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I am beginning to agree with Duane.
I Am beginning to see the light Duane. I don't understand why a normal OSA patient would need an Auto titration system. It is my findings that these machines seem to allow more events then a machine with a preset system. It is almost like going through a titration study everynight. I feel that if you don't have central , complex apnea or any of the underlying causes that you should go with a straight forward system(still fully data capable). I feel that if an auto titration system is not needed, you might actually be doing yourself a great disservice by purchasing one anyway.
What does sleepguide think?
What does sleepguide think?
Views: 45
Replies to This Discussion
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Permalink Reply by The SleepGuide Crew on
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The goal is to get the patient comfortable using a pressure that is as close as possible to the pressure at which his/her apnea/hypopnea events were "zeroed out" during the sleep study. For some patients unwilling or unable to do a titration study, we can see prescribing an auto adjusting machine with a fairly wide range, say between 7 and 12, and then read the data and take it from there as to how to narrow up the range. in other words, it can be a substitute for a titration, we'd think. that said, the goal should be to figure out what that magic number is and stick to it as close as possible. make sense?
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Permalink Reply by RockRpsgt on
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No I don't understand. If a patient was zeroed out in a titration study then that should be what his machine should be set at. A machine that varies would allow for more events. Which in my opinion is not a true treatment of the problem. Kind of like only inflating my tires half way. Ok lets look at the waht you gave me. 7-12 Say at 7 the AHI is 18 and at 12 it is 4. How many hours and how many events are going to happen before this reaches 12. I don't feel that this is a good substitution for a titration.
The SleepGuide Crew said:The goal is to get the patient comfortable using a pressure that is as close as possible to the pressure at which his/her apnea/hypopnea events were "zeroed out" during the sleep study. For some patients unwilling or unable to do a titration study, we can see prescribing an auto adjusting machine with a fairly wide range, say between 7 and 12, and then read the data and take it from there as to how to narrow up the range. in other words, it can be a substitute for a titration, we'd think. that said, the goal should be to figure out what that magic number is and stick to it as close as possible. make sense?
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Just saying prescribing an auto-adjusting machine with a range of, say, 7-12, is a conceivable substitute for an in lab titration when an in lab titration is not possible for one reason or another. so what you'd do is (1) diagnose the patient with OSA; (2) send the patient home with an auto adjusting machine with a range of say 7-12; (3) let the patient use that machine for a couple of weeks; (4) analyze the data to find out where within the 7-12 range the patient experienced the fewest events -- i.e., "zeroed out"; then (5) re-set the machine at that number at which the patient was zeroed out at home and send the patient home.
what do you think of that approach?
Rock Hinkle said:No I don't understand. If a patient was zeroed out in a titration study then that should be what his machine should be set at. A machine that varies would allow for more events. Which in my opinion is not a true treatment of the problem. Kind of like only inflating my tires half way. Ok lets look at the waht you gave me. 7-12 Say at 7 the AHI is 18 and at 12 it is 4. How many hours and how many events are going to happen before this reaches 12. I don't feel that this is a good substitution for a titration.
The SleepGuide Crew said:The goal is to get the patient comfortable using a pressure that is as close as possible to the pressure at which his/her apnea/hypopnea events were "zeroed out" during the sleep study. For some patients unwilling or unable to do a titration study, we can see prescribing an auto adjusting machine with a fairly wide range, say between 7 and 12, and then read the data and take it from there as to how to narrow up the range. in other words, it can be a substitute for a titration, we'd think. that said, the goal should be to figure out what that magic number is and stick to it as close as possible. make sense?
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What about the patients that stay on auto titrating machines? I see your point, but the situation you are describing is not the one I am talking about.
The SleepGuide Crew said:Just saying prescribing an auto-adjusting machine with a range of, say, 7-12, is a conceivable substitute for an in lab titration when an in lab titration is not possible for one reason or another. so what you'd do is (1) diagnose the patient with OSA; (2) send the patient home with an auto adjusting machine with a range of say 7-12; (3) let the patient use that machine for a couple of weeks; (4) analyze the data to find out where within the 7-12 range the patient experienced the fewest events -- i.e., "zeroed out"; then (5) re-set the machine at that number at which the patient was zeroed out at home and send the patient home.
what do you think of that approach?
Rock Hinkle said:No I don't understand. If a patient was zeroed out in a titration study then that should be what his machine should be set at. A machine that varies would allow for more events. Which in my opinion is not a true treatment of the problem. Kind of like only inflating my tires half way. Ok lets look at the waht you gave me. 7-12 Say at 7 the AHI is 18 and at 12 it is 4. How many hours and how many events are going to happen before this reaches 12. I don't feel that this is a good substitution for a titration.
The SleepGuide Crew said:The goal is to get the patient comfortable using a pressure that is as close as possible to the pressure at which his/her apnea/hypopnea events were "zeroed out" during the sleep study. For some patients unwilling or unable to do a titration study, we can see prescribing an auto adjusting machine with a fairly wide range, say between 7 and 12, and then read the data and take it from there as to how to narrow up the range. in other words, it can be a substitute for a titration, we'd think. that said, the goal should be to figure out what that magic number is and stick to it as close as possible. make sense?
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in favor of staying with an auto adjusting cpap only when a narrow range fixed around the titrated/"zeroed out" pressure setting is used, not some broad range. and only then if the patient cannot tolerate the titrated/"zeroed out" pressure setting, and after comfort features like EPR and Flex at the straight titrated/"zeroed out" pressure setting are not enough to make the patient comfortable. at least that's the current opinion. could be persuaded otherwise if a principled and persuasive argument is made to the contrary.
Rock Hinkle said:What about the patients that stay on auto titrating machines? I see your point, but the situation you are describing is not the one I am talking about.
The SleepGuide Crew said:Just saying prescribing an auto-adjusting machine with a range of, say, 7-12, is a conceivable substitute for an in lab titration when an in lab titration is not possible for one reason or another. so what you'd do is (1) diagnose the patient with OSA; (2) send the patient home with an auto adjusting machine with a range of say 7-12; (3) let the patient use that machine for a couple of weeks; (4) analyze the data to find out where within the 7-12 range the patient experienced the fewest events -- i.e., "zeroed out"; then (5) re-set the machine at that number at which the patient was zeroed out at home and send the patient home.
what do you think of that approach?
Rock Hinkle said:No I don't understand. If a patient was zeroed out in a titration study then that should be what his machine should be set at. A machine that varies would allow for more events. Which in my opinion is not a true treatment of the problem. Kind of like only inflating my tires half way. Ok lets look at the waht you gave me. 7-12 Say at 7 the AHI is 18 and at 12 it is 4. How many hours and how many events are going to happen before this reaches 12. I don't feel that this is a good substitution for a titration.
The SleepGuide Crew said:The goal is to get the patient comfortable using a pressure that is as close as possible to the pressure at which his/her apnea/hypopnea events were "zeroed out" during the sleep study. For some patients unwilling or unable to do a titration study, we can see prescribing an auto adjusting machine with a fairly wide range, say between 7 and 12, and then read the data and take it from there as to how to narrow up the range. in other words, it can be a substitute for a titration, we'd think. that said, the goal should be to figure out what that magic number is and stick to it as close as possible. make sense?
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Permalink Reply by Duane McDade on
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HOLD ON YOU GUYS!! I titrate 4-8 patients a week. Try one yourself, Man! You see someone have Apneas and gasping for air like thier dying @ let's say 11cm/h20 and after the CPAP is turned up to 12 maybe just some snores with Hypopneas. Then when the pressure is uped to 14 .....BOOM all is well. SO you're going to sit there and say that an auto ranging CPAP is not going to add to this patients Apnea! I've had patients in my Lab telling me they were about to give up and just say "what the heck, i'll just die, this SH@t isn't working." DO YOU GUYS WORK FOR A COMPANY THAT MAKES THESE THINGS, OR ARE YOU JUST GOING TO BAT FOR THEM??! OK ! I'm done Thanks Rock you Rock!
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Permalink Reply by sleepycarol on
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I have an apap set to a pressure of 9 to 15. I have been able to get my AHI down to <1, and some nights it is 0. I would not want to be on a straight pressure of 15 all the time. My average is 10/11 most of the time, but the machine climbs higher on some nights.
So if I read you right, I should leave my pressure at 15, right? How would that help me? It seems it is just pushing more air into me that is not needed.
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Carol, the problem with auto paps is they don't have enough information to titrate, 9-15 is a wide range. I understand that 15 is a pressure that would be hard to deal with. The machine doesn't know what your pressure is, I will sometimes have the DME REP. adjust an auto machine to a smaller range (in your case it might be 10 -12cm/h20.) but what would be better is to ramp for 10 minutes or so.....to your pressure. It might not be 15, is that what your Doctor said 15. What is your sleep # ?
sleepycarol said:I have an apap set to a pressure of 9 to 15. I have been able to get my AHI down to <1, and some nights it is 0. I would not want to be on a straight pressure of 15 all the time. My average is 10/11 most of the time, but the machine climbs higher on some nights.
So if I read you right, I should leave my pressure at 15, right? How would that help me? It seems it is just pushing more air into me that is not needed.
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Jeff, you should not have pressure needs night to night. Your pressure is not 10 one night and then 18 the next ! its not even 15 one night and 16 the next. It's the same every night until you loose weight, get an Operation a Oral device. It's got to be something like that. Not just what mood your in. Please dont get me wrong I don't enjoy dissagrements me and my wife never have had terse word for eachother. But, These machines are playing with your well being. Don't believe the HYPE a little tube you can use for your Fish tank can not do the job! Logic will overcome. P.S. I'm not getting paid to say this there is no motivation besides everybodys health.
j n k said:Rock,
I advocate getting a sleep study with a titration. It's the right thing to do, in my opinion.
I also advocate giving an auto-titrating machine to every patient. Not so that the machine can auto-titrate every night with it set wide open. But so the patient can use the machine in a restricted range and use the efficacy data to optimize therapy effectiveness and comfort.
A titration is a snapshot of one night. A very VALUABLE snapshot that every patient needs, in my opinion, but a one-night snap nonetheless. It is a good starting point. But it is just a starting point, for many patients whose needs fluctuate over time--overnight and over the months and years.
I agree that the algorithms in the auto machines are far from perfect and that they don't work quite as advertised just yet, meaning, set wide open 4-20 cm. Used that way, you are absolutely right that the patient will have a higher AHI than using straight CPAP or BPAP. But if the data is looked at and the machine's range is restricted a bit based on that information, an APAP can be a beautiful thing.
Please note that every APAP can be run as a straight machine too. So giving a patient an APAP doesn't force the patient to use it in auto mode all the time. But it gives the patient, or doc, the ability to check to see the numbers, since APAPs are all efficacy-data machines.
I will use myself as an example. I have lost 25 pounds in 10 months. But I don't have to go in for another PSG to see if my needs have changed. I was able to see my data and see that I could lower my pressure by about 2 cm and have my OSA fully treated without suffereing from the aerophagia I had been dealing with. Do you really think my doc would have cared enough about my aerophagia to order a new PSG, or that insurance would have paid for it? No. But giving me the APAP gave me the tools to deal with my problem to increase my comfort, improve my quality of life, and remain compliant. Otherwise, I would have been stuck at the prescribed pressure.
A PSG titrates a patient for sleeping on his/her back. If I find a way to stay off my back, since my OSA has a positional component, my pressure needs are different. An auto can deal with that better than anything. Should a patient be required to sleep with the pressure needed to deal with REM in supine ALL NIGHT? That is unduly high pressure that may keep the patient from being compliant. And there is no need for that patient to deal with that.
The question is actually academic, since autos are here to stay. The only question is, do we force patients to run them wide open, 4-20, or do we teach patients how to self-titrate using the information their auto-titrating machine gives? Not every patient will understand how to do that, just as not every diabetic understands how to monitor their needs day to day either if they don't get the training they need and the support they need. So the answer is training and support. They will be the keys to future patient comfort and compliance.
For me, expecting the sleep doc to discern my pressure needs night to night, week to week, is like expecting a doc to exercise for me and plan all my meals. It's my life. I have to be the one who exercises, eats properly, and sleeps effectively. All I ask is for the tools to be able to do that and the guidance to find my way. Medicine is for the purpose of helping the patient, not getting in the patient's way. It helps the patient to get him/her a PSG. But it also helps the patient if he/she gets a full-data machine that has capabilities the patient may choose to use to be comfortable and compliant.
I fail to see how anyone who truly cares about patient comfort and compliance could argue against allowing patients to have the latest technology available to them, which the patient may choose to use or not to use.
Insurance doesn't care one way or the other, since APAPs have the same codes as stripped-down CPAPs. If the docs don't mind, and insurance doesn't mind, what possible reason could a tech have for objecting, other than, perhaps, job-security issues? ("Hey, I won't have a job if people don't have to come to the lab all the time to find out what pressures they need!")
Give the patient what the patient needs, give the patient options, train the patient, and it will all work out. Because it SHOULD be all about the patient. If it isn't, this industry is way out of whack and will go down under its own weight eventually.
jeff
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Permalink Reply by Judy on
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I've gotta disagree w/you, Duane. Of course, I'm just a patient. But we do NOT sleep the same every night. And we certainly do NOT sleep the same in a sleep lab as we do at home.
And don't misunderstand me!!! I'm a FIRM believer in full in-lab PSGs evaulations AND titrations.
BUT, what about the quality and experience of the sleep tech - who well may be "just" a sleep trainee, NOT a sleep tech, NOT an RPSGT?? A lot of labs are using sleep trainees w/one RPSGT to, uh hum, "supervise several "off the street" trainees. AND, there seem to be plenty of sleep "specialist" doctors who gorged and purged to get their accreditation and just sign off on the "tech"'s scoring w/o doing their own? The field of sleep medicine is really going thru some serious "growing pains" and for far too many sleep "specialists" is just a "cash cow".
I'm w/jnk on this one.
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The only answer I have for that is. I know how you feel Judy, but the truth of the matter is....You might not feel the the same every night, you might have a cold , a stomach ache, a headache perhaps, maybe you're worried about a loved one...I agree with you, with all my heart. The nature of your obstruction (what causes the Apnea) remains the same. I've seen it a couple of hundred times on sleep check ups, and re-titrations. If someone looses wieght or has an operation or oral device there can be a dramatic change from time to time but ones obstruction stays the same. It has the same wieght so it takes the same amount of pressure to move it out of the way. That's the math. But yes people do feel differnt every night yes. But that can't change your pressure. When your sleeping the game changes you loose your muscle tension. It's a diffrent world. You're right, but so am I
Judy said:I've gotta disagree w/you, Duane. Of course, I'm just a patient. But we do NOT sleep the same every night. And we certainly do NOT sleep the same in a sleep lab as we do at home.
And don't misunderstand me!!! I'm a FIRM believer in full in-lab PSGs evaulations AND titrations.
BUT, what about the quality and experience of the sleep tech - who well may be "just" a sleep trainee, NOT a sleep tech, NOT an RPSGT?? A lot of labs are using sleep trainees w/one RPSGT to, uh hum, "supervise several "off the street" trainees. AND, there seem to be plenty of sleep "specialist" doctors who gorged and purged to get their accreditation and just sign off on the "tech"'s scoring w/o doing their own? The field of sleep medicine is really going thru some serious "growing pains" and for far too many sleep "specialists" is just a "cash cow".
I'm w/jnk on this one.
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The reason I question this is because I had an in-lab bi-level titration in March of 08. Results: IPAP 13, EPAP 8. No mention of a high Leak rate.
I had a second in-lab bi-level titration at another lab in Oct 08. Results: IPAP 10, EPAP 5 and a chin strap the last half of the night.
No weight change. No other health issues or changes.
I was sleeping better - finally - at straight CPAP of 8 cms after some struggles from March 07 to March 08. I noticed improvement on bi-level IPAP 13, EPAP 8 in VPAP Auto mode March 08 to Aug 08 when doctor switched me to VPAP Auto in Spontaneous mode rather than auto mode. And THAT was a step BACKWARD. A disconcerting "puff" at the end of inhalation, beginning of exhalation that destroyed efforts to get to sleep and maintaining sleep that I did NOT experience in auto mode. Yet 3 doctors at the sleep lab were unable or unwilling to even discuss much less determine the cause. My DME's RT had no idea. The sleep doctor at the Oct 08 sleep lab wasn't even willing to discuss it, just do another titration. We did. IPAP 10, EPAP 5, chin strap. And STILL the disconcerting "puff" at end of inhalation and end of exhalation in Spontaneous mode. So I said "screw it" and went back to auto mode and sleep the best so far and W/O the disconcerting "puff".
Get rid of that disconcerting "puff" at the end of inhalation and beginning of exhalation and I'l be MORE THAN HAPPY to use my VPAP Auto in Spontaneous mode rather than auto mode. But NOT UNTIL.
I do have COPD and do use 2L of 02 supplementation w/my VPAP Auto. The Oct 08 bi-level titration doctor didn't order the 02. And after handing me the printed out script, he took it back and handwrote the addition of 2L of 02 supplementation.
I use the S8 ResLink and Nonin XPod oximeter and sensor every night and the ResScan 3.7 software and cable reader and have experimented w/and w/o 2L of 02 and I definitely need the 2L of 02 supplementation.
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