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How Dangerous are CPAP Machines?
Peter Farrell, the Founder of ResMed, is notorious in the Sleep Medicine establishment for saying “The only way you can get injured by one of our machines, at least the low level ones, is if somebody picks the goddamn thing up and slams you over the head with it.”
But still RTs and other sleep professionals cringe at the idea of letting a patient adjust his or her own pressure settings, based on the notion that high pressures can kill you. Furthermore, they say that no amount of disclosure to the patient of possible risks will justify letting the pressures change without a doctor's say so.
What's the truth?
Views: 14940
Replies to This Discussion
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Permalink Reply by D. W. Conn on
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Over titration is a real issue and yes it can do harm. I would rather cut off my left leg then have to agree with an RT but alas just this one time. and to all my RT pals..im just kidding I would only cut off my finger.
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Permalink Reply by RockRpsgt on
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LMAO
D. W. Conn said:Over titration is a real issue and yes it can do harm. I would rather cut off my left leg then have to agree with an RT but alas just this one time. and to all my RT pals..im just kidding I would only cut off my finger.
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Permalink Reply by Mike on
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D.W., you and Rock have my implicit trust. At least with you guys I know you're coming from the right place, your hearts (not your wallets)
D. W. Conn said:Over titration is a real issue and yes it can do harm. I would rather cut off my left leg then have to agree with an RT but alas just this one time. and to all my RT pals..im just kidding I would only cut off my finger.
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Permalink Reply by Kath Hope www.hope2Sleep.co.uk on
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Totally agree, but am confused as to how a patient would know if centrals increase. Do certain machines show this?
j n k said:Overtitration is a nonissue.
When pressure choices are put in the hands of the patient, the patient naturally wants pressure as low as possible but high enough to prevent events.
If the patient can do simple addition and subtraction on a first- or second-grade level and has a full-data machine, the patient would see AHI go up if overtitration occurred and centrals increased, and the patient would then go the other direction to achieve the lowest AHI. It's that simple, that easy.
And that concept has been documented scientifically:
"This study demonstrates that self-titration of CPAP in patients with OSA is as efficacious as manual titration in a sleep laboratory, with similar subjective and objective outcomes, and CPAP compliance. Clearly, for this strategy to be successful, the patient must understand when and how to change the CPAP."--American Journal of Respiratory and Critical Care Medicine, Vol 167. pp. 716-722, (2003) "Can Patients with Obstructive Sleep Apnea Titrate Their Own Continuous Positive Airway Pressure?" by Michael F. Fitzpatrick, Christi E. D. Alloway, Tracy M. Wakeford, Alistair W. MacLean, Peter W. Munt and Andrew G. Day.
http://ajrccm.atsjournals.org/cgi/content/full/167/5/716
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Thanks for that descriptive reply, which will no doubt help others too. I, personally, tweak my own machine fairly often - especially now the nasal stuffiness is back after the turbinates op :( Hope my ENT surgeon has something else up his sleeve to offer when I see him on Tues. What I didn't know was that some machines show which were likely centrals as opposed to obstructive events. Can I trouble you to ask which machines do this please?
j n k said:Home machines that report AHI will report apneas (whether central or obstructive) as apneas. In fact, home machines happen to be great at catching apneas, as long as leak is under control.
Some newer machines will even differentiate between the two, telling you which ones were likely centrals and which ones were likely obstructives. But that differentiation isn't needed when self-titrating, really. And here's why . . .
If you raise your pressure and your numbers get worse over the next week or two, even just a little bit, you simply lower your pressure back down. In fact, if you raise your pressure and your numbers stay the same over the next week or two, and you don't feel any better either, you simply lower your pressure back down. Some have found that they feel better at a pressure lower than that prescribed, and if the numbers don't get worse and the patient still feels good, that should be fine.
All that being said, it is always best when the doc is on board with what any patient does, so I am not suggesting that anyone out there ignore advice from a doc. I am just a fellow patient passing on what fellow patients with cooperative docs have found has worked for them.
Self-titrating CPAP is much easier, and safer, than a diabetic titrating his own insulin day to day, after all, as most all insulin users have to do.
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Thanks for this JNK - truly grateful and I shall be doing some investigations :) Good Night from the UK. Kath
j n k said:Some machines use the "forced oscillation technique," or FOT, to estimate likelihood of an event being central, as described in the following white paper from ResMed:
http://www.resmed.com/us/assets/documents/product/s9_series/1013916...
Machines with that capability are available here in the US in the Philips-Respironics PR System One line of machines and in the ResMed S9 line of machines.
Note that the System One calls the likely centrals "clear airway apneas." ( http://advancedeventdetection.respironics.com/waveforms.aspx ) That is a particularly honest way to put it, in my opinion, since it is only the measured status of the airway that the home machines use to judge whether there may have been a central component to the event. That method is not as accurate as using effort belts around a patient's belly and chest, as is done during a nocturnal PSG. That industry-standard, gold-standard method allows for events to be labeled as "mixed," as well. FOT is better than nothing, and a useful thing to do--just not as good as PSG.
I would not base the purchase of a machine on that feature alone, since, as I mentioned earlier, as long as all events are being scored in some consistent way, that is enough trending information to self-titrate, whether the patient knows if any particular apnea is mostly central in nature or not.
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What if instead the over titration causes more events? Over titrating deos not always end with central apneas. More often it will cause RERAs before centrals(unless you live at any type of elevation). These events would show up on the data as hypops. How do you suggest this be eliminated through self titration?
I do not think that the true long term effects of CPAP or overtitrating are known as of yet. The longest anyone has really been on a machine is about 25-30 years. the amount of people that have been on therapy this long is pretty small. The first study on this length of use is not even out yet. We are now getting people on PAP at an even earlier age. The next generation of PAP users will most likely be on PAP for up to 40 if not 50 years. to say that there is not going to be some side effects on the body with this lenght of use is a little naive. We are already seeing pts in the hospital with stomach problems that may be from long term CPAP use. I do think the therapy outweighs the effects when we talk about living a quality life.
j n k said:Overtitration is a nonissue.
When pressure choices are put in the hands of the patient, the patient naturally wants pressure as low as possible but high enough to prevent events.
If the patient can do simple addition and subtraction on a first- or second-grade level and has a full-data machine, the patient would see AHI go up if overtitration occurred and centrals increased, and the patient would then go the other direction to achieve the lowest AHI. It's that simple, that easy.
And that concept has been documented scientifically:
"This study demonstrates that self-titration of CPAP in patients with OSA is as efficacious as manual titration in a sleep laboratory, with similar subjective and objective outcomes, and CPAP compliance. Clearly, for this strategy to be successful, the patient must understand when and how to change the CPAP."--American Journal of Respiratory and Critical Care Medicine, Vol 167. pp. 716-722, (2003) "Can Patients with Obstructive Sleep Apnea Titrate Their Own Continuous Positive Airway Pressure?" by Michael F. Fitzpatrick, Christi E. D. Alloway, Tracy M. Wakeford, Alistair W. MacLean, Peter W. Munt and Andrew G. Day.
http://ajrccm.atsjournals.org/cgi/content/full/167/5/716
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You are a sexy man when you talk sleep! I really enjoy reading your post. You are one of the few that have truly tested my knowledge in this field. You are one of my favorite tweakers.
I agree with you completely.;)
I just wanted to make sure that everyone knew that overtitration is not always signified by central apneas. More often than not it will just cause arousals or fragmented sleep.
j n k said:What I meant was that over-titrating is a nonissue in the sense that it is unlikely when pressure tweaks are in the hands of the patient. No patient wants to raise the pressure without a reason. Higher pressure generally is less comfortable. Only if lower numbers or feeling better is the result will a patient raise pressure. If anything, there is a higher risk of under-titration than over-titration, for that reason. Ideally, patients titrate away RERAs by being aware of how rested they feel in the morning.
To stress my position, I think a lab titration is the most valuable thing there is for anyone with OSA. That initial titration is very important, in my opinion, to document how someone reacts to pressures. After that, small tweaks based on weeks worth of data may help how a patient feels, but that doesn't mean ignoring the information from the titration or ignoring doctors. A patient playing a more active role should not prevent the doctor and RT continuing to play their role in the medical team. The ideal situation is mutual respect and teamwork. And the basic schematic outlining the approach of the entire team should be based on a scientific, yet artistic, titration by a highly trained RPSGT. In my opinion.
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Permalink Reply by Janknitz on
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Very interesting discussion. JNK, I especially liked your point that if overtitration is so dangerous they would not send people home to auto-titrate on machines set with "wide open" pressures running 4 to 20 cm.
The beauty of allowing CPAP users to adjust their own pressures is that it engages them in the process to take an active role in their care. This can only increase compliance. Even if a too high pressure causes one or two centrals, that is certainly safer than untreated apnea.
Some people are not good candidates for being able to understand or take an active role in their care, but those who can should be encouraged to do so.
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Permalink Reply by Daniel Quarberg on
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I feel that the only way to be injured or killed by a CPAP is by not using the thing!
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The truth (as I see it) is they want to keep control over your use of CPAP. It's called job security, if we are not allowed to change the setting then we "need" them. The last two CPAPS' I bought I told them if they did not give me all the directions (they usually keep the tech instructions) and show me how to change the settings I would take my prescription and go somewhere else to purchase my machine. Both times the tech got the owner/manager and they did exactly what I asked for.
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