Which APAP? S8, S9, Intellipap, or System One?

I've never done PAP therapy before, and I'm trying to figure this out with a variably foggy brain, so please correct any errors in my reasoning and tell me the things I'm missing. I'm paying for this out of pocket and have not done a sleep study, hence I don't know what pressure I'll need. I've only considered the four machines in the title because they seem to be the most popular and there is plenty of information about them. But I'd be willing to consider other options if you've got something better.

I've rejected the PR System One because of the way Respironics handles exhalation relief. I understand that the pressure comes back before you're done exhaling to allow a sub-therapeutic pressure while exhaling and still keep the airway open. That's not a bad idea, but I suspect I might be one of those who can't tolerate it. I tried simulating this by pinching my nose partway shut at the end of each exhalation, and it triggered a fight/flight response after just a few breaths. Given that my immediate goal for therapy is to give my adrenal glands a rest, this is not promising.

To simulate using a machine without ER, I pinched my nostrils most of the way shut all the way through exhalation. Lying down and breathing steadily this way, I became quite relaxed.

To simulate the mini-bipap style of ER used by Resmed and DeVilbiss, I pinched my nostrils most of the way shut at the beginning of each exhalation, and then eased up to to partway shut. This was also relaxing.

Obviously I don't know how any of this relates to actual forced-air PAP therapy, but it makes me think I might be better off without C-Flex or A-flex, even if I have to set a higher minimum pressure to keep my airway open. Also, I haven't seen any complaints about EPR or Smartflex, but I've read reports from several people who felt rushed to inhale by the Respironics machines.

I've eliminated the S9 because of complaints on this forum that with optimistic AHI readings consistently in the low tenths or even zero, the data is useless. Even if I had had polysomnography, I'd still need data from home to do this properly. Seasonal allergies are a significant component of my respiratory problems, and hence I expect I'll need to tweak my settings occasionally as my airway changes.

That leaves the S8 and the Inteillipap.

Noise is a concern, and the Resmed claims 2db less (about 13% less loud), but if the manufacturers can't even agree how to measure AHI, I seriously doubt they're all measuring noise the exact same way. There's a lot more to it than the distance from the noise source, and without a complete and rigid standard for acoustic measurements, the numbers published by different companies are completely useless for comparison. Often it's the quality rather than the quantity noise that determines the annoyance factor anyway. Both machines are reported as quiet by users, but I haven't yet run across anyone who has tried both.

S8 Autoset II
Pro:
+More data? I thought it recorded breath by breath flow and pressure data, but I read a post recently that made me think I was wrong about this.
Con:
-Proprietary and now obsolete data card, reader, and cable. A strong indicator of pointy-headedness at Resmed. Possibly a problem with Windows XP Pro x64. Likely a major headache with Linux.
-More expensive, even for a used machine.

Intellipap Autoadjust:
Pro:
+Customizable ER waveforms
+Customizable events
+SD card
+Software known to run in Virtualbox
+Less expensive.
+End user support. DeVilbiss even has reps on the forums.
Con:
-Can't see low-level data
-Complaints that the humidifier is hard to open
-Pug ugly

It's a shame that the Intellipap gives you the ability to customize how it responds to flow measurements but does not show breath by breath data so that you can see exactly how the machine and your body respond to each other before and after any tweaks. If only they'd write that data to the card! ATM, I'm leaning toward the Intellipap anyway, but I'd like some feedback from people with more (any) experience with these machines.

I came down to trying to decide between the S9 and Intellipap. I ended up withthe intellipap. I have no problem with the humidifier. Looks weren't important to me. I think they are both good machines.

Larry

I have 2 Respironics APAPs, one with C Flex, one with AFlex. There are different settings for each and a person can even turn them off. I use AFlex now, the rhythm is so much like my own natural breathing I don't even notice the pressure. Exhaling against pressure is not as difficult as you might think. Depends on the pressure and the person. My minimum is 10 and my maximum is 18. I have no problems and it has never made me feel rushed.

The people that I have heard complain about being rushed were using CFlex at 3 and the rhythm was too fast, if they turned it down, they did just fine.

Whatever you get if you are self treating and self titrating the software will make it go a whole lot smoother.

Thanks Pugsy. Your post made me go look up Aflex again. http://aflex.respironics.com/

It says "Set minimum pressure at 6 cm H20 to enable A-Flex." Does this mean that the minimum must be exactly 6 cm, or that it must be at least 6cm? And does the pressure stay down until you start to inhale?

I'll definitely install the software. Not sure if I could get Respironics EncorePro working under Linux, but at least they've got a 64-bit Windows version.

Just got my Intellipap Auto and although filling the humidifier is unusual it is by no means hard. Filled it the first time over the kitchen sink using a Styrofoam coffee cup and didn't spill a drop. The tank is removed from the humidifier and handled on its own. Technically can't help you yet but 2 decibels of sound is totally negligible audibly - your mask will make more noise than the machine will (at least mine does). Never seen the S8 up close and personal but the S9 AutoSet is two pieces and much wider than the De-Vil'-biss with its integrated humidifier 'under' the the main unit. I have heard good things about the S8 and the same goes for DeVilbiss. To each his own. Good luck with whichever you choose.

I am not one of the "pros" on this site but I think you have overanalyzed the different machines. You will find many thousands, probably hundreds of thousands, using all the machines you mentioned and doing well with the therapy. Like most things in this world none of the machines are perfect. I have the S9 and noise just is not a problem. There is no noise from the machine even if you have it within 12 inches of the bed! Have you ever tried xpap therapy? Reading any forum on any device (TV, Cars, xpap) will certainly help guide you in the right direction but you should not think that just because a few people post a negative about any machine that it is a POS. I would be happy with any of the units you mentioned. Have you been to a DME to see and touch the various models? How are you going to buy one without a prescription? I would be more concerned about a mask that will work for you!! If you have never had a sleep study how do you know that xpap is the answer?

Bob

Otter wrote:It says "Set minimum pressure at 6 cm H20 to enable A-Flex." Does this mean that the minimum must be exactly 6 cm, or that it must be at least 6cm?

It means the minimum pressure setting must be at least 6 to use A-Flex. Doesn't have to be exactly 6...can be more.

Otter wrote: And does the pressure stay down until you start to inhale?

No. Even with A-Flex, the pressure will start back up before the exhalation is entirely finished. But... A-Flex makes the whole thing so smooth (much smoother to me than C-Flex alone) I doubt most people even notice the smooth transitions. A-Flex feels like very natural breathing in and out to me. I have to realllllly concentrate to pick up on the changes while A-Flex does its thing.

Of course everyone is different.

My thoughts about a couple of things you mentioned in your first post (excellent post, by the way, Otter!!)

About your partially closing the nostrils experiments...

Otter wrote:Obviously I don't know how any of this relates to actual forced-air PAP therapy, but it makes me think I might be better off without C-Flex or A-flex, even if I have to set a higher minimum pressure to keep my airway open.

Having used C-Flex, A-Flex, and EPR with and without "EasyBreathe", I believe those attempts, creative as they were (you're a lab-rat in the making...I can tell...and that's a good thing!) cannot feel anything like what those various exhalation relief features feel like when a person is actually breathing through a mask with them. Many (probably most) people find any of them quite comfortable. And many are surprised, as the night goes on, to find that even without any exhalation relief feature at all breathing with CPAP air coming in feels effortless enough that they have to put their hand up to feel the exhaust vent air shooting out, to believe the machine is even on.

Otter wrote:I've eliminated the S9 because of complaints on this forum that with optimistic AHI readings consistently in the low tenths or even zero, the data is useless.

Well, I don't subscribe at all to that complaint that a few others have raised. Nor would I characterize the change ResMed made in how the S9 defines hypopneas as giving "optimistic" AHI totals. I sure wouldn't rule out an S9 at all based on any of that, if it were me.

The one thing I would not want, if I were getting an S9, is the "climateline" hose or the H5i integrated humidifier for it. I'd get the Aussie heated hose and the Fisher & Paykel HC150 humidifier to use with an S9. I use those two items with any brand/model machine I have. Handy whenever I switch to another machine. Less expensive in the long run since if I buy a different machine, I don't have the expense of buying a proprietary hose/humidifier each time if I want great rainout control with heated humidification.

Rested Gal and I are on the same page with AFlex. It is hard to describe but I really don't feel much resistance. Of course I have been doing this a long time but way back in the beginning with the CFlex I was able to exhale just fine and in fact early on I would often put my hand over the vent to confirm there was air still moving. The body does get accustomed to the pressure rather quickly. First few times might feel a bit weird but it is funny that what seems like a gale when we first start, winds up feeling like the machine isn't even on by morning.

When I got the APAP with AFlex, course just had to try it and it was a pleasant surprise that while CFlex was okay, AFlex was more natural. I use AFlex of 2. I never feel rushed or short of breath. I have never tried ResMed's EPR though. Never had a chance to use it. Each one goes about the relief differently. Some people who have had one and tried the other may have a preference.

Side note. I used my APAP with CFlex to home screen my sister and brother in law. They easily adapted to it and in fact at my setting the machine at minimum of 4 complained about not enough air moving. That was more of a problem than the exhaling against the pressure. You would have to know my sister. I can say this because I know she won't read this but she is a big weenie. They each did 3 nights on the machine. She didn't appear to have any events or pressure increases in response to events but her husband did. Pretty definite but he is still in denial and won't use it.

Do I think Respironics is better than ResMed? Heck no. They will both give very good therapy. I chose Respironics way back when I started because the software for it gave me more information than ResMed did at the time. Now they pretty much report the same thing and ResMed lets you zero in and expand time lines for more details. Respironics software doesn't.

Good luck in your decision and treatment. Lots of work but totally worth it.

My two cents here as a former user of the S9 and a current user of the System One (BiPAP Auto).

1) I would NOT go with the S8: Older technology AND a proprietary data card. The deal breaker for me would be the proprietary data card: The card needs a specialized card reader; the card readers are not easy to find---particularly here in the states. When I was moved from APAP to bi-level, I gave very serious consideration to the Resmed VPAP Auto 25, which is based on the S8 as well as the PR System One BiPAP Auto. My DME would have ordered either machine for me. I took a long time making this decision. A whole lot of things went into that decision. But the deal breaker for the VPAP Auto 25 was that proprietary data card. I worried greatly about that: What to do if/when the card fails? How to get my hands on a card reader? And while the card readers were still available last fall from web-based Australian DMEs, some of their web pages indicated they could not ship them to US customers.

2) EPR on both the S9 and Flex on the System One can be turned off if need be. The S9's EPR was reasonably comfortable for me, although I was sensitive enough to detect its rise in pressure right near the end of each exhale. The BiFlex on my System One BiPAP was very uncomfortable because I did notice that the rise back to full EPAP pressure happened sooner than the rise in the Resmed EPR algorithm. However, at my current pressures (min EPAP = 4, max IPAP = 8), I don't miss Flex at all now that I turned it off.

3) The S9 and the System One are both reasonably quiet. I personally notice more noise with the System One, but that's mainly because its hum is at a bit lower of a frequency and I've got a mild to moderate high frequency hearing loss in one ear and a moderate high frequency loss in the other ear. So the S9 is just "harder" for me to hear anyway.

4) The on-board LCD data on the S9 runs rings around the System One's on-board data. Gives you enough information to make reasonable decisions about whether leaks may be a problem and whether the pressure setting may need to be tweaked even if you don't download the (free) ResScan software to look at the detailed data. Of course, the System One does have minimal data on board and you can legally obtain the patient oriented software to look at the full detailed data. When I was making my initial decision between the S9 APAP and the System One Auto, the difference in one-board data and the free software wound up being the critical things that lead to getting the S9. And part of me really wishes that I'd been able to adjust to APAP. [But I really do better on the BiPAP for several reasons that I won't get into here.]

5) Try to get the DME to let you actually try breathing with all three machines that you considering so that you can compare them for yourself. Or at least see if the DME will let you listen to all three machines with a hose and mask attached to them.

cortez356 wrote:I am not one of the "pros" on this site but I think you have overanalyzed the different machines. You will find many thousands, probably hundreds of thousands, using all the machines you mentioned and doing well with the therapy. Like most things in this world none of the machines are perfect.

Of course. My hope is to get one whose imperfections are not a major problem for me personally.

Have you ever tried xpap therapy?

No, but I'm new at this, hence the questions.

Reading any forum on any device (TV, Cars, xpap) will certainly help guide you in the right direction but you should not think that just because a few people post a negative about any machine that it is a POS.

I didn't say anything about any of these machines being a POS. But this is a major purchase that I'll have to live with for while, and I'm trying to avoid hitting myself in the head later and saying, "If only I'd known.." All of these machines are probably great for most people. Each of them is probably horrible for someone. If there's on that's horrible for me, I'd like to figure that out ahead of time and get something else. If you think that is over-analysis, you and I approach the world in very different ways. Thanks for your thoughts, though. I need all the help I can get.

Have you been to a DME to see and touch the various models?

No, I'm doing this online because the locals' prices are too high. I wasn't very impressed with them when I took my mother in to get her setup a few years ago, anyway. I suppose I could go look, but I'm tired all the time and it's a bit of a drive. This could be very useful for masks, though.

But though it sounds very simple, realistically, a trip to the local DME would probably slow me down two weeks. Between the things I must do and my chronic exhaustion, I'm stretched that thin. I wound up in the ER recently because of problems with my adrenal glands that I suspect are due to years of untreated OSA. Maybe not, but it's one problem I know I have, so I'm starting there. (I'll see an endocrinologist in June if I haven't improved.) It's spring, my allergies are already acting up a little, and if I don't get moving on this I think I'll be in serious trouble.

How are you going to buy one without a prescription?

I'm not. My doctor was glad to prescribe the machine for me.

I would be more concerned about a mask that will work for you!!

I am too. I have a beard and need a full face mask, so that may be complicated. That's another thread, though.

If you have never had a sleep study how do you know that xpap is the answer?

I'm not sure that it is THE answer, but it's part of the answer. I have plenty or risk factors, and have been carefully managing the airway I have with herbs, antihistamines, saline, a humidifier, etc. I trained myself to sleep only on my side years ago to reduce my snoring, and I can no longer sleep on my back at all. Maybe that's just because it's become unfamiliar, but I'm sure enough that it's apnea to gamble the purchase price of an apap rig. I've been certain that I have OSA for a couple years now simply because I wake up struggling for breath sometimes. Though I kept putting off doing something about it partly because I'm too tired to keep up with the world, and partly because I didn't want to have to wear the mask, now I am eager! How's that for a diagnostic criterion?

The sleep study would wind up costing me better than three grand. And while it would give me much better data than I can get from a machine at home, it couldn't include the variables introduced by my allergies. I've discussed this with a respiratory therapist, and he thinks it's reasonable to proceed, self/auto titrating without a sleep study.

It looks like you've done your homework.
I have a PR 1 that my insurance purchased and an Intellipap which I purchased (they are 1/2 the price) I use them interchangeaby and like them both. Have never tried the S9 but from what I hear, it's very good and it seems like it is the choice of the majority here (too expensive for me though). I don't think you could go wrong with any of them.
The masks are another issue and Im still trying different masks in search of the "perfect mask". A leaky mask will ruin a nights sleep. I prefer nose pillow masks but use my FFM when my nose is plugged. Plan for some trial and error. This is where your DME can come in handy since they should be able to have you try on a number of different masks until you find one (or with me two) that work well.

Go with the Resmed S8 APAP. Good machine. I survived on one for years and did extremely well on it. Its durable and works. Its data capable. It does not detect centrals, but who cares? Its a little louder than the S9 and modern machines, but again, who cares? You wont notice it once you are getting good sleep.

Intellipap I am personally curious about, know nothing about it. I have a phillips respironics A-flex APAP as a backup but have not used it much and it seems more like an old school APAP like the S8 Resmed...durable, fast response to apneas and hypopneas, a little cheaper than Resmed gear. I figure my next APAP will be another Phillips Respironics. I dont think Resmed will be around more than about five more years going by what I am seeing of their latest stuff and their corporate attitude towards their customers.

Eric

Otter wrote:

cortez356 wrote:How are you going to buy one without a prescription?

I'm not. My doctor was glad to prescribe the machine for me.

Mine was too, and I had never even been a patient of his.

Otter wrote:

cortez356 wrote: If you have never had a sleep study how do you know that xpap is the answer?

I'm not sure that it is THE answer, but it's part of the answer. I have plenty or risk factors, and have been carefully managing the airway I have with herbs, antihistamines, saline, a humidifier, etc. I trained myself to sleep only on my side years ago to reduce my snoring, and I can no longer sleep on my back at all. Maybe that's just because it's become unfamiliar, but I'm sure enough that it's apnea to gamble the purchase price of an apap rig. I've been certain that I have OSA for a couple years now simply because I wake up struggling for breath sometimes. Though I kept putting off doing something about it partly because I'm too tired to keep up with the world, and partly because I didn't want to have to wear the mask, now I am eager!

The part I emphasized in bold red sounds like how I was thinking...

Otter wrote: How's that for a diagnostic criterion?

Sounds good to me.

Otter wrote:The sleep study would wind up costing me better than three grand. And while it would give me much better data than I can get from a machine at home,

I thought that way, too.

Otter wrote:it couldn't include the variables introduced by my allergies. I've discussed this with a respiratory therapist, and he thinks it's reasonable to proceed, self/auto titrating without a sleep study.

I don't have allergies, and I didn't discuss it with anyone (you were smart to do that) but... what you're planning to do sure worked well for me.

My story - why/how I started using "cpap":
viewtopic.php?p=5977#5977

EricinNC wrote:I dont think Resmed will be around more than about five more years going by what I am seeing of their latest stuff and their corporate attitude towards their customers.

I gather that most manufacturers see the DME's as their actual customers, and end users as "compliant" herd animals following orders. That is an extremely annoying attitude that I hope will change as the people who actually use the machines vote with their feet. Hence the point for DeVilbiss.

Thanks, all. You've given me a lot to think about.

Robysue, you could have been typing straight out of my head. The proprietary data card on the S8 sounds like something I'd regret.

I'm afraid that even if the low AHI thing isn't an issue, the S9 is still out unless I can find a much better deal. With the humidifier and whatnot, the PRS1 winds up being only about 60 bucks more than the IP with the Smartlink module, $160 if I actually buy the software. But the best deal I've found for the S9 is more than $400 over the PR1. Too bad, as I've heard great things about viewing data on the S9's own screen.

If A-flex is a much more domesticated animal than C-flex, though, the Philips machine is back in. How exactly is the pressure relieved on the Philips? They say it's not he same for every breath. Is there a valve, or does the blower just slow down in a less regulated fashion than in the mini-bipap style machines?

It's now DeVilbiss vs Phillips. I think both can run of 12 volts if needed. Intellipap has end user support (indicating a much more healthy corporate attitude), and is more customizable, but doesn't give as much data. System One has better data, but costs a bit more. The basic choice seems to be between control, and the data that would help me understand how to use that control. Both are appealing to me, but I can only afford one machine.

Would I actually use the low-level pressure and flow data, or do I just imagine that because I always want to know as much as I can about everything? I never really outgrew my "terrible twos".

The ability to change events and waveforms on the IP appeals to me because if there's anything I don't like about the way it works, I'll probably be able to fix it. But as has been pointed out, the more limited settings on the PR1 do work for most people.

Hmmmm.