Sleep doc only wants CPAP, not APAP

[quiescence at last]

I don't think what is the right machine was in question. I read the original poster a whole different way, because I think REMfan does have a data capable machine that *can* be changed to APAP, but was set up for single pressure.

The docs reasoning was the question. REMfan, in time you may know enough to do your own settings and review your own results. You do have control over your settings. I believe the most important initial task is getting used to the machine and mask. 14 cm H2O may end up being optimal, but a more ginger approach can be had if you take your own control.

Since the doc cannot know how involved you would end up being, the fixed pressure approach and one setting session may be the best considering the mix of patients and level of apathy seen in them.

Can you tell us the model of your machine, such as 560xx, as this will indicate how capable it is?

Last question - how are you sleeping, and how do you feel?

QAL

[Mark Douglas]

Everything I read here says as long as you maintain compliance the ins co could care less what you do. I have no more use for a straight cpap than I do a single speed bike. Even in flat Florida I used several gears. If I were to advise the OP it would be to read this board and self educate then pin down the doc as to her reasoning and If I found it lacking I would blow her off and doit myself. Oh wait I did do it myself and don't have a sleep doc, dme, or ins co to please.

[tedburnsIII]

This OP obviously has 02 issues, and 14cm is apparently OP's optimum pressure (likely while supine and in REM). Unless OP without fail sleeps on his/her side, my advice is to go with the doctor at 14, if it can be tolerated.

I've had issues with 02 but have had aps/hyps clear for the most part at very LOW settings of 6 or 7. No can do, if I am to respect my titration schedule, which recommended 12cm! The optimal pressure will not only clear these events with an RDI<5, but minimum Sa02 must equal or exeed 90%! OP's aps/hyps may clear but 02 will likely be inadequate.

So, I went ahead and purchased a CMS50D+ overnight pulse oximeter and did my own studies. I can 'get by' at auto settings as low as 9.5 or 10, but I hope to be able to tolerate a minimum or straight setting of 12cm eventually as I do end up sleeping on my back, which is better for it.

[lmoretti]

My doctor prescribed CPAP @9cm. I questioned a bit about APAP, but didn't fight too hard. Talked to my supply house, and they only stock APAP machines so the machine I picked up today (just starting therapy) is set at a fixed 9cm of pressure.

I'm going to use that (monitoring with SleepyHead) until after my follow up appointment, then I'm going to change it to APAP with a range of probably 7-11cm to see what happens. Depending on the graphs and data, I may adjust further from there.

[Sleeprider]

This OP obviously has 02 issues, and 14cm is apparently OP's optimum pressure (likely while supine and in REM). Unless OP without fail sleeps on his/her side, my advice is to go with the doctor at 14, if it can be tolerated.

I've had issues with 02 but have had aps/hyps clear for the most part at very LOW settings of 6 or 7. No can do, if I am to respect my titration schedule, which recommended 12cm! The optimal pressure will not only clear these events with an RDI<5, but minimum Sa02 must equal or exeed 90%! OP's aps/hyps may clear but 02 will likely be inadequate.

So, I went ahead and purchased a CMS50D+ overnight pulse oximeter and did my own studies. I can 'get by' at auto settings as low as 9.5 or 10, but I hope to be able to tolerate a minimum or straight setting of 12cm eventually as I do end up sleeping on my back, which is better for it.

I'll disagree with you Ted, to the extent that if ventilation (oxygenation) is a real issue here, is is not treated with CPAP but with BiPAP. The pressure support (difference between IPAP and EPAP) is what encourages greater ventilation rates than is achievable with CPAP.

The whole argument of the doctor is specious. People are treated on many different machines, the simplest being CPAP. Patients with real oxygenation issues are not treated on CPAPs, and once pressure exceeds 14, BiPAP is generally indicated anyway so that the exhalation pressure can be reduced. CPAP is titrated to reduce events to the lowest pressure that effectively treats OA, H, Snores and possibly RERA as determined in a titration study. APAP does exactly the same thing in exactly the same way, except it is capable of responding to flow limitations and snores to increase pressure to prevent OA and H. As a result, it can be set to a slightly lower minimum pressure, and will increase pressure as necessary to account for sleep position and sleep stage. Some people respond better to CPAP, others to APAP. Since APAP can operate as CPAP, and they cost the same, you might as well have the APAP.

FWIW, I have not spoken to a sleep doctor since 2008. You can cut this guy out of your life and finances once you have your script and copies of all your studies and prescriptions. Be sure you get a full data recording machine and you'll never need him again. That might be the crux of the issue.

[tedburnsIII]

My comments were solely based upon the Clinical Guidelines. It is worth a read, and there is some ambiguity re role of 02 levels elsewhere in the document, but I copied and pasted a relevant part into a .png file uploaded to photobucket:




The Guidelines only recommend switching over to BiPAP at recommended pressures >15cm.

Here's my titration part of the split-night study, which apparently conforms to the Guidelines (optimal pressure as 12cm):

[bwexler]

First it would help to know exactly which PR Series 60 machine the OP has, 560 or???
Then , since the doc was concerned about O2, I would recommend acquiring a pulse Ox monitor. I have the CMS 50i.
Then download Sleepyhead software (free) and learn to use it. There is plenty of help here.
I would monitor and evaluate my results for the first week and then I could make an informed decision on what adjustments might be necessary.
I would then maintain the documentation to show the doctor why I took control and made the necessary adjustments.
If the doctor doesn't approve of my methods, I would fire that doctor. Been there done that.

[PaytonA]

I'll disagree with you Ted, to the extent that if ventilation (oxygenation) is a real issue here, is is not treated with CPAP but with BiPAP. The pressure support (difference between IPAP and EPAP) is what encourages greater ventilation rates than is achievable with CPAP.

I do not understand how BiPAP oxygenates any better than CPAP. Could you please explain.

[Sleeprider]

Payton, the pressure reduction in EPAP allows more air to be exhaled by some people than exhalation against pressure. The tidal volume can be influenced by setting the pressure support. In fact, if set too high it can induce centrals by purging too much CO2. This link explains how tidal volume can be targeted by pressure support: http://www.healthcare.philips.com/main/h.../setup.wpd Bilevel therapy is commonly used in COPD, chronic obstructive, asthma, and other patients to improve volume and ease breathing, but the same principles apply to pretty much anyone. In my own case, my tidal volume on APAP at 11-14 averages in the mid to upper 540 to 610 mL range. With BiPAP Min EPAP 8.0 Max IPAP 18.0 PS 5.0-8.0 (cmH2O), the tidal volume average 630 to 680.

You can pretty accurately target tidal volume with BiPAP settings and have much more influence on overall blood oxygen levels than with CPAP. Keep in mind, the use of EPR and Flex, there is a low level of pressure support in many CPAP and APAP machines, but if ventilation (oxygenation) is a concern, most doctors will turn to Bilevel.

[tedburnsIII]

I have seen alot of praise for APAP on this board, so I asked my sleep doc about enabling it on my machine. She didn't want to because she wanted it at 14 CPAP to achieve the best oxygen level. I suggested we set it for a range that did not fall below 14. She wasn't interested. Do you veterans agree with her approach?

Well, I don't consider myself a veteran yet , but I believe the only way to go is an Auto Adjusting machine.

I'm not sure why any Doctor leans toward a straight CPAP setting based on an overnight study, because it is only one night. Your docs reasoning is to achieve the best oxygen level? Makes no sense to me, because an auto CPAP will adjust to your needs. I really believe that some doctors just don't know enough about the auto machines and what they can do for you, or they simply are afraid of losing control.

You are the patient! Tell her you want a fully data capable Auto CPAP machine, then tell her she can set it to CPAP mode with a straight setting instead of Auto. You can always change it yourself. :grin: Remind her that an APAP can be used as a straight CPAP, but a CPAP can only offer you that straight setting. You don't know what your future needs will be.
Good luck!

I must disagree with portion in bold, above.

When my APAP is set to a low minimum of 7 or 8 the average pressure amounts to 7 or 8. At 7 or 8 average pressure my low 02 is at 83%, which is unacceptable and dangerous. See my post #16 with the titration table, above.