Sleep doctor has given me three options

[Dyssomniac]

Because you are susceptible try a normal daily cleaning of your pillows. The other thought is to try a hybrid mask that fits under the nose, Amara View or the new ResMed F30 I believe.

Thanks. I have a pretty thorough pillow-cleaning regimen going, but will ask about these masks.

[Fats Drywaller]

About bi-level: The Rx for that is different because the insurance HCPCS code for it is different and it costs more. This might be TMI, but there's an HCPCS reference here (PDF) on the Resmed web site.

About masks: Another under-the-nose type, called nasal-cushion rather than nasal-pillows, is the PR Dreamwear. That frame can be converted between nas-pil and nas-cushion just by changing the nosepiece, and each nosepiece is available in a few sizes. However, the Dreamwear is noisy because the air travels through the hollow silicone frame. The new Resmed N30i seems to have the same problem to some extent although it might not be as severe; see the reviews and discussion threads about it. The noise is a problem for some people but not others, and it should be considered before getting either of those. (In case it matters, I've used both Dreamwear types but not N30i.)

The Fisher & Paykel Brevida nas-pil design is very highly recommended by me and probably by a few others here but it doesn't have anywhere near the exposure or popularity of the poster child Resmed Airfit P10, which is a real shame. A scandal, IMAO. The Brevida has very soft, pliable silicone nasal pillows that have caused no problems for me over the last eight or nine months. I tried the P10 recently and couldn't stand it because the nas-pil lumps are much too hard and painful. I think the perceived problem with the Brevida is that if you look at the photos, it seems to be much more invasive than the P10, and that turns people off and they say "Obviously, I wouldn't be able to put up with that." But that's not what actually happens when you put the mask on. It's very soft and comfortable and is nothing like the P10 in that way. It also has a better headgear design and hose-connection design.

Actually, I have come to the conclusion lately that the Emperor P10 has no clothes. The Brevida really should be in the P10's place at the supposed top of the heap of nas-pil designs. One huge item of evidence in favor of that is that many P10 evangelists here have said (I'm paraphrasing) "Oh, the pain and the sores in the nostrils are no big deal, and they go away after a while; just use lanolin cream, like Lansinoh." To which I say "Whaddaya, nuts?" Why should it be necessary to treat pain & sores caused by a defective mask design? The Brevida doesn't cause those, so you can do an end-run around that problem and avoid having to stock up on Lansinoh.

All of that is assuming that you can get by OK with a nas-pil or nas-cushion design in the first place, having no problem with mouth-breathing.

[Fats Drywaller]

P.S. about masks: Brevida product page: https://www.fphcare.com/homecare/sleep-a...ks/brevida

[Fats Drywaller]

-- Going back to the cervical pillow, are they items that we usually buy ourselves, rather than obtaining them through medical providers? Is there much involved in getting them sized, fitted, adjusted, etc?

Yes to the first and no to the second, and they're not expensive. Just take your neck measurement and be sure to buy a collar that's large enough. Search here on AB for recommendations of brands. Caldera Releaf (sic) Neck Rest is one that's good up to 17.25 inches, that mfr's size L (15.25 to 17.25). Larger than that, there's another brand whose name I can't remember.

P.S.: That's about soft cervical collars. A pillow-like neck rest with a cutout in it isn't quite the thing because it doesn't keep the chin from dipping.

[Sleeprider]

For your goals of reducing RERA, we need to minimize the flow limitation that accompanies positional apnea. This requires some pressure support that the Philips System One and Dreamstation CPAPs do not have, however BiPAP does.  Pressure support is the difference between inhale pressure and exhale pressure, and the Philips CPAPs don't do that. Resmed on the other hand does provide up to 3-cm difference with its CPAPs and much more with the bilevels (VPAP).  

To understand this better, read the wiki on Flow Limitation http://www.apneaboard.com/wiki/index.php...Limitation and also why bilevel is the better choice for treating upper airway restriction and flow limitation http://www.apneaboard.com/wiki/index.php..._and_BiPAP

The Resmed Airsense 10 Autoset uses EPR (exhale pressure relief) as a comfort feature, but the 3-cm of pressure difference is enough to help many people to overcome flow limitation that the Philips machines do not respond to. The Autoset does this by providing higher inhale pressure and rapidly increasing CPAP pressure when it detects flow limitation. This limits FL and prevents OA. By doing this, the respiratory volume is not compromised by flow limitation, requiring an arousal and recovery breathing which is the definition of RERA as detected by the CPAPs.  Almost invariably, you will observe users of Philips machines having higher hypopnea and RERA while the machine passively sits there and does nothing.  As a result, a Philips auto CPAP must be set to a much higher minimum CPAP pressure.  The Resmed machines as discussed above, address this through both pressure support which improves tidal volume and minute vent, and by rapidly increasing pressure at the first sign of flow limitation. The event is avoided altogether.

Thanks. I read the article on UARS and BiPAP, but the first link produced an error "There is no text in this page."

Let me play back what I'm hearing to see if I'm understanding it correctly. I took your comments to mean:

-- Resmed machines like the Airsense 10 Autoset would be much better than a Philips machine (such as the one I had prior experience with)

-- The Airsense 10 Autoset might provide adequate support for my needs, but a bilevel machine might be even better.

I think it would be very straightforward for me to request and receive an AirSense 10 from my HMO, though I'd have to confirm whether what they furnish is the Autoset model. As for BiPAP, I've never discussed that with them so I don't know if it would just be a matter of requesting something different or whether my doctor would need a more complete diagnostic rationale for prescribing a BiPAP machine.

Some questions:

-- Is my understanding above correct?

-- Is there a BiPAP machine I might ask my doctor about as an alternative to the AirSense 10 Autoset?

-- Going back to the cervical pillow, are they items that we usually buy ourselves, rather than obtaining them through medical providers? Is there much involved in getting them sized, fitted, adjusted, etc?

-- Re my question about sleeping with my head elevated using a large wedge pillow, does this seem like it could be any issue for apnea treatment?

Thanks again for all the comments -- this is very helpful.

The first link is still working for me http://www.apneaboard.com/wiki/index.php...Limitation, or search Flow Limitation in the Wiki search.


It will be much easier to obtain the Airsense 10 Autoset than any bilevel. Generally insurance will not fund the bilevel unless there is an underlying medical necessity or you don't tolerate CPAP.  That is why my suggestion for the Resmed is relevant. It is a limited bilevel at the cost of a CPAP, and easier to get.

A soft cervical collar or wedge is pretty common kit here. They cost anywhere from $10 to $50 depending on how extravagant you feel and insurance does not cover it.  The whole purpose is to get a comfortable fit that prevents your chin from tucking.  Common names are Caldera Releaf or Dr Dakota Snoring Stop, and you can see those on Amazon as well as related products.  They work to resolve positional apnea on or off CPAP.  Be sure you can fit a few fingers between the collar and your neck, and use the measurement from the top of your sternum to the base of your jaw for height.

Using a wedge pillow to effect an inclined position has mostly been effective for people with aerophagia (air ingestion) and may help with untreated obstructive apnea. If the incline causes your chin to drop the obstruction will occur. I am not familiar with many benefits for wedge pillows for most of us.

[Fats Drywaller]

Because you are susceptible try a normal daily cleaning of your pillows. The other thought is to try a hybrid mask that fits under the nose, Amara View or the new ResMed F30 I believe.

Thanks. I have a pretty thorough pillow-cleaning regimen going, but will ask about these masks.

To clarify, since your profile says full-face mask at the moment: I think what bonjour meant was a daily cleaning, with soap & water, of the silicone mask pillows (nosepiece).

The humidity level, which really means the level of heat, can make a big difference to congestion. Some models including the Resmed A10 (don't know about the PR machines) also have an "automatic" setting for that, which is worth trying. If heated humid air turns out to be bad for your sinuses but cooler humid air is OK, then switch the heater off but keep water in the tank to use passive humidification. In the summer, some people add ice cubes to the tank. Then there's the option of no humidification: tank empty and heater off (or else humidifier attachment removed ... with the A10, you replace the tank with a special Resmed side cover).

[Dyssomniac]

About bi-level:  The Rx for that is different because the insurance HCPCS code for it is different and it costs more.  This might be TMI, but there's an HCPCS reference here (PDF) on the Resmed web site.

Thanks, it sounds as though a good starting point would be to request the AirSense 10 Autoset. I'll call Wednesday and confirm whether they are able to supply the Autoset specifically.

About masks:  Another under-the-nose type, called nasal-cushion rather than nasal-pillows, is the PR Dreamwear.  That frame can be converted between nas-pil and nas-cushion just by changing the nosepiece, and each nosepiece is available in a few sizes.  However, the Dreamwear is noisy because the air travels through the hollow silicone frame.  The new Resmed N30i seems to have the same problem to some extent although it might not be as severe; see the reviews and discussion threads about it.  The noise is a problem for some people but not others, and it should be considered before getting either of those.  (In case it matters, I've used both Dreamwear types but not N30i.)

The Fisher & Paykel Brevida nas-pil design is very highly recommended by me and probably by a few others here but it doesn't have anywhere near the exposure or popularity of the poster child Resmed Airfit P10, which is a real shame.  A scandal, IMAO.  The Brevida has very soft, pliable silicone nasal pillows that have caused no problems for me over the last eight or nine months.  I tried the P10 recently and couldn't stand it because the nas-pil lumps are much too hard and painful.  I think the perceived problem with the Brevida is that if you look at the photos, it seems to be much more invasive than the P10, and that turns people off and they say "Obviously, I wouldn't be able to put up with that."  But that's not what actually happens when you put the mask on.  It's very soft and comfortable and is nothing like the P10 in that way.  It also has a better headgear design and hose-connection design.

Actually, I have come to the conclusion lately that the Emperor P10 has no clothes.  The Brevida really should be in the P10's place at the supposed top of the heap of nas-pil designs.  One huge item of evidence in favor of that is that many P10 evangelists here have said (I'm paraphrasing) "Oh, the pain and the sores in the nostrils are no big deal, and they go away after a while; just use lanolin cream, like Lansinoh."  To which I say "Whaddaya, nuts?"  Why should it be necessary to treat pain & sores caused by a defective mask design?  The Brevida doesn't cause those, so you can do an end-run around that problem and avoid having to stock up on Lansinoh.

All of that is assuming that you can get by OK with a nas-pil or nas-cushion design in the first place, having no problem with mouth-breathing.

I see in my notes that I tried the P10 three years ago, but had a hard time tolerating it through the night so I went back to the F10. I should update my profile here because it was accurate for the last time I used APAP a couple of years ago, but is not current now. When I call Wednesday, I'll ask specifically if the Brevida is an option.

-- Going back to the cervical pillow, are they items that we usually buy ourselves, rather than obtaining them through medical providers? Is there much involved in getting them sized, fitted, adjusted, etc?

Yes to the first and no to the second, and they're not expensive.  Just take your neck measurement and be sure to buy a collar that's large enough.  Search here on AB for recommendations of brands.  Caldera Releaf (sic) Neck Rest is one that's good up to 17.25 inches, that mfr's size L (15.25 to 17.25).  Larger than that, there's another brand whose name I can't remember.

P.S.:  That's about soft cervical collars.  A pillow-like neck rest with a cutout in it isn't quite the thing because it doesn't keep the chin from dipping.

Thanks for the details, I'll check those out. Based on my dress shirt size, the Caldera Releaf sounds like it should fit fine.

I think what bonjour meant was a daily cleaning, with soap & water, of the silicone mask pillows (nosepiece).

The humidity level, which really means the level of heat, can make a big difference to congestion.  Some models including the Resmed A10 (don't know about the PR machines) also have an "automatic" setting for that, which is worth trying.  If heated humid air turns out to be bad for your sinuses but cooler humid air is OK, then switch the heater off but keep water in the tank to use passive humidification.  In the summer, some people add ice cubes to the tank.  Then there's the option of no humidification: tank empty and heater off (or else humidifier attachment removed ... with the A10, you replace the tank with a special Resmed side cover).

Funny, I heard it as "pillows" as in what you rest your head against, but I see he probably meant the nosepiece gear.

I have a feeling that when I get the new machine, I'll need to spend some time getting dialed in on the sinus/nasal front.

[Dyssomniac]

The first link is still working for me http://www.apneaboard.com/wiki/index.php...Limitation, or search Flow Limitation in the Wiki search.

It will be much easier to obtain the Airsense 10 Autoset than any bilevel. Generally insurance will not fund the bilevel unless there is an underlying medical necessity or you don't tolerate CPAP.  That is why my suggestion for the Resmed is relevant. It is a limited bilevel at the cost of a CPAP, and easier to get.

A soft cervical collar or wedge is pretty common kit here. They cost anywhere from $10 to $50 depending on how extravagant you feel and insurance does not cover it.  The whole purpose is to get a comfortable fit that prevents your chin from tucking.  Common names are Caldera Releaf or Dr Dakota Snoring Stop, and you can see those on Amazon as well as related products.  They work to resolve positional apnea on or off CPAP.  Be sure you can fit a few fingers between the collar and your neck, and use the measurement from the top of your sternum to the base of your jaw for height.

Using a wedge pillow to effect an inclined position has mostly been effective for people with aerophagia (air ingestion) and may help with untreated obstructive apnea. If the incline causes your chin to drop the obstruction will occur. I am not familiar with many benefits for wedge pillows for most of us.

Yes, the link is working for me now. Don't know what the problem was.

It's sounding like I'm heading for an Airsense 10 Autoset with mask tbd, plus a Caldera Releaf.

Re the wedge pillow, my question wasn't really whether it would help with apnea, but rather just to make sure it wouldn't be a problem. It's pretty important for me for reflux and tinnitus issues.

[Fats Drywaller]

I have a feeling that when I get the new machine, I'll need to spend some time getting dialed in on the sinus/nasal front.

Something that could be non-intuitive is the size of nosepiece used. When getting a mask from a DME, be sure to get all sizes included in the full mask package, sometimes called "fit pack" or "fit kit", and don't take the word of any tech, therapist, etc. about what size fits you. Try the sizes at home, at your leisure. It's not only about the patient's nostril size, but about the volume of air that can be delivered through the opening in the silicone. So my guess is: if congested, try a larger nosepiece, assuming that the mask is of the cushion or pillows type and other likely causes of congestion have been dealt with.

[Sleeprider]

Re the wedge pillow, my question wasn't really whether it would help with apnea, but rather just to make sure it wouldn't be a problem. It's pretty important for me for reflux and tinnitus issues.

That makes sense to me. I know a lot of member have had good results for GERD/reflux with the wedge.