First Sleep Dr. visit after starting CPAP

[klm49]

Greetings fellow "cpaptalkers" I started CPAP 4/8/2016 after having a Sleep Study done followed by a Titration done at a Sleep Clinic. I was extremely impressed with the Clinic and the Dr. My initial study showed 21.6 AHI (/hr) and the AHI was 1.2 at the conclusion of the Titration study.
I can say that I have made progress but am still having to take a nap in the afternoons usually because I don't seem to get enough sleep the night before. There has been 6 or so days where I managed to make it all day without a nap. I have only had one night where my AHI was over 5 and usually it is 2 or less. I get some exercise as I take care of Youth Soccer fields year round. The first week I started CPAP I had a day or so where I felt really rested, but not many since then. My main concerns are my arousals (RERA) and snoring as indicated on Sleepyhead. I was afraid my Dr. might get upset at me so I did not bring up Sleepyhead and results with him. I did not want to lose my machine. Apparently he found nothing in my data to concern him and made no changes to my settings. He did order equipment for an overnight oximetry report which I will pick up today. His main concern was that the DME supplier had not been giving me replacement cushions and had the schedule for a full new mask every 3 mos. He said the cushions need to be replaced every 4-6 weeks. He said the leaky cushions might be causing me to not be refreshed. I dont see much change in leak rate in sleepyhead. Unfortunately he told me that he was going to stop taking Medicare so it sounds like I have been kicked to the curb as it were. I am sure if I have a bad oximetry report he will follow up on that. I have COPD so my SPO2 levels arent that great to start with. During the Sleep study my Sao2 minimum was 76% and avg. was 88 with Sa02<89% of 37.1. During my Titaration min Sa02 was 86% and avg. was 92% with Sa02 <89% 1.4. I would appreciate any comments/suggestions anyone can make. My main questions are should I be concerned about my RERA's and what can be done. I am posting a recent nights Sleepyhead data:



Any help appreciated. My machine is an APAP in CPAP mode, should I possibly be using it in APAP?

[Pugsy]

In cpap mode the Respironics machines don't flag Flow Limitations...so the absence of any FL flags doesn't mean much here. I would suggest for sure changing to APAP mode no matter if you use a range of pressures or continue to use a fixed pressure.
I think having the FL flagging available is something we need to see especially with your snores and RERAs showing.

If you switch to APAP mode and want to use a single non auto pressure...just set the minimum to equal the maximum and it will function like cpap mode but the FL flagging will be turned on and I am betting you will see some FLs get flagged when you see the snores and RERAs flagged.

Now..about the RERAs...and the snores...when you are seeing those that means that the pressure is not quite holding the airway open as good as it was doing when you don't see those clusters of snores or RERAs.
Why the probable need for more pressure only during those times...probably either you were on your back or possibly REM stage sleep because with either it is common to have our OSA be worse and/or need more pressure. From the pattern shown I would think REM sleep but it could be supine sleeping or maybe a combination of both.

So you need a little more pressure during those times of the night and not the other times.
You can either use a little more fixed pressure all night or set the machine in apap mode with a minimum and maximum range so that the machine can go up as it senses the need only during those times of more pressure needs.

The AHI is nice and low...and if you are sleeping great and feeling good then there's no urgent need to change anything but with your reporting still needing to nap...if it were me I would try to clean up the report a bit and see if reducing those clusters of RERAs, snores and hyponeas (and I would bet you see some FL clusters too if FL flagging was turned on) helped my sleepiness during the day.

I personally prefer to not use higher pressures all night (and at this point we don't know how high you might need) so I would try apap mode and let the machine sort it out if it were me.
Should you find that the variations in pressure when using apap mode cause a problem...cross that bridge should it happen. Most often the problems might be some aerophagia (air in the belly causing pain) or big pressure changes making leaks worse or causing a person to wake up. You may or may not have those problems...not everyone will have those problems with auto adjusting pressures.

I have been in this situation...had reports like yours because my OSA is worse in REM sleep and I sometimes would need significantly higher pressures in probable REM sleep. I would see the pressure climb to 18 cm from 10 cm....I sure didn't want to use 18 all night just to cover the REM sleep.

If it were me I would try apap mode with a small range to start with and see what happens...like the minimum being what you are using now and the maximum 2 cm above that.

[LSAT]

Is your sleep doctor affiliated with the DME?

[klm49]

Pugsy, Thanks so much for the reply. After having read/lurking on the posts here I had sort of come to the conclusion that APAP might be of value. I really dont understand why the Dr. prescribed me an APAP machine if I just use CPAP on it? I hope I didnt mislead you, I am not sleeping all that great. I wake up 3-5 times a night usually to reposition my mask or scratch my nose. I woke up once thinking the machine wasnt working, but it was. I cant even tell there is pressure on inhale and only slightly on exhale. I think I am not fully adjusted to sleeping with the head gear yet.

[klm49]

LSAT, No DME and Dr. are not affiliated. The Dr. does supply machines and cpap supplies from his office but he told me that it was against Medicare rules for Dr. to also be the DME so he gave me one near my home. When I told him what the DME's schedule for supplies was he sort of got mad and his comment that them wanting to give me a new mask every 3 mos. and no cushions in between was pretty dishonest in his book. He said they do that because they make more money off of a mask than cushions in his opinion. The DME called me when they got his prescr. for the oximetry study and I mentioned the cushions to the lady and she told me they do the 3 mo. thing because people change masks a lot when starting CPAP. She did agree to start giving me the cushions monthly. I don't know who to believe, but as long as I get what I need Ill be happy! This is all new and confusing to me. I didn't figure out till last Dr.'s visit that "Medicare Compliance" is only done once in the 1st. 31-90 days, after that they just keep paying.

[Pugsy]

Some docs just don't routinely prescribe apap mode for any number of reasons but they may prescribe it just to have it available...and sometimes DMEs will dispense apap routinely because they can set it to cpap mode (if that is what the doctor put on the RX with a fixed pressure). An apap capable machine is a cpap so they aren't doing anything wrong by dispensing an apap capable.

I don't know that what we see on your report which indicates sub optimal pressure only during those clusters is responsible for the poor quality sleep or not...but it could be a factor.

There is some truth to it taking time for our brains to get used to sleeping with the mask and machine to where the brain doesn't keep waking us up multiple times during the night with a nudge saying "hey dude, do you know you have an alien plastered to your face?" It took me several months to get totally past those sorts of wake ups.

It's also normal to wake up a few times in the night for no apparent reason. Most of the time we don't remember those wake ups but if you are remembering 4 or 5 or more...I am betting there were even more that you don't remember. We can't expect to eliminate all of them (like it's normal to awaken after REM stage sleep) but we can at least try to improve on the things that could maybe stand improvement.

Do you take any meds of any kind? If so, what?
Sometimes meds have side effects that cause wake ups or cause us to be drowsy during the day.
I take a pain pill that comes with a "may cause drowsiness" sticker but I can't take it at night because it also causes insomnia. It never causes me to be sleepy...but the insomnia is a known side effect in a small percentage of people who take that med. Sometimes you have to did deep in to the side effects to see if by chance meds are impacting things. Not saying that meds take the entire blame but they could be a factor.

Whatever the cause of the wake ups during the night...the more we have then the more we have a chance of our overall sleep quality being poor and when sleep is poor quality we are just going to want to take a nap to help us out. Also hours of sleep...I had a short night last night for unknown reason...woke up earlier than I wanted and couldn't go back to sleep and I have no idea why I woke up early.
In terms of OSA therapy I know that I have it optimized but I know I will still likely have a strong urge to take a nap at around 4 PM...

Finally....sometimes it is just something that we have to "give it time" for the body and mind to come to where they feel at peace with this alien on our face but I always figured we might as well investigate other possible culprits for not sleeping so great while we are "giving it time". Might get lucky and stumble upon something that helps. In your situation...at least there is something showing on the report that might...stress the might...be a culprit is less than optimal sleep quality and it's sure worth investigating and trying to fix it just in case you get lucky and fixing a very minor sub optimal therapy situation results in sleeping a little better.

Up to you to decide what you are comfortable doing or not doing but at the very least...change it to apap and set minimum to maximum to see what the FLs show.

[Sonnyboy]

LSAT, No DME and Dr. are not affiliated. The Dr. does supply machines and cpap supplies from his office but he told me that it was against Medicare rules for Dr. to also be the DME so he gave me one near my home. When I told him what the DME's schedule for supplies was he sort of got mad and his comment that them wanting to give me a new mask every 3 mos. and no cushions in between was pretty dishonest in his book. He said they do that because they make more money off of a mask than cushions in his opinion. The DME called me when they got his prescr. for the oximetry study and I mentioned the cushions to the lady and she told me they do the 3 mo. thing because people change masks a lot when starting CPAP. She did agree to start giving me the cushions monthly. I don't know who to believe, but as long as I get what I need Ill be happy! This is all new and confusing to me. I didn't figure out till last Dr.'s visit that "Medicare Compliance" is only done once in the 1st. 31-90 days, after that they just keep paying.

Resmed put together a nice fact sheet showing the Medicare schedule.

http://www.resmed.com/us/dam/documents/ ... sories.pdf

[Hang Fire]

I didn't figure out till last Dr.'s visit that "Medicare Compliance" is only done once in the 1st. 31-90 days, after that they just keep paying.

Not correct. Once every year you will have to get a doctor to certify to Medicare that you are compliant.

[klm49]

Hang Fire, When I was researching it on internet I didn't see the yearly mentioned, but it would make sense.

[klm49]

Pugsy, I take the following daily:
Symbicort
Lisinopril
Simvistatin
low dose aspirin
I use a "Rescue Inhaler" as needed but I dont think it does anything so I rarely use it.

[klm49]

Sonny Boy, Thanks that pretty much echoes the ones I had found on the internet.
The list my Dr. gave me says FFM cushions every 4 wks, max. of 8 weeks and hose every 3 months, max 6.

[LSAT]

Sonny Boy, Thanks that pretty much echoes the ones I had found on the internet.
The list my Dr. gave me says FFM cushions every 4 wks, max. of 8 weeks and hose every 3 months, max 6.

That list is over kill.....Most masks do not wear out very often..they are plastic....the cushions need periodic replacing. My personal mask is 18 months old and my cushions last 8-10 months...sometimes longer.. Hoses last forever.....When you follow that schedule only the DME makes out$$$$. You should however, have a back up of everything...just in case. When your doctor recommended that, I assumed that he was part of the DME and getting his share of the $$$.

[palerider]

Sonny Boy, Thanks that pretty much echoes the ones I had found on the internet.
The list my Dr. gave me says FFM cushions every 4 wks, max. of 8 weeks and hose every 3 months, max 6.

just because you CAN go buy new tires for your car every month, doesn't mean you SHOULD!!!

same with cpap supplies. there's no reason to throw away money replacing perfectly good parts.

my first mask *frame* lasted for a good four years... I had to replace the headgear three or four times, and a couple parts of it.... but replacing a mask every few months, just because I *could* or because someone trying to sell me stuff said I should? that's crazy.

[Sonnyboy]

Sonny Boy, Thanks that pretty much echoes the ones I had found on the internet.
The list my Dr. gave me says FFM cushions every 4 wks, max. of 8 weeks and hose every 3 months, max 6.

just because you CAN go buy new tires for your car every month, doesn't mean you SHOULD!!!

same with cpap supplies. there's no reason to throw away money replacing perfectly good parts.

my first mask *frame* lasted for a good four years... I had to replace the headgear three or four times, and a couple parts of it.... but replacing a mask every few months, just because I *could* or because someone trying to sell me stuff said I should? that's crazy.

Palerider you are absolutely right but you never know when your DME is going to foul up an order or how long it will take them to get it fixed so I recommend accessing backups early in the game and then you don't need to continue reordering just because you can.

[RogerSC]

Yeah, my DME originally tried to follow the Medicare list. I ended up with a lot of backup nasal pillows, cpap filters, and so on. It wasn't too long before I told them to ask me what they should send and not just send the maximum that Medicare will reimburse. Once I have a couple of backups, I'd rather the DME store the rest for me in future instead of having a closet full of unused cpap supplies here *smile*. This has been an ongoing process, involving me sending stuff back occasionally when I already have backups...I mean, how many hose and humidifier tanks, etc. do you need, anyways?

It pays to keep an eye on those DME's *smile*. They'll send a lot of stuff that you probably don't need, since they make a profit on everything that you keep. And if you see what they bill Medicare as opposed to what Medicare pays them, it is ridiculous...but that's a whole other issue. I've speculated in the past that they take those differences as tax losses, otherwise why bother to bill what they know Medicare (or other insurer) won't pay?