"please keep me updated about oximeters "
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Adjusting air pressure.
How do you adjust the air pressure of the cpap machine? I have a remstar plus from respironics.
Views: 202
Replies to This Discussion
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Permalink Reply by Preston Jones on
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Thank you. This was just what I was looking for.
j n k said:Some of the professionals on this board prefer that I not give out that information directly. But the informatin is freely available in many locations on the internet, as discussed in the following link:
http://www.apneaboard.com/CPAP%20Adjustment.htm
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Permalink Reply by RockRpsgt on
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Welcome to sleepguide Preston. I wish you luck on your therapy. I hope that you and your physician have a good realationship. It is important that he/she knows about the changes that you are getting ready to make. I would like to talk to you about the dangers of over titration. No your probably not going to pop a lung.
The damage caused by overtitrating is one of long term. Our lungs are pretty amazing in the fact that they are comprised of organic material with a great deal of elasticity. There are quite a few different theories out there right now on the long term effects of PAP therapy. I have spoken to several RTs who seem to think that long term CPAP may actually damage the lungs over a period of time. I work with an RT that will do anything to get his pts on Bpap for this reason. Overtitrating will at times cause your lungs to over fill. Not all of the time, but part of the time. This action will cause your lungs to stretch, stress, and eventually weaken. Once they become weak they will begin to harden. This in turn will cause them to lose the elasticity that makes them work so well. The result would be a more limited lung capacity or volume.
http://www.healthsystem.virginia.edu/internet/anesthesiology-electi...
I am not against tweaking. I actually believe that it is the only way to achieve 100% effectiveness in PAP therapy. Just make sure that you understand the process. Changing your pressure without your docs knowledge transfers the liability from them to you.
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jnk you may be right. You may also be wrong. The true effects of over-titration are still out. To say that PAP therapy has no effect on lung volume would be the disinformation here jnk. I am not speaking out against self titration. I just think that anyone that self titrates should have all of the knowledge to do so. You and anyone else giving random people whom have not demonstrated the required knowledge could actually hurt their therapy. Just because a risk is small in no way takes away from the need for it to be taught to those that chance it. The side effects of medication are slim, yet they are still told to us.
There is a long term study on the effects of PAP therapy. It is being very well guarded by the docs at Stanford. Wonder what they found. Almost all of the studies that I have read on the long term effects of PAP therapy have ended with "more research should be done".
That was a good link from rested gal.
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I did not imply anything. I just asked a question. This was not an attack on you, Stanford, or tweaking. PAP therapy does effect the gas exchange that goes on in your lungs, as does sleep. Just because it is not an overwhleming effect does not take away from it. The AARCs entire premise for RTs in sleep is that PAP therapy does effect the respiratory system. CPAP and Bpap are used in hospitals to assist in pts with respiratory failure. That is a fact. To say that PAP pressures are completely insignificant in lung function would be the true mis-information here jnk.
http://www.ncbi.nlm.nih.gov/pubmed/17492379
Non-invasive ventilation.
Masip J.
ICU Hospital Dos de Maig, Consorci Sanitari Integral, University of Barcelona, Barcelona, Spain. jmasip@ub.edu
Non-invasive ventilation (NIV) refers to the delivery of mechanical ventilation to the lungs using techniques that do not require an endotracheal airway. Essentially, there are two modalities: continuous positive airway pressure (CPAP) and pressure support ventilation (NIPSV). In acute pulmonary edema (APE) both modalities have shown a faster improvement in gas exchange and physiologic parameters with respect to conventional oxygen therapy. CPAP is a simple technique that may reduce preload and afterload, increasing cardiac output in some patients. It has been successfully used in APE in the last 30 years, demonstrating a reduction in the intubation rate and mortality. The most common level of pressure is 10 cmH(2)O. NIPSV is a more complex mode that requires a ventilator and experience. It is usually applied with an expiratory pressure (EPAP or PEEP), resulting in a bilevel pressure modality (BIPAP). This technique has been introduced most recently in APE and has also shown a reduction in the intubation rate and a tendency to reduce mortality. The inspiratory help may be particularly useful in those patients with fatigue and hypercapnia. However, this hypothetical advantage over CPAP has not been demonstrated in comparative trials. The ventilator is usually set at 5 cmH(2)O of EPAP and inspiratory pressure between 12 and 25 cmH(2)O, although initially, the level of pressure support is lower. It is essential to achieve a good adaptation and synchronicity between the patient and the ventilator, reducing leakage to a minimum. The use of facial masks, high FiO(2), and sedation with opiates are complementary maneuvers that may be recommended in this context in the majority of patients.
Just because a doc sends a pt out the door with an auto setting of 4-25cmwp does not make it right. You yourself have argued against this. Right now there is no knowledge needed to self titrate other than the button combination. That right there is the true fault with self-titrating.
j n k said:Don't be silly, Rock. You and I both know that even at present no "knowledge" is needed for a patient to be trusted with an APAP that is set up so that it can go as high as 25 cm whenever it feels like it for however long it wants to.
And if Stanford had seen ANY early indications of danger to patients in their study, there fine ethics would have required them to go public with that information immediately. Shame on you for implying otherwise. ;-)
jeff
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jnk, I am not going to argue with you anymore. You saying that you are sure of my implications on these matters is purely totalitarian. I did not say that long term use of PAP was dangerous. I said that we do not truly know. My original post was on the dangers of over-titrating. you have taken my words out of context once again. What do I know though. Good luck with your sleep career. I am done
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Now, now, boys. jnk, I hate to part company w/you at any time - BUT "I" do not believe in publicily posting the instructions for changing therapy settings. I've shared access to the Clinicians Menu and shared many a Clinicians Manual - BUT - I've done so PRIVATELY, via PM or e-mail and that is the way that "I" believe that particular information should be shared. NOT PUBLICLY.
There are those who just can't resist playing w/their new toy just because they learned how. Whether it does them harm or not I'm not going to get into. BUT it CAN lengthen the time it takes them to get acclimated to xPAP therapy if they are changing things willy-nilly w/o any idea of what they are doing and why.
I didn't buy into that at first - but - I've since read posts by more than one ditz who didn't have the SLIGHTEST idea of what they were doing or why. And a couple of them I just plain gave up on as just too .... whatever to ever understand and grasp the fundamentals.
So, I say share all the info you want and God bless you for it, but I would prefer to see you share some of that info privately.
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I still love you jnk. I have said it many times. I find much humor, and education in the disagreements on the finer points of our aggreements. I did not mean to lash out on you. My frustration was probably due more to my current situation than to your post.
As for whether or not I agree with the Rts in question I can't say. I truly don't know. I have had conversations with many RTs and pulmonologist on the possible risks of CPAP on lung elasticity. All agree that this possible risk could be higher in cases of over-titration. They all stress to me that the industry and the insurance companies should put more emphasis on the use of Bpap. My doctors will NOT send anyone out of our lab with a high pressure in which a need has not been proven. Very few of our pts are put on APAP. When they are the parameters are leashed as you suggested.
I will apologize if indeed I did scare anyone. That was not my intention. I do not have anything against tweaking your therapy. I just believe that a certain amount of knowledge should be demonstrated prior to receiving that information. That knowledge should include the inherent risks. This does not matter if the are theoretical or proven.
As far as complete self titration, or trial by autopap it can be done. I have seen and read wonderful results found in controlled lab environments. Those results are not truly indicative of self or auto titrations though. In the real world we do not have controlled environments. Most people that go this route do so alone. Compliance with this type of therapy outside of a lab environment is very poor. Overall PAP compliance is less than 45%. Meaning that there are millions of unused PAP units sitting in closets. I believe that everything should be done to educate the public on the benefits and possible risks of treatment. This sometimes is going to put me in a bad light as not all of the information I learn is going to be positive.
jnk I am a human elephant. I forget nothing.
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I probaly should have added this to my original posting. Most of the docs in my sleep network are pulmonologist. We are taught to calculate lung volume (VTE) for all of our pts undergoing a titration study. This knowledge can be helpful in finding optimal titration pressures. It can also be very helpful in preventing over-titrations.
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I do not fully understand the concept behind this as of yet jnk. i am sure that I will get a greater understanding of it as we go along. When a pt is first put on the low pressures of PAP their VTE is generally much lower than what it should be. As we approach event cessation typically the VTE will reach optimal volume. this is due to the pt getting the need o2. At high pressures we are basically shoving or forcing air into the airway. If the air is to much it will result in leaks, lip purging, or the inhalation of too much air. I mean it has to go somewhere right? We have all inhaled to much air at some time or another. It usually hurts all the way down. In some pts we can see the results of too much air in the vte as it will spike. typically we will also see arousals, centrals, or a drop in co2 in these pts. these last events are common in overtitrations. If in conjunction with those we see spikes in VTE then common sense tells me that they are related.
j n k said:How?
I don't get the relationship between volume and pressure in that context and how it relates to possible "over-titration."
Of course, I probably still won't "get" it even if explained to me. But it would be interesting to hear anyway.
jeff
Rock Hinkle said:We are taught to calculate lung volume (VTE) for all of our pts undergoing a titration study. This knowledge can be helpful in finding optimal titration pressures. It can also be very helpful in preventing over-titrations.
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That's my guys!!! Yep, I do love the two of you both very, very much. And I do so love your sharing information. Where the heck would I be w/o you two?? jnk, I'm so glad you "got" what I was so clumsily trying to say. NEVER stop sharing, just some privately, most publicly.
And now, Rock Hinkle, you have me FASCINATED by this VTE mention since I have COPD and haven't the SLIGHTEST idea of my lung volume as compared to "normals", etc. All the time I spend educating myself on OSA, xPAP and Crohn's and I don't spend any on COPD. Altho I always get copies of my PFTs and spirometries I don't understand one freaking thing about what the abbreviations and numbers mean. And haven't bothered to learn.
My Resmed VPAP Auto reports Tidal Volume and Minute Ventilation but I don't even have the slightest idea whether either is higher or lower which is better, an improvement or not so good as the night before, etc. My VPAP Auto doesn't report Flow. I know my 95th percentile Respiratory Rate tends to run 22-23 which is higher than the 12-20 "norm" so understand its good when sometimes it is lower, like 21. And I never could wrap my head around the differences between the Mean and the Average. Duh!
Resmed ResScan Definitions
Tidal volume = the volume of air inspired or expired in one respiratory cycle (breath)
Respiratory rate = the frequency of breathing, expressed as the number of breaths per minute
Minute ventilation = the volume of air breathed in (or out) w/in any 60 second period
Flow = an estimate of the air flow entering the lungs. It is derived by taking the total flow and then removing the leak and the mask vent flow components.
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Permalink Reply by Stephane Bergeron on
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Rock Hinkle said:Very few of our pts are put on APAP.
Could you explain to me why that is Rock? You know, as we've talked about it before, that I have insisted on an APAP myself. Especially after I found out that my prescribed fixed pressure would have been 15. I could not fathom how I could have tolerated such a high pressure of air continuously blowing in my face or nose. I would have tried my very best to get used to it but I'm not sure I would have succeeded even if I know many people do it.
Now with my APAP, I have been 100% compliant for nearly 2 months now with great numbers to boot. My doctor was very happy about it and was not surprised and didn't mind that I tweaked my low pressure a bit. I'll see the technologist at my DME next week so she can explain the reports to me in detail. I'm actually looking forward to it as I hope to learn more than I already know about it. For instance, my AHI has never been above 3.9 and those nights that it happened, it was the Vibratory Snores that brought the numbers up. Yet my wife tells me I never *audibly* snore anymore and my quality of sleep has dramatically improved (I used to move a lot while sleeping, twitches, spasms and stuff like that... no more). So I'd like to know what she thinks about that (and what you think too if you have ideas on the subject).
Now I cannot say what my numbers and the effects of my therapy would have been if I'd been on a fixed CPAP but I believe I would have struggled adjusting to it a lot more. I also cannot say how my titrated pressure would have been if I had been in a controlled environment. All I know is that, with my APAP, my pressure usually varies between 6 and 8 and sometimes 9 with very occasional peaks at 10 or 11. So I'm sure that 15 would have been exaggerated as a fixed pressure.
Everyone's case is different of course but my experience would favor the use of APAP for most unless they have conditions that would be better treated with a CPAP. For me, using an APAP has made it a lot easier to stick with my therapy.
Rock Hinkle said:Compliance with this type of therapy outside of a lab environment is very poor. Overall PAP compliance is less than 45%.
Wouldn't it be even the more reason to make patients' therapy as comfortable as possible so people have a better chance to stay with it? To me, that means an APAP unless there are medical reasons to not use one like increase of central apneas and other factors I don't know about. But again, everyone is different and there are probably people who do prefer the feel of a fixed pressure but, even then, an APAP can be set that way so why not let patients try both and see for themselves what works best for them? I don't believe this decision can be made in one night during a sleep study.
My $0.02 CAD ;)
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Comfort of therapy is the key to all succesful titrations Stephane. Everyone's case is different. Some will do better on APAP while others adjust better to a fixed. Our docs will use APAP on pts whom are REM specific, need high pressures, or have positional problems. The problem that i see is that patients are being sent out of the lab with APAP settings of 4-20cm with no follow up for 6 months. You were sent out on 4-15cm. More effort needs to be put into monitoring this typ of therapy so as to give the patient a better chance. Had you not changed your pressure yourself, how long do you think you would have lasted?
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