New User, question about Friday's DME appointment

[retired_guy]

I have been using ResMed Elite set at 6 since I started in February and have had no problems.
I don't understand what you mean retired_guy about a straight 6 not being good.
I have not found that a heavy force.

(PS retired_guy how did you go with your Airfit P10, did I miss your follow up comment?)

Straight 6 might be great for some, such as you and the OP perhaps. For me personally if some techie tried to restrict me to one fixed pressure, especially a low one, there would be problems. For me if I'm not getting 7 or better I think I'm going to suffocate. That seems to vary with a lot with folks, and it may have to do with my crappy lungs. But at 9/14 my O2 stays perking along at 93% which is pretty darn good for an old guy with "severe" (my shiny asx) emphysema. Don't accept anything the good doctors tell you......................

My humble opinion is if a techie dude were to prescribe a fixed 6, I would be happy to oblige by using a machine that would vary between a low of 6 and a high of 10. Not that I don't trust the wisdom of the techies, but they really don't have a lot of experience with my body. 2 hours in a sleep clinic don't cut it.

I'm doing fine with my P10. Currently I'm back to using the large pillows rather than the medium. Last night they managed to behave very nicely. When they get cranky, I'll go back to the medium. ....we have an understanding.

[Gabby]

Hi retired-_guy, sorry I just don't understand what you mean by suffocating with a 6? Is that because it is a low number?
If I was able I would love the auto set machine. Just saying I am making do with what I have.

Happy for you and your Airfit. I prefer the large but sometimes also go back to medium. Large do tend to cause aggravation on outside of one nostril, a small sore has developed

[ImaSurvivor]

Low pressures for some of us feels like suffocation. When I had my titration and trying different masks, it was an awful feeling of suffocation. Being new to it, I was blaming the masks but most of the problem was really due to the low pressure of 4 they were starting me out at. After going through a couple masks, I remarked I thought CPAP was supposed to give you air not make you feel like you were being denied air. The tech said she would raise the pressure for me and I was at least able to get started with the sleep study. When I brought my CPAP home I had that same feeling. I knew the ramp had been set to start at pressure 4 and it seemed an eternity for it to raise enough to feel comfortable. I did a lot of squirming those first couple nights suffering through the low pressures then decided the ramp was not for me and turned it off.

As for the low pressure of 6, I was told by the tech that auto machines are not given for low pressures because they are more expensive machines. I didn't know at the time that it doesn't matter as far as insurance is concerned because they are the same line item. Had I known it, I would have countered with a response. I was making it quite clear to everyone what machine I wanted. As it turns out, my pressure is 10. I was given an auto machine but set on CPAP setting. The therapist told me I just made it in with an auto machine and the cut off is pressure 9.

It is my opinion to push for the auto machine. Even if it is set on CPAP, it can always be set to APAP later if it is decided it is needed. Sleep studies are just one night and not necessarily what happens every night. I wanted an APAP machine so as not to jump through the hoops of trying to exchange machines at a later time. I am still set on CPAP but there are times I consider trying the auto setting to see if I can get more consistent low numbers. While my AHI and leaks are not above the acceptable range, I would like to see them lower more regularly.

[Sleepster]

When I asked why a CPAP and not an APAP the tech? told me that I didn't need the APAP because the level of pressure I needed was so low and the titration study showed that it stopped all the events & snoring.

My question, is should I still request from the DME to get an APAP & set it to work as a CPAP?

You can ask for one, but your insurance company may not be willing to pay for one. Perhaps you could swing a deal with the DME where you pay the difference in price between the CPAP and APAP.

At a pressure of 6 cm, you don't need a APAP. Unless there are complications such as aerophagia or you have some health problems other than simple obstructive sleep apnea.

I don't understand the complaints from people in this thread about a pressure of 6 cm being so low it suffocates them. We walk around all day breathing air at a pressure of 0 cm and we don't suffocate.

One advantage to PRS1 machines over ResMed is that you don't have to remember to download your data every week.

[retired_guy]

I don't understand the complaints from people in this thread about a pressure of 6 cm being so low it suffocates them. We walk around all day breathing air at a pressure of 0 cm and we don't suffocate.

Simple. If my nose could keep up with what my body thinks it would like to have there wouldn't be an issue. But when I walk around breathing all day I'm mouth breathing a lot. If I tried to do much with my mouth shut all the time, it wouldn't work out well.

[Sleepster]

That makes sense. I've heard that some people who are normally mouth-breathers during the day can use a nasal mask.

Before I had sinus surgery I immediately became a mouth-breather when I laid down as my nose would plug up.

[robysue]

A note about "breathing at low pressures."

A lot of how a CPAP feels at the beginning of the night is psychological. People with pressure needs of 10 cm or more get used to having a pretty strong breeze blowing in their face when they put the mask on each night. And when the pressure is quite low (like 4-6), they do notice the lack of the strong breeze, and it can make them feel as though there is not enough air coming into the mask to inhale as deeply as they want in a comfortable fashion.

But there are also people who have very low pressure needs who have no problems at all inhaling at low pressures. I'm 3.75 years into CPAP therapy. My current BiPAP Auto range starts the night off with IPAP = 6 and EPAP = 4. And that is NOT a ramp setting---those are my minimum pressures so I spend a lot of time each night at 6/4. I have no problems inhaling at these pressures at all, but I'm used to them.

I'll add this: When I changed my settings to straight BiPAP at 8/5.5 (roughly my 95% pressure levels) for a week or so back last December, I felt as though I was breathing against a hurricane at the beginning of the night and I needed a ramp to be comfortable enough to get to sleep. To me an IPAP = 8cm does feel like a hurricane and (when I'm awake) exhaling against 5.5cm does require a lot of extra effort. But objectively speaking, these are low pressures and anybody who regularly uses pressures above 10cm is not going to describe how they feel as a "hurricane" although that's the way they feel to me.

My point is this: Telling the OP that s/he is going to be uncomfortable with his/her titrated pressure of 6cm before the OP even starts therapy does no-one any good. The OP needs to try the titrated pressure. If it's enough to control the OSA, the OP will likely find that 6cm provides plenty of air for comfortable breathing. Moreover, the OP may be just as likely to find that 6cm feels like a hurricane and have some trouble exhaling against the pressure as s/he is to find that 6cm is so low that inhalation is problematic.

In my opinion it does no one any good to tell a newbie who has not even started therapy that their titrated pressure is too low or too high to ever be comfortable. Let 'em start their therapy with an open mind and then tell US whether they are having problems with inhalation (inhalation pressure may be too low for comfort) or exhalation (exhalation pressure on may be too high).

And when a newbie DOES complain of "not being able to breathe comfortably", it's equally important to tease out whether the breathing difficulties lie with inhalation (not enough air for comfort) or exhalation (too much air for comfort) rather than just assuming the newbie's problem must be "pressure is so low no one can breathe" or "pressure is so high no one can breathe"

[robysue]

When I asked why a CPAP and not an APAP the tech? told me that I didn't need the APAP because the level of pressure I needed was so low and the titration study showed that it stopped all the events & snoring.

My question, is should I still request from the DME to get an APAP & set it to work as a CPAP?

You can ask for one, but your insurance company may not be willing to pay for one. Perhaps you could swing a deal with the DME where you pay the difference in price between the CPAP and APAP.

In the US, CPAPs and APAPs are billed under the exact same insurance billing code (if your insurance company pays by code, as most do.) Hence a script for "CPAP at n cm" legally allows you to buy an APAP---provided you can find a DME willing to sell you one.

Under most insurance contracts with DMEs, the DME is usually forbidden from charging an "upgrade" fee for setting a patient up with an APAP rather than a CPAP.

In other words: If your insurance is (partially) paying for the machine, the DME will get the exact same $$$ regardless of whether they set you up with a PR System One SE (el cheapo brick) or a Resmed S9 AutoSet (most expensive APAP on the US market).

Of course this fact explains why it's in the DME's (short term) financial interest to set up newbies with bricks rather than APAPs. And why the sleazy DMEs lie to customers and say "your insurance won't pay for an APAP" or even "your insurance won't pay for a full efficacy data machine."

But it's also worth noting that the negotiated "price" between the DME and the insurance company for providing a CPAP to a patient is usually well in excess of what the on-line DMEs charge as the retail price of the S9 Autoset.

[PaytonA]

A note about "breathing at low pressures."

A lot of how a CPAP feels at the beginning of the night is psychological. People with pressure needs of 10 cm or more get used to having a pretty strong breeze blowing in their face when they put the mask on each night. And when the pressure is quite low (like 4-6), they do notice the lack of the strong breeze, and it can make them feel as though there is not enough air coming into the mask to inhale as deeply as they want in a comfortable fashion.

But there are also people who have very low pressure needs who have no problems at all inhaling at low pressures. I'm 3.75 years into CPAP therapy. My current BiPAP Auto range starts the night off with IPAP = 6 and EPAP = 4. And that is NOT a ramp setting---those are my minimum pressures so I spend a lot of time each night at 6/4. I have no problems inhaling at these pressures at all, but I'm used to them.

I agree with what Robysue has said and would like to add a little to it. There are some of us to whom neither side of this equation is bothersome. My pressure is 20 and my ramp starts at 4 (never bothered to change it). I use the ramp and never feel suffocated nor do I feel like I am being blown off the planet at my full pressure. As Herb points out, even 20 cm/H2O is not really that high a pressure except maybe when one is trying to keep a mask sealed.

Obviously some are more sensitive to this than others. It makes me wonder, however, if the suffocation feeling may not also be a function of flow restriction in the mask and the speed of one's inhalation.

Best Regards,

PaytonA

[Sleepster]

In my opinion it does no one any good to tell a newbie who has not even started therapy that their titrated pressure is too low or too high to ever be comfortable.

I agree completely. It's counterproductive to do so.

And it's certainly not a valid reason for preferring a APAP to a CPAP, as it seems to me was being done in this thread. What APAP's do is allow people who need higher pressures to spend more time at lower pressures where they are more comfortable.

Here's an example. It was determined during the sleep study that I needed 13 cm of pressure to keep my airway from collapsing. The problem for me is that at that pressure I swallow lots of air. This was so uncomfortable that it actually caused pain that was keeping me awake at night.

It turns out that the only time I need a pressure of 13 cm is when I sleep on back. I don't normally sleep on my back, but I was so exhausted during my sleep study that I actually fell asleep on my back for awhile, and it was at this time that the tech had to raise the pressure to 13 cm to keep my airway from collapsing.

Now I'm perfectly happy with a pressure of 12 cm, because I never sleep on my back.

If it were necessary to raise the pressure to 13 cm or higher to keep my airway from collapsing, but that higher pressure caused discomfort or pain for whatever reason, a doctor might prescribe a APAP. Or, if other complications had arisen, the doctor may have found it necessary to switch me some other kind of machine.