Getting a CPAP without a sleep study

[SuperSleeper]

I am a physician who over the last decade has seen over 5000 patients with snoring or apnea. I sold my sleep practice to tend to some family matters and am now doing general medicine practice for a change of pace. Nonetheless, I am seeing a lot of apnea in my general medical practice and remain frustrated by the ongoing confusion around the "necessity"of a sleep test before starting CPAP. There is in medicine a common practice called an empirical trial wherein a physician starts a treatment in a patient even though they are not entirely sure of the diagnosis (eg use of a diuretic in a patient suspected of having congestive heart failure before an echocardiogram has been done). I could name several other examples, but the basic principle is that if the probability of the disease is high based on clinical evidence (OSA often fits this criteria) and the treatment used is relatively nontoxic (eg CPAP), then you can bypass the test and start into treatment directly so long as you monitor the outcome to prove that you have obtained the expected results (eg improved awakedness, cognition, etc). It is the medical version of the mantra " the proof is in the pudding".

In my practice, we were mandated to test by insurance rules and would use a home test whenever possible to keep cost down. In the mid90's we did not have auto-adjust so our titration methodology was based on rigorous surveillance of clinical symptoms at different pressures with a basic premise being that the pressure that eliminates snoring usually vanquishes apnea as well. The arrival of auto-adjust machines extinguished the need for any in-lab titration for a simple reason: one night of monitoring is rarely enough sample time to determine one pressure that is best since OSA varies from night to night inherently (random/unexplained) and systematically (alcohol use or not). One of our last abstracts reported the clear benefit that weight loss had on both apnea and the pressure required (the opposite is true: weight gain will require a higher pressure). Bottom line is this: as insurance for non-catastrophic medical issues erodes as it has been and people are starting to feel the pain of the expense of doing a sleep test for 1500-2500 and paying for a good chunk if not all of it, we are going to see this question asked more and more. I have apnea myself, and knowing what I know based on my extensive experience, I would never do a full polysomnography for titration of pressure, just as I will never dose a patient's blood pressure medication based on one office visit measure or 6 office visit measures, but rather constantly adjust based on each visit. This practical clinical approach of "new data, new decision" is similar, though not as efficient, as the way an auto-adjust CPAP works. As far as skipping the diagnostic test, make a list of why each symptom that leads you to believe you have sleep apnea, start on auto-adjust, revisit the list after 2, 4, 6 weeks and ask whether all of the symptoms are gone. If they are, then you have conducted a successful empirical trial; if any remain, consult a physician re the possible explanations (eg you are still sleepy because CPAP is intrusive to a good night's sleep in your case or you have periodic limb movements as well that need to be treated

[SuperSleeper]

Welcome to Apnea Board, Doctor Rick -

You're a rare breed - it's so refreshing to see a doctor promote the advantages of a patient taking control of their own treatment and even going so far as to suggest that a patient can conduct their own "empirical trial" with regard to the effectiveness of CPAP treatment.

I think you're correct on the direction of this self-help movement in Sleep Apnea - and a weakened economy will also put pressures upon health care providers to come up with less expensive options for patients.

As a former Sleep Doctor, if you have some time, I'm sure many members here would love for you to write any further insights, observations or experiences you might have as to the "best" or "safest" way to conduct such a self-diagnostic test with CPAP.

Thanks for posting!

[SuperSleeper]

Well I have gone this far so I figure I'll do the triation tonight. I have a friend that works at a medical equipment supplier and just put a call in to him about making sure I get an auto machine. Like I said before I have had a scrip for an auto machine from my family doctor before I did anything and was seriously considering just doing it all myself. Hopefully I not end up spending too much more money with the study and buying local using my insurance and having to pay 20% of the total as opposed to just ordering everything offline and paying out of pocket.

One thing that has been disappointing thus far is the amount of info that I am getting from the lab. They really don't want to tell me too much and sometmes I feel like they are avoid answering all the questions I have asked. I was hoping to come out of the sleep studing beening again more prepared and well informed as to what my next step is. They would have been just fine doning the study and not tell me anything other than its time to come back and we will hook you up to this magic machine that is way to complex for me to understand anything about.

My next question is what machine to get. I have been leaning toward the S9, with the DeVilbiss IntelliPAP coming in second. I thought at first get a mid priced unit but there has to be a reason for a couple hunder bucks more for the S9. Is it best to use the on board info to diagnos useage or use the software?

[SuperSleeper]

Chilly - The computer software is always going to be much better than the "on-board" menu system. Also, you can download the ResMed version for free (ResScan - go to our private Members Only Forum for the info on how to get the download link). The DeVilbiss SmartLink software package is going to cost you about $150, so you almost have to add that to the price when comparing the two products.

That would make the DeVilbiss system come in at around $600 or so (price including the software package), while the ResMed system would be about $870 (which would include the cost of a cheap $20 SD card reader). That's a large difference of $270.

The DeVilbiss has a 3 year warranty, the ResMed 2 years. Weight wise, DeVilbiss is 2.75 lbs, ResMed is 1.8 lbs. for the machine by itself.

Size is different - DeVilbiss is 4.2" x 6.5" x 6.9" and the ResMed is 6" x 5.5" x 3.25".

ResMed does offer the Climate Control hose, but the DeVilbiss has nothing like it available.

The ResMed S9 is a bit quieter, coming in at 24 dB, while the DeVilbiss IntelliPAP is 26 dB.

ResMed is much more popular than DeVilbiss, not sure if that makes a difference or not. The DeVilbiss SmartLink system uses a smart card, and not a standard SD card like the ResScan system does. From what I have heard, the ResScan software offers more functionality than the DeVilbiss as well, but I have not independently confirmed this.

[SuperSleeper]

I am leaning toward the S9 machine and will request that it be prescribe to me. I don't think I will see the sleep doc between now and then but will tell the techs tonight its what I want.

I am getting pretty excited about getting a machine. I just keep thinking about how great it would be to not be tired all the time and have to nap every day. Last night I know I woke up close to a dozen times and looked at the clock. So if I remember waking up that many times I am sure I woke up four times more than that.

[SuperSleeper]

If it's at all possible, have your doctor write a prescription for an "auto machine, x min. cm y max. cm H2O, mask, and supplies" without naming brands. That way you're free to choose whatever equipment that you want and/or works best. The doctor does not have to be specific. If s/he is, ask yourself why!

chillywig,
The techs at the sleep center probably are not allowed to give you much information. Just like when I have my mammorgrams done and the tech can't tell me if there is a suspicious lump, but has to keep a smiley face and let me wait to hear from the radiologist or my regular doc. Legally techs can't give you a diagnosis. After my first sleep study (not a split), when I asked the tech how things looked, just said, "make sure you remember to bring home the list of what medical supply companies we work with" - her only legal way of letting me know I have apnea issues.

[SuperSleeper]

So it turns out that I have severe apena. 41 AHI on the first night.

Trying the get the auto machine prescribed was very difficult. I considered naming the people at the lab that were totally against anyone using an auto cpap. I requested it and tried sweet talking everyone in the lab with no success. After my titration night the order came through for a cpap with a pressure of 13. I called the lab back and finally got ahold of someone that understood my reasonings for wanting the auto machine and said she would ask the doc if he would prescribe me one, which he did.

Dealing with Apria hasn't been all that much better. The Doc just wrote on the original scrip for a resmed auto s9, so I guess it is either a cpap setting of 13 or auto setting of 8 to 20 which confused the hell out of the people approving claims. I still haven't gotten anyone to tell me how much this is going to cost me yet.

I'll have the machine next week hopefully. Is there any reason to try the cpap mode on the S9 or just run auto? I have already downloaded the software and about half read through the manual. I think the lab said the titration night my AHI was still like 30 but might be wrong.

[SuperSleeper]

That's great you're getting an S9 AutoSet, Chilly- I think you'll like it.

You can run it in either straight CPAP mode or Auto mode. I think it will work better for you in auto mode, however, unless you primarily have central sleep apnea as opposed to the more common obstructive sleep apnea. Your sleep doctor should be able to tell you this.

I think you'll be okay with the range set from 8 to 20. After you run it for a few nights, if you use the free ResScan software, check the average pressure and your AHI, and you'll probably find that it's somewhere around your prescribed 13 cm/H20 of pressure.

Let us know how your AHI level does with this machine and how you feel after a week or two! ...and welcome to the Society of Hoseheads

[SuperSleeper]

Well I finally got a machine. Yesterday went to Apria to pick up my new S9. When I got there the tech started getting it out of the box and I looked at the label which said S9 Elite CPAP. Long story short the order got messed up. I think the employees could tell I was NOT happy so they gave me a REMstar auto to use until the S9 auto shows up. The tech actually didn't remove the manual so I have both, even though I knew how to get into the setup mode after watching her set it up. 8 to 20 cmH20 starting ramp of 6. It took a little time to get used to it. Messed around with it and kind of got used to the pillows and breathing against the pressure. The machine doesn't have too much diagnostic info but had an AHI of 4 and it went to 90% 10 times last night. So it looks like a CPAP set at 13 wouldn't be enough pressure all night. I did wake up once and found I had pulled the whole mask off my face, slipped it back on hit the ramp button and next thing I knew it was morning. I woke up at 7 and had the day off, normally I'd sleep in but couldn't go back to sleep. I have not done much today and would normally have taken at least one cat nap on a day like today but that has not happened. When I woke up I felt like either the machine figured out my rhythm or I figured out the machines because breathing didn't seem as difficult as last night.

I have been a little stuffy and sneezey this after noon. I had the humidity set on the recommended 2 and bumped it to 3 sometime it the night because I felt a little dry. My furnace is running right now and sometimes in the past have ran a humidifier in my bedroom in the winter. Does anyone have to run their humidifier higher in winter months? Maybe its unrelated allergy issues?

So to finish the story....

Back in September I was considering getting a CPAP without getting a sleep study. I really felt like I needed the machine and didn't want to wait months to go through the sleep study and insurance BS and just get one. I think I had a case of the "I wants" and can be impatient plus I assumed it would cost about the say since I was going to have to pay 20% of everything.

My 20% of the sleep study I was billed for was $853. I waited about 90 days and went in to pay my bill and asked for a discount. The gave me another 30% off so I paid $597. I was told I would also have to pay 20% of the equipment I was prescribed but for what ever reason I have never received a bill from either Apria or my insurance.

So after all I have been through I'm glad I had they study done. It ended up costing less and I am fairly confident that I do not have any other underlying issues. The CPAP has made quite a difference in my daily life. I'm not tired all the time, my blood pressure has come down and I even dropped a few pounds. It took a long time to get here but it was worth the wait!

[SuperSleeper]

I just wanted to say thanks for this thread. I too was thinking about going forward (or trying to) without the study. It was interesting reading all of this. Thanks for letting us follow along!

To add to this thread, I would suggest anyone trying to change their own pressure read this first:

http://www.apneaboard.com/adjust-cpap-pr...re-on-cpap