery or expending more out of your own pocket to get something you can live with the rest of your nights.

5. Immersion – Some people would call this obsession. There must be a better way to live with this disorder so we go in search of those answers. Contacting our Doctors, the DMEs and accessing the Internet for any possible scrap of information we can devour. Learning AHI isn’t blue fin tuna but the Apnea Hypopnea Index which is how many disruptive incidents you average per hour (anything over 5 is considered OSA with most of us clocking in 20 or above). Then finding out that these incidents not only disrupt beneficial rest but limit the oxygen our brains require to function.

When you hit this phase you discover the most important thing about our treatment. You are not alone and others are there to share their support and experience. They too are struggling just as you are and they have been gathering the same information you hunger for. All the various masks have been tested by real users. They have equipment set ups that work outside the labs. You discover shoulders to cry on, people to laugh with and the ability to vent with people who face the same struggles.

6. Ownership – After you are diagnosed and the equipment is delivered you are cut loose to deliver your own therapy. It is up to no one but yourself to see that you keep up treatment. There are no physical therapists guiding you every night. The Doctor may have bi-annual visits to see how you are doing but it all falls on your shoulders. Only you can make this work and realizing this you have the most important ingredient for success.

So you take advantage of the support and advice you have found. Pushing for the equipment that will help you cope with this therapy the best way you can. Doing some “Lab-Ratting”, trying all the various modifications others have found useful. You start employing rubber bands, panty hose and various household items to improve the seal of your interface. Finding simple things like attaching your hose to the wall with a hair band (Scrunchy) can allow you to turn over without breaking a seal. You invest in options like a heated humidifier or the Australian Heated Hose to combat Rain Out and consider upgrading to an automatically adjusting CPAP (APAP). Trying anything to make your nights tolerable.

7. Inflation – Maybe you only get a few hours of uninterrupted sleep, but then the periods become longer and longer. The morning fog begins to lift and your day starts the same way as those not suffering from a Sleep Disorder. Energy starts returning along with greater motivation for life. You still struggle, but now you are reaping the benefits you have been seeking.

Your family is sleeping better because their sleep is not disrupted by your snoring. They also get more of you because you have more to give. This isn’t even mentioning extending your life expectancy. The therapy finally transforms from something you can’t live with, to something you can’t live without.

Now I can’t say you won’t be running through some of stages over and over again. The final stage is one that you may find only intermittently. However, there is one thing that is perfectly evident. If you give up and get lost in your denial, or frustration, then the potential reward will be completely lost.

What is Feeling Good? © by Perry Holzman. Used with permission.

Posted to www.cpaptalk.com on Sat Dec 24, 2005 10:51 am

"Walking Dead" is where most of us start at. That is how a person with severe OSA problems feels before PAP. You seem to sleep very well - are always tired, cannot think hardly at all, and can barely function well enough to eat, bathe, do a basic job (with not a good performance), and usually come home to die in front of the TV and sleep (you can sleep at the drop of a hat). Life is no fun at all, and you can be extremely frustrated because you know that something is wrong and you used to be able to do better. Your personal relationships sink to all time lows. You are probably so far out of it that your "other" in life may seek others for intellectual level or intimate companionship so that they can have a life at all (The best time to tell your “other” that you love them or care for them is before someone else tells them – I suggest that you do so daily – starting right now: even if you are not in the “walking dead” zone).

"Basic Treatment" is the next step. In my case this happened first on CPAP, then on AutoCPAP that was set-up totally wrong for me. All the sudden you feel much better. You start to notice that there is more to life than you have been experiencing lately. You now find the energy to do things in the morning you really should have been doing all along like flossing teeth, or some house cleaning. But you still cannot think clearly like you used to, while your job and personal relationships improve a little, you still come home from work exhausted, and retire to the TV or recreational reading because you don't have the mental energy to do anything else.

It is amazing how well you feel compared to before - but you still don't have the energy that you remember (or that you see other people with). Naps are still needed if you are to function at all throughout the day. Often it takes a couple of months – but there comes a point where you know that you are not where you should be.

I will note that most sleep doctors are satisfied once a person progresses from Walking Dead to Basic Treatment. They consider you a success, and are not likely to provide much support past this point. My personal experience is that I was better off dealing with a family doctor to move beyond this point as I was dealing with other health issues.

"Advanced Treatment" may follow. Here your feel so tremendously great compared to before. Life starts to be good again; you can see that there is a future (especially in the morning when you get up). Your sleep seems to be under control, you have the opportunity to do things in your job and personal life that you could not even imagine before. Mentally you can start to think of several different things early in a day. But you still feel run down in the afternoon (this must be normal you figure) and look forward to bed each night.

"Mental Zest" is where you want to be, what happens when treatment is really working well for you. All the sudden your mind and life is free again. You typically wake up feeling great, can do multi-tasking of different mental task (which really helps your job and personal life), and have energy all day. Can stay up much of a night if needed - with energy and mental involvement - without major effects on the next day. You can see how to make life great once you solve those problems that accumulated when you weren’t feeling so well (and some of those problems can be major issues to solve). You finally realize that this is what normal life should be. You may recognize at this stage that this is how you felt when you were a teenager. As long as you have a positive attitude about yourself and life - you are ready again to take on the world…

It took me years to get to the Mental Zest stage. I would like to claim that I can stay there. Pollen season knocks me back to the Advanced Treatment, and excessive work hours can easily knock me back to the Basic Treatment Stage (simple exhaustion). Proper diet, nutrition, and exercise are also required to keep you at the Mental Zest stage.

May each of you have a safe and quick journey to “Mental Zest.”

Humor by Mike Moran: http://www.cpaptalk.com/viewtopic/t20673/CPAP-Has-Made-Me-A-Changed-Man-Humor.html and Feb 07, 2006 Why Do I Stay On CPAP? (Humor)

Not written by healthcare professionals. The information and opinions offered are not intended or recommended as a substitute for professional medical advice. Permission to use for free educational purposes.

Tips for Newcomers to Sleep Apnea

2011-12-10T10:13:00.000-07:00

For people with Obstructive Sleep Apnea and their healthcare professionals, peer coaching article #9, updated 21 November 2011

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, whether CPAP, AutoPAP or APAP, or BiPAP, 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?” in this blog, smart-sleep-apnea at blogspot dot com.

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 physician 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. From a sleep study, you need to know your AHI, Apnea Hypopnea Index, or the number of “events” (apneas/no breath and hypopneas/shallow breath) you have per hour, and whether your sleep apnea is mild, moderate, or severe. 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 CPAP fails, these days surgery is rarely 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 CPAP machine, or APAP or BiPAP. 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. If your machine doesn’t have a display of AHI, you may 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 CPAP 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 CPAP 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 so you can breathe through it (or get a full face mask). 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, prayer, or therapy to build a peaceful, harmonious, and beneficial relationship with your CPAP machine and equipment (masks, heated humidifier, hose or heated hose, bed pillow, machine software). The modern APAP machine with a heated humidifier, display or smart card with software is a marvelous invention. In contrast, for most people, masks are problematic, but there are many options to explore, and hopefully designers and 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.

Humor by Mike Moran: Dec 01, 2005 CPAP Slogans

Source: 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, 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

Your CPAP Support Team

2011-12-10T10:08:00.000-07:00

For people with Obstructive Sleep Apnea and their healthcare professionals, peer coaching article #10, updated 21 November 2011

It Takes a Village

This article describes an ideal team. Very few people have the ideal startup team in sleep apnea treatment. You can still be successful at CPAP if you have only some of the elements. Success depends on YOU.

Why is it necessary to have a support team?

1) Because it can be difficult to adjust to the cumbersome CPAP (CPAP, AutoPAP, BiPAP) treatment for OSA (obstructive sleep apnea). About half the people who start CPAP therapy fail, and failure increases their risk for heart attack, stroke, car accidents, 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 some people there are two missing links – good information sources and an informed person to help with frequent therapy questions. Some patients are largely on their own with OSA treatment. Basic and detailed therapy information and ongoing assistance at a local DME (Durable Medical Equipment or home care provider) are not as easy to find as you might expect, compared to the quality of care in a hospital or medical clinic. Technicians (respiratory therapists, clinicians, or sleep technicians) even at many large, national DMEs, and even if patient-centered and kind, may be hampered in assisting you by organization constraints (fear of litigation), misinformation, or dysfunctional organizational systems. For example, the technician is not allowed to share certain information with you such as general information about pressure settings and refers you to your doctor who prescribes the pressure settings but who may not be an experienced sleep specialist. If you spoke to the same technician in a more neutral setting such as an AWAKE support group meeting, maybe they could 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 and it may take a long time to get if you do manage to order 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 done by a neutral, unbiased, patient-centered respiratory therapist.

Ideal team members: a doctor experienced in sleep medicine, specialist doctors, 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, OSA web sites.

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, family doctor, physician assistant, or nurse practitioner 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 equipment and 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.

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 which is a noninvasive and low risk treatment option, he/she may not be up-to-date on the long term results of certain surgical techniques – or maybe you would benefit from surgery.)
What types of CPAP treatment does the doctor use? Does he/she categorically disapprove of APAP (auto CPAP)? (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” with the doctor as manager of the therapy and the patient as passively obedient and compliant? Which style are you as a patient?

If after a few visits you find that your doctor’s style and your style of handling your therapy are incompatible, find a different sleep doctor, if you can.

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.

3. DME or home care provider. You may be assigned to a Durable Medical Equipment 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) or technician 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 may not 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 release forms), 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, hybrid) 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 that brand for you? Will getting it take an unreasonable amount of time or money?
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 and billing information?
How well do they handle equipment replacements and repairs and billing?
Does dealing with them relieve your stress as a new CPAP 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 home care respiratory equipment 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. See if your insurance plan will cover purchases through them. 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, and a huge inefficient infrastructure, online prices are astonishingly low for the same high quality equipment offered at much higher prices by large national DMEs with local offices. 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 online at www.cpap.com. Can you try on the specific masks that seem promising at a sleep center and buy it there? Can your local DME order the mask and let you try it? Or it may be easiest and most cost effective just to order the mask through the online DME.

5. The sleep center or hospital sleep lab may be a resource beyond your initial sleep study. 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 sleep center’s sleep tech’s skills at mask trials and mask fitting with the skills of the respiratory therapist at your local DME?
Does it offer these services to people who are not former patients? Are services free to former patients 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?
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 American Sleep Apnea Association (ASAA) AWAKE groups or another organization?

6. Online support group. A very helpful community of xPAP (CPAP, APAP, BiPAP) users is found at www.cpaptalk.com. You can ask individual questions and quickly get a variety of supportive responses from people with experience. Sponsored by www.cpap.com, this forum gives back information to the CPAP community. If you regularly read this forum, you may quickly find that you know more about certain practical aspects of sleep 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.

7. Community support group. Look for American Sleep Apnea Association (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 xPAP 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 masks? 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.

Mike Moran in a contemplative frame of mind: Nov 21, 2005 Embracing the Hose

Source: Based on personal experience with Obstructive Sleep Apnea.

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.

Short List of My Best PAP Equipment

2011-12-10T10:04:00.001-07:00

For people with sleep apnea and for their healthcare professionals, peer coaching article #11, updated 23 November 2011

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 CPAP 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 a display of AHI and mask leaks, or 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 pressure) with exhalation relief, which can also be used in the straight CPAP mode, so you get two machines in one; more options, 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. In the six years I’ve successfully been on CPAP, I’ve never needed straight CPAP (only one pressure). But I’ve used APAP every night, and adjusted the pressure range upward several times because of weight gain, without the need for another costly sleep study.

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 BiPAP machines with different pressures for inhalation and exhalation, or an auto-adjusting BiPAP.

2. Machine software (not covered by insurance and usually bought online) so my doctor and I can monitor and adjust my therapy and I can succeed. I found this essential when I started APAP, since my physician was not very knowledgeable about the details of CPAP therapy and the Respiratory Therapist at the Durable Medical Equipment provider was also not helpful, referring me to my physician. I was on my own in discovering effective therapy, aided by software reports. I had a fully data capable APAP machine with software showing 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. Now that APAP has worked well for me for a few years, I find that a machine with a display of AHI is adequate, rather than using software.

3. A heated humidifier, machine-specific for comfort (a key success factor), healthier airways, avoidance of nosebleeds and dry mouth, and use of a full face mask.

4. A heated hose, if it comes with the machine, or an Australian 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, from cpap dot com.

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 CPAP 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. Mask preference is very individual.

6. A bed pillow such as the PAPillow that works with the mask. It's used on top of 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.
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 and rechargeable battery pack 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

Medicare will pay for a replacement machine every five years and many insurance companies follow Medicare guidelines. Since technology advances so rapidly, you may want a new machine every five years, keeping your previous machine as a backup.

9. For those who need it: An overnight recording pulse oximeter to measure blood oxygen saturation levels. Perhaps your physician can issue one for you to use at home for a one-night test. If you buy one, be sure to get not just an ordinary pulse ox, but one that can record oxygen levels all night and generate a report. It may cost up to $500, bought online. It’s useful if you require supplemental oxygen at night or your oxygen saturation rate is dangerously low without CPAP. I don’t have a pulse ox but borrow one occasionally to check on my treatment. It’s very handy to loan to relatives and 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

Places to get PAP equipment at your own expense:

http://cpap.com and other online CPAP retailers

Online sites for used equipment: Beware of used machines with a permanent tobacco or campfire smoke smell or pet or other odors, and used masks that have not been thoroughly disinfected, if the previous owner had a staph infection.

Humor by Mike Moran: Mar 07, 2006 CPAP for Fun and Profit (Things been way to serious lately)

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.

CPAP Machine Choices

2011-12-09T19:40:00.000-07:00

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

Contents

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 http://www.cpap.com/cpap-faq/Machines.html#FGID-2

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.

Three 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 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 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
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 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

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 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.

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 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:
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

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:
http://www.cpaptalk.com/viewtopic.php?t=13326

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

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
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?

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: 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

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

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 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.

CPAP Humidifiers

2011-12-08T15:00:00.000-07:00

For people with sleep apnea and for their healthcare professionals, peer coaching article #13, updated 3 December 2011

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, auto APAP, or BiPAP) 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 through passive humidification, air blowing over the unheated humidifier water. 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 makes 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 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 may hold more water and can deliver higher levels of humidity. 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.

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, for use in humidifiers and steam irons. If you are traveling or run out of distilled water, it’s okay to use bottled or 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.

After drying, replace the humidifier on the machine. Make sure the humidifier connects snuggly to the machine, to avoid air leaks. To fill, use the user friendly opening or 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. If you want to use aroma therapy, use it in another room while awake.

Rarely, a particular humidifier may leak. If that’s the case, to protect furniture, consider keeping the heated humidifier and machine on a waterproof surface in case you spill water or there is a leak. Some options are a cookie sheet with a rim or an inverted plastic lid from a large storage box.

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 buying a spare, backup water chamber if the cost is low. 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 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.

CPAP Mask Choices

2011-12-08T14:57:00.000-07:00

For people with sleep apnea and for their healthcare professionals, peer coaching article #14, updated 1 December 2011

So many masks, so little time.

PAP (Positive Airway Pressure whether 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
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, 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 .for mask comparisons.

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 of having two types of masks: 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. 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 (Durable Medical Equipment provider). 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 every night. 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, plop 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.

Warning against giving up on CPAP and instead substituting supplemental oxygen

Understandably, adapting to CPAP and a mask is difficult. It may take 6 weeks to 3 months for most people to adapt, sometimes longer. Some people give up prematurely and quit CPAP, instead going on supplemental oxygen at night. The problem is that if you have sleep apnea, the oxygen is not getting through your air passages to your lungs, whether on oxygen or not. If your physician orders oxygen, be sure that there is a home follow-up by using an overnight recording pulse oximeter to check whether the oxygen is getting into your blood stream. If the oxygen alone isn’t enough, become better informed about CPAP equipment and support and try CPAP again. (As a separate topic, some people are prescribed oxygen to enhance their CPAP. Then they get the benefits of both treatments.)

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.

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 these myths are 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.

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, http://www.cann-ease.com 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 products like natural 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 .

See nasal pillows selections at http://www.cpap.com/cpap-masks/nasal-pillow-cpap-mask.php

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.

See full face mask selections by manufacturer at http://www.cpap.com/cpap-masks/full-face-cpap-mask.php

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/cpap-masks/nasal-prong-cpap-mask.php

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 an oral mask, see http://www.cpap.com/cpap-masks/oral-cpap-mask.php

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 Tips for Newcomers to Sleep Apnea, Checking CPAP Pressure Settings, Solving 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

Feb 17, 2006 The Incredible Growing Mask

http://www.cpaptalk.com/viewtopic/t26444/Housebreaking-Your-Mask-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 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.

Soving CPAP Mask Problems

2011-12-08T14:55:00.000-07:00

For people with sleep apnea and for their healthcare professionals, peer coaching article #15, updated 1 December 2011

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 (built-in) 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 behavioral 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. Perhaps you can work with your local sleep doctor, sleep lab, or therapist 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

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 can be both good and bad. A good “leak” is actually not a leak. It 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 from the side if 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 (possibly 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.
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 occurs 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. A full face mask does not cover the full face, but it does cover the mouth and nose. 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. Since mouth leaks are unpleasant, the person may unconsciously learn to keep their mouth closed, so the leak goes away. 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, since you would then need to breathe in through the mouth.

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

Jan 17, 2006 Kentucky Fried Nose Jan 10, 2006 Introducing PS-PAP

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.

Solving Common CPAP Equipment Problems

2011-12-07T19:05:00.000-07:00

For people with sleep apnea and for their healthcare professionals, peer coaching article #16, updated 1 December 2011

Hose Management, Venting, Bed Pillows, Rainout, Aerophagia

People give up on CPAP treatment because of discomfort caused by the equipment. Simple therapy information is sadly lacking. Untreated obstructive sleep apnea can lead to a poor quality of life and is potentially fatal. Here are some equipment user tips that can help you successfully manage your therapy. See also Common Side Effects in the Answers section of http://www.cpap.com/ , http://www.cpap.com/cpap-faq/Common-CPAP-Side-Effects.html#FGID-158

Hose Management
Catch Me If You Can
A manufacturer’s product photo shows an incorrect setup, the dangling hose. Help from www.cpap.com: “CPAP hose management becomes more important to side sleepers. The hose should never hang between the CPAP and the bed. This weight will put a side force on the mask, causing leaks and discomfort. A portion of the hose should be lying on the bed so that the forces it places on the mask are minimized.”

Start with the machine set below your head level, on a night table’s lowest shelf or low footstool, to minimize condensation or rainout from the humidifier and reduce noise, and to prevent a flood if the humidifier tips over while you are using it. Attach the hose to the mattress and then headboard or wall. Use a clamp, cup hook, twister tie, or large safety pin holding an elastic ponytail band or Scrunci, then thread in the hose. Or use a hose clip as seen in the discussion thread http://www.cpaptalk.com/viewtopic.php?t=10498

When the hose comes from above your head, it has room to coil on the bed, reducing pulling on the mask which reduces mask leaks. It makes it easier to change positions from side to side or back. It eliminates the problem of keeping the hose under or over your arm or under or over the bed covers. Exception: with the new hybrid (nasal pillows/mouth) mask, the hose must come from beneath, or else it will make the vent noisy.

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.

Bed Pillow

What Dreams May Come
If you are overly relying on a soft or hard pillow to keep your mask in place, you have a poorly fitted mask or poor choice of mask. Try adjusting the fit or getting a different mask. If your mask is properly fitted and your mask and pillow are fighting, try a smaller firm pillow, so the mask can hang off the side; or a buckwheat pillow, neck pillow, or memory foam pillow which gives the mask some support. Make sure the pillow doesn’t interfere with your mask if you are a side sleeper. When you are pillow shopping, if you don’t mind acting strangely in a store, try out the pillow, imagining what your mask would do.

Consider the PAPillow, described at www.PAPillow.com, in a low wedge pillow or higher double edge pillow, available at http://shop.talkaboutsleep.com/?action=info.display&category=papillow-difference
Similar pillows are available at http://www.cpap.com/simple-find-cpap-products/misc There are also orthopedic, memory foam pillows. Discussion thread on cervical neck pillows: http://www.cpaptalk.com/viewtopic/t16851/Cervical-Positional-Effects-on-Snoring-and-Apneas.html and http://www.targetwoman.com/articles/neck-pillow.html

Some CPAP users report a lower AHI (apnea hypopnea index of events per hour) if they use a bed wedge pillow. Linen stores may sell lower bed wedges; medical supply stores and online stores sell slightly higher bed wedges and memory foam bed wedges, which can be used in combination with a PAPillow. See the discussion thread on silent acid reflux at http://www.cpaptalk.com/viewtopic/t14288/Strange-treatment-question.html

Rainout or Condensation in the Hose
A River Runs Through It

Rainout video: http://www.cpap.com/downloadVideo.php?VGID=16

In a cool bedroom, if you have a heated humidifier as part of your PAP (CPAP, APAP, BiPAP) machine, water may condense in the hose running between the humidifier and your mask. It can drip on your face, causing discomfort and mask leaks. Try several of these remedies to reduce or perhaps eliminate rainout.

- Raise the room temperature, if you can sleep comfortably.

- Place your machine and humidifier well below your bed, near the floor on a low shelf or footstool, so the 6 foot hose and any water have a long vertical run before reaching your headboard. (You may need a 10 foot hose if you have a very high bed.) Hold the hose in place with a hose clip or elastic ponytail band pinned to the edge of the mattress, and another on the headboard. This is a first step, but may not work to eliminate rainout.

- Common advice is to keep the hose under the blanket, which seldom works. If you are using effective hose management, this is not an option, since the hose is coming from the headboard.

- Turn down the heated humidifier to the lowest, coolest setting. If that doesn’t work, turn off the heat but continue to use the humidifier (passive humidification or passover). If your nose gets congested or your throat and mouth get dry, find another remedy.

- Wrap the hose in bubblewrap, light socks or tights with the toes cut open, or make or buy a fleece hose cover like the Snuggle Hose http://www.cpap.com/simple-find-cpap-products/cpap-hose-tubing

- If your mask has its own hose, you may need to cover that also. A light covering made from old pantyhose or tights reduces weight and drag.

- A reliable way to completely eliminate rainout is to buy a heated hose. A reliable add-on heated hose is the “Aussie hose” from SleepZone in Australia, http://www.sleepzone.com.au/. Allow up to 3 weeks for delivery to clear US customs. If necessary, cover the heated hose with a second hose cover. The Aussie hose has its own insurance code number, so it may be reimbursable. People use their heated hose summer and winter. Since the heated hose is so effective, some people don’t want to be without it in case of breakage, so they have a second, backup heated hose.

- One Fisher and Paykel straight CPAP machine package includes a heated hose and humidifier. See http://www.cpap.com/productpage/fisher-paykel-hc604-cpap.html

Aerophagia, Bloating, Swallowing Air
Finding Neverland

This may be a temporary condition as you adjust to PAP or a new mask, or it may be recurring or ongoing. Symptoms range from being painful to being merely socially embarrassing. See your doctor to rule out other related digestive disorders.

From www.cpap.com: “AEROPHAGIA. The word "phage" in Greek means "to eat." Aerophagia is literally to eat air. In the modern context, it means swallowing too much air, a common cause of gas in the stomach and belching. This is sometimes a result of CPAP Therapy. Unfortunately, the best solutions for this problem are not a catch all but instead an attempt to find the middle ground between needed CPAP pressures. Here's what you can do:

1. Tell your CPAP prescribing physician. It may be better to decrease the CPAP level a bit and put up with some minor airway problems if we can significantly decrease the bloating. Sometimes this works great, sometimes not at all. An auto adjusting CPAP should also be considered as these machines reduce the average pressure the user receives. Get help setting the maximum pressure on the auto as the highest pressures can make things much worse.

2. As the chin of a CPAP user nears the chest, air has a greater chance of entering the digestive tract. Where possible, keep the chin up in relation to the torso.

3. Sleeping in a position different than normal helps keep the air out of the stomach. Try different sleeping positions. Left side, right side, inclined with pillows, or flat.” More ideas to eliminate aerophagia:

- Try a bed wedge to sleep with the head elevated.

- To keep your chin up, try a PAPillow, neck pillow, or memory foam pillow, but make sure it’s compatible with your mask when you sleep on your side. You should be able to fit your fist between your chin and chest. See http://www.snoringpillow.com/int/index.htm

- Try an APAP machine. If already on APAP, reduce your top pressure, as long as your AHI (apnea hypopnea index) continues to remain low; or try the straight CPAP mode.

- Try a BiPAP machine or auto BiPAP machine.

Ideas to cope with aerophagia:
- Drink carbonated water or a fizzy beverage in the morning to help belch out gas.
- Use wind-relieving yoga postures that compress your abdomen in the privacy of your bathroom or boudoir.
- For digestive gas in the stomach, try over-the-counter simethicone products like Gas-X.
- For digestive gas in the intestines, try over-the-counter activated charcoal tablets.

Humor by Mike Moran: Nov 11, 2005 Rain Drops Keep Falling On My Nose

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.

CHECKING Your CPAP Machine Settings - Basic Information

2011-12-07T19:02:00.000-07:00

For people with sleep apnea and for their healthcare professionals, peer coaching article #17, updated 1 December 2011

Part 1 of 2 on PAP Pressure
Tips for All PAP (Positive Airway Pressure) Users (CPAP, APAP, BiLevel)
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 or stopped breathing and hypopneas or partial breaths). 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 effects are 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 of events per hour) above the normal 5 or below events per hour, or still feeling tired or sleepy during the day. For example, 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” of increased pressure. 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 incorrectly 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 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 (RT) 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 for the right dosage pill. 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. If you attend an AWAKE patient support meeting at a sleep lab and bring in your machine, the technicians there may calibrate your machine (do free pressure checks). AWAKE meetings are sponsored by the American Sleep Apnea Association.

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 an older, “classic tank” Respironics REMstar autopap, that would be heat/humidity level, C-Flex exhalation relief level, ramp or startup pressure and duration of ramp, 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, nurse, or doctor. If you can’t program your 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 (Durable Medical Equipment or Home Medical Equipment) 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, so other patients won’t be harmed.http://jcwebnoc.jcaho.org/QMSInternet/IncidentEntry.aspx The DME needs feedback to improve their quality of service to other patients.

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 and pressure settings are working well.

Even better, get a machine with a smart display or software to more precisely show how well your therapy is working each night.

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 if you are technically inclined. 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? 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.

CHANGING Your CPAP Pressure Settings

2011-12-07T18:59:00.000-07:00

For people with sleep apnea and for their healthcare professionals, peer coaching article #18, updated 1 December 2011

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 (Positive Airway Pressure) 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 (or physician’s assistant, nurse practitioner, nurse, respiratory therapist) 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 CPAP machine 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 because they do not have a competent Respiratory Therapist (RT). 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 (Durable Medical Equipment provider) 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. Some manufacturers offer 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. 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.

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

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.

Everyday CPAP Safety

2011-12-06T14:45:00.001-07:00

For people with sleep apnea and for their healthcare professionals, peer coaching article #19, updated 3 December 2011

Don’t depend only on the DME (Durable Medical Equipment or Home Medical Equipment) provider to provide safety information. Read the user manuals and warnings that come with your equipment and use common sense.

Machine, Humidifier, Hose Safety

If you have an ear or sinus infection or nosebleed, it may be best to stop PAP (Positive Airway Pressure CPAP, APAP, BiPAP) until the infection clears up. Ask your physician.

Put your PAP machine, heated humidifier, and heated hose on a surge protector to protect them from electrical spikes, as you would any expensive electronic equipment. See the discussion thread at http://www.cpaptalk.com/viewtopic/t18447/CPAP-in-lightning-storm.html

Clean or replace air filters at proper intervals, less frequently if your room is fairly clean and oftener in allergy season if you’re allergic to pollens.

Don’t block the air intake of the machine.

To prevent a flooded face if you pull on the hose and tip over the humidifier, and to discourage rainout (condensation) in the hose from backing up into your mask and possibly breathing it into your lungs, place the humidifier and machine below your bed, preferably on a low shelf just above the floor. The floor may be too dusty. Most of the hose should be vertical, not dangling. To minimize rainout, try a hose cover, homemade or bought at places like www.cpap.com To eliminate rainout, use a heated hose from SleepZone in Australia, http://www.sleepzone.com.au/index.html

To prevent mold, mildew, or bacterial buildup in the humidifier and inside the machine – remove, open, empty and air dry the humidifier every morning. It’s not necessary to completely disassemble the humidifier baffle, just shake out the excess water or remove enough to let it dry completely.

Use only distilled water in the humidifier to prevent mold, mildew, mineral deposits and to avoid getting chlorine from tap water in your lungs.

To prevent mildew and critters growing in the hose, disconnect the hose from the machine and mask and let it air dry every morning. In high humidity if the hose doesn’t air dry in a day, alternate between two hoses.

Don’t put additives into the humidifier water. Essential oils and fragrances are made for light dispersion in the air of a room, not in concentrated form in respiratory equipment that forces a high volume of air into your lungs.

Power Outages and Alternative Power Sources

For a few people with certain types of heart disease or extremely low blood oxygen saturation levels, nightly PAP is absolutely essential. If the electricity goes off, their life could be in danger. Find out from your doctor if you are likely to be one of those people. For them, power backup is essential. The power company has a form, to be signed by your doctor, to indicate that it’s life threatening for you to go without power, although they can’t promise to restore your power sooner than anyone else.

Some electric companies may give discounts to PAP users. See http://www.cpaptalk.com/viewtopic/t23864/Possible-Discount-on-Electric-Bill-with-CPAP.html

For emergency preparedness during a power outage lasting several days, talk in advance with your local police department, fire department, hospital, Recreational Vehicle owner, or any place that has its own generator. Find out if you could use their power overnight during an outage. A doctor’s letter of medical necessity or copy of your CPAP prescription or sleep study will be helpful documentation.

For most PAP users, especially those with severe sleep apnea, an alternative power source may not be essential but is desirable to avoid fatigue, sleepiness, or drowsy driving after power outages. A few PAP machines have a built-in power battery. All PAP machines can run on DC power from a car battery, or better yet, recreational vehicle or marine deep cycle battery, including an AGM, Absorbed Glass Mat or gel battery, or universal power supply. A generic DC power cord probably won’t fit your machine. Get a battery and power cord before they are needed. www.cpap.com sells machine-specific batteries and machine-specific DC power cords. See the discussion threads at http://www.cpaptalk.com/viewtopic.php?t=9599&postdays=0&postorder=asc&start=0
http://www.cpaptalk.com/viewtopic/t17394/what-if-the-power-goes-out.html

If your PAP machine broke, how long would it take to get a loaner during repair or a new machine? Do you still have the prescription in hand to order a new machine? Could your local DME promptly provide a loaner? If you have an old PAP machine, perhaps it can still serve as a backup. Or you may want to invest in a smaller machine for travel or camping and as a backup with its own built-in battery. When a storm is coming, some PAPers put their battery-operated machine next to their usual machine, in order to make a quick switch if the power goes out.

Keep and travel with extra spare parts, such as a hose, mask, filters, rubber hose gasket (to connect the hose to a machine opening), extension cord and small surge protector for hotel rooms.

Mask Safety

All masks have vents to clear the carbon dioxide you exhale. When you get a new mask, ask the respiratory technician to show you the vents. If you have a mask and don’t know where the vents are, put the mask on under pressure, and use your hand to feel the exiting air flow. (Make sure you’re not feeling a leak from a poor fit.) Never block the vents with anything! Make sure your pillow, your bed partner’s pillow, bed covers, or any improvised mask adaptations aren’t blocking the vents. If your hose rotates in front of a vent, it may be noisy, but it won’t block the vent.

If your machine is set at the lowest pressure, 4 or 5 cm H2O, you may be breathing in some of your exhaled carbon dioxide. This is usually not a safety concern, but it may lead to discomfort interpreted as mask intolerance, insomnia, or a mild feeling of suffocation. Some people are more comfortable with 6 or 7 cm H2O or more as their lowest pressure setting, to make sure all the carbon dioxide is cleared from their mask.

If your machine has an alert alarm for a mask or hose disconnect, considering turning it on. If your mask often disconnects from your hose, get a longer 10 foot hose or an 18 inch hose extension. There are hose-to-hose connectors and right angle connectors sold at www.cpap.com

With a nasal mask or nasal pillows, if your machine stops because it breaks or because of a power outage, you could breathe through your mouth. Mouth taping or sealing is unsafe. For people who have a stuffy nose, or whose nose becomes stuffy during the night, mouth taping makes no sense, since they need to breathe in air through their mouth. Mouth breathers need a full face mask, covering both nose and mouth. For those who leak exhaled air through the mouth, there are two safe options. One is to train yourself to close your mouth while sleeping, since opening your mouth while on PAP is an unpleasant sensation. Another solution is to use a full face mask.

Since a full face mask covers both nose and mouth, it is designed to let you breathe through the mask in case pressure is lost by a hose disconnect, machine failure, or power outage. If your full face mask has a safety valve rather than vent holes, make sure it works properly. With a full face mask, to avoid regurgitating food and aspirating it into the lungs, a dangerous condition, don’t eat food less than three hours before sleeping and don’t use the mask if nauseous. Practice removing the mask quickly in case you need to suddenly vomit or have acid reflux. Don’t use a full face mask if you can’t remove it quickly because of sedation, poor dexterity, or decreased mental alertness. (Source: T.S. Johnson, MD, Sleep Apnea – The Phantom of the Night, pages 166-7)

Alcohol and Sedatives

Alcohol is first a relaxant, so it may make your throat close up even more. Then it acts as a stimulant, which could lead to awakening later at night. Alcohol may help you fall asleep quickly, but keeps you in the lighter stages of sleep so you miss the deep, restorative sleep stages. If you wake up groggy, it’s because of dehydration and loss of quality sleep. If you drink alcohol, it may be easier on your sleep to have a drink at lunch instead of dinner; or at least avoid alcohol three to four hours before bedtime. Drink a glass of water for every glass of alcohol, which will help clear the alcohol out of your system and reduce dehydration.

Sleep doctor T.S. Johnson warns that all sedatives, hypnotics (tranquilizers), and sleeping pills, except antihistamines, worsen apnea and should be avoided. Consult your sleep doctor if you use them. (Source: Sleep Apnea – The Phantom of the Night, page 134)

Medic Alert

You may want to carry a card in your wallet with emergency medical information, stating that with obstructive sleep apnea, “airway management may be difficult – avoid sedatives, narcotics, and tranquilizers” and similar information. List your physicians’ contact information and type of PAP and pressure. A wallet card is provided in Appendix A of Sleep Apnea – The Phantom of the Night Medic alert cards and bracelets can be found online. See See http://www.cpaptalk.com/viewtopic/t28102/Medical-ID-bracelet-for-OSA.html

With common sense, your CPAP equipment should give you many years of safe use.

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.

Preventing and Reporting Errors in Your Care

2011-12-06T14:43:00.000-07:00

For people with sleep apnea and for their healthcare professionals, peer coaching article #20, updated 3 December 2011

Patient safety resources
“An ounce of prevention is worth a pound of cure.”
To prevent errors in your CPAP treatment, do not blindly trust the actions of healthcare professionals. 1) Become informed about your treatment. Good places to learn about CPAP are the articles and links in this blog. 2) Check that your physician/ physician assistant/ nurse, respiratory therapist, Durable Medical Equipment provider are doing the right things for your personalized, effective treatment, including providing the correct equipment (machine, masks, etc.)

Many Durable Medical Equipment (DME) or Home Medical Equipment companies, especially large national DMEs and hospitals in the US, and some international healthcare organizations, are evaluated and accredited by The Joint Commission, (The organization was formerly known as JCAHO, pronounced “Jayco”, the Joint Commission of Accreditation of Healthcare Organizations. Now it’s called “The Joint Commission.”) The Joint Commission offers free online videos and pamphlets at http://www.jointcommission.org/general_public.aspx

A useful book is You: The Smart Patient by Dr. Mike Roizen and Dr. Mehmet Oz.

Reporting a legitimate complaint
Do I have a moral obligation to report this poor treatment?
"Right is might."

1. To your doctor
Your doctor is managing your care from a medical perspective. If your complaint is about poor treatment that has or could affect your health or other patients, for example, the respiratory therapist making a prescription error in setting up your CPAP machine, consider informing your doctor. He/she may not take action, but may advise you about possible actions you could take.

2. To The Joint Commission
If you receive substandard quality of treatment care from a DME (or hospital), the problem is twofold: what happened to you, and possible harm to other patients if you don’t report it and the problem goes unacknowledged and uncorrected by the DME. Consider fining a complaint with The Joint Commission, which uses information to strengthen its oversight of DMEs and improve the quality of care. Although you may remain anonymous, it may be more responsible to give your name. For information about the complaint process, see http://www.jointcommission.org/report_a_complaint.aspx

To submit a new complaint online, go to

http://jcwebnoc.jcaho.org/QMSInternet/IncidentEntry.aspx

E-mail: complaint@jointcommission.org
Fax: 630-792-5636
Mail: Office of Quality Monitoring
         The Joint Commission
         One Renaissance Boulevard
         Oakbrook Terrace, Illinois 60181

E-Mail: complaint@jointcommission.org

Be sure to read Report a Complaint at http://www.jointcommission.org/report_a_complaint.aspx before submitting a complaint.

3. To the DME
Working directly with the DME is the most important action. Find out a little about the DME’s organizational structure or chain of command by asking them how they are structured. Then set up a face-to-face meeting with the DME, or phone, or email or write. Work above the organizational level at which the problem occurred, and go up the chain of command if you think it’s useful, in talks or by copying others in correspondence. For example, if the problem occurred with the respiratory therapist, talk to the lead RT/supervisor, and branch manager or regional manager. If the problem occurred in customer service, talk with the customer service manager. If the problem is serious and appears to be organization-wide, such as a lack of quality and safety procedures potentially resulting in harm to the patient, write to the president and copy the regional manager.

Be courteous, professional, assertive, factual rather than accusatory, and document your facts. Provide details and evidence from your notes, software reports, prescription, orders, or billing about what happened when, with whom. Tell them the consequences of their error; actual consequences that you experienced, or potential consequences or harm to yourself and other patients if the problem continues. Let the DME know you informed your doctor and filed a complaint with The Joint Commission. Ask the DME to respond to you about what corrective action they plan to take, with you and to prevent the same problem happening with other patients, locally, regionally, and in the organization as a whole. Let them know you will relay the follow-up information to your doctor and insurance company.

4. To your insurance company
The DME contracts with and is paid by your insurance company. Consider using the insurance company’s complaint process to report the DME.

Be a champion for good. Each voice counts, whether or not you see immediate results.

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.