Replies to This Discussion

Permalink Reply by RockRpsgt on May 2, 2009 at 4:46pm

jnk the AASM also thinks that RRTs don't need anymore training to be able to get sleep certified. or anyone else in the medical industry for that matter. Not that the AASM is wrong, but everything they say is open for interpretation and debate. They are not a perfect governing body. We can quote them, and bring up post all day. This post was to get patient's opinions not the AASM's. As a sleep tech I am perfectly aware of where they stand.

j n k said:

Duane,

Did you miss this post (below), which is the statement of AASM's stand on autos?

jeff

(ps: No, I don't work in the industry. I am a patient. With an autobilevel. That works. Great. :-))

j n k said:

For any who might want to argue with the AASM:

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2225554 :

Practice Parameters for the Use of Autotitrating Continuous Positive Airway Pressure Devices for Titrating Pressures and Treating Adult Patients with Obstructive Sleep Apnea Syndrome: An Update for 2007
An American Academy of Sleep Medicine Report


. . . These devices may aid in the pressure titration process, address possible changes in pressure requirements throughout a given night and from night to night . . .

. . . certain APAP devices may be initiated and used in the self-adjusting mode for unattended treatment of patients with moderate to severe OSA without significant comorbidities (CHF, COPD, central sleep apnea syndromes, or hypoventilation syndromes); (6) certain APAP devices may be used in an unattended way to determine a fixed CPAP treatment pressure for patients with moderate to severe OSA without significant comorbidities (CHF, COPD, central sleep apnea syndromes, or hypoventilation syndromes); (7) patients being treated with fixed CPAP on the basis of APAP titration or being treated with APAP must have close clinical follow-up to determine treatment effectiveness and safety; and (8) a reevaluation and, if necessary, a standard attended CPAP titration should be performed if symptoms do not resolve or the APAP treatment otherwise appears to lack efficacy. . . .

. . . there are some assumed or potential limitations associated with PSG-directed CPAP determinations. These include the cost and inconvenience of repeat PSG due to incomplete titrations, the potential bias of in-laboratory versus in-home environment, and the potential to prescribe pressures that are not suitable due to the inherent limited sampling introduced when titration takes place over only one, or in the case of split-night studies, one-half night of recording. Pressure requirements may change over time due to variability in weight, change in underlying medical conditions, or resolution of upper airway edema caused by repetitive apneas.3–5 One night of titration to eliminate respiratory events that occur during REM sleep or in supine positions may yield a therapeutic pressure estimate that is higher than that needed on average for effective therapy.6,7 Although some have suggested that higher pressures may hinder compliance in certain patients, in general there is little evidence to suggest that higher pressures systematically lead to worse compliance.8,9 Nonetheless, the desire to improve the efficacy and comfort of treatment and to simplify or improve pressure titration has inspired the development of autotitrating positive airway pressure (APAP) devices.9 . . .

. . . Polysomnography directed CPAP titration is still the standard method for determination of effective CPAP pressure.
. . .

. . . A download of information from the APAP devices may reveal useful information, such as excessive mask leak, or an excess of apneas or hypopneas, which may guide decisions for further evaluation or treatment. . . .

Duane McDade said:

what the heck are you talking about ??? AASM is not standing berhind these auto machines, CPAP, Bi-LEVEL and VPAP thats what they back ...these have been proven to work. Have you been reading the lastest articals in the AASM magazine? I don't get the idea that they back these things with even a 30% approval, but that would just be the articals I choose to read. We arn't rebelious around here we just want our patients to get better. Do you work for resperonics or something I'm amazed by your zeal here! What's up Dude?
j n k said:

You and your doc aren't the first to take a stand that differs from AASM, and you won't be the last. I don't agree with them on everything, myself. And that's cool, as long as it doesn't affect anyone's accreditation.

More people may be on the same page after July 1. ;-)

Duane McDade said:

It's very plain to me that them there fancy words they be using in that there auto-pap book have got you turning cartwheels! You can believe what they write if you want this is America Still, at least it was last time I checked.
I surrender Jeff, I can't and don't want to pull up web sites to prove my point, I didn't say I just saw Bigfoot, or anything like that. I do these Sleep Studies almost every night, and thats my reference guide. I just hope they feed the chimps that they test these machines with you talking about, I've a good mind to call SPCA on them. The Doctor I toil under has only been in this field for 30 years , and he doesn't think too much of auto-paps too! It's your sleep do what you want, but don't try to treat the other patients here, thats all I ask. The companys that make this stuff are trying to make $ they say anything to do that. Auto needs more parameters to not just a tube and pressure sensor. It's not enough. CPAP AND BI-LEVEL RULE! AND VPAP when needed too! I'm out!

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, especially 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. And for some patients, having a slightly higher AHI but being compliant is better than being stuck at high pressures and the patient then giving up on therapy completely.

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 pressures, which I no longer need.

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 May 2, 2009 at 7:37pm

I'm going to make a suggestion: Watch WHICH Reply To This you use - or delete the whoe long repetive posts included in the upper Reply To This. Its a terrible waste of bandwidth or whatever you call it to include almost the entire thread in your reply to a thread. And this bandwidth or whatever you call it is NOT free, it is costing SOMEONE to keep this forum afloat and available.

Speaking of which - the internet is running out of "space" and they expect "brown outs" to start in 2010. This is mostly due to YouTube and another site I didn't recognize gobbling up so much internet space. And the powers that be want the health care industry to start maintaining medical records online??? And the financial industry wants us to pay our bills online? Manage our finances online???

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Permalink Reply by Mike on May 2, 2009 at 8:26pm

no worries, Judy. text like this actually doesn't take up much bandwidth, so it's really just a matter of what everyone wants to do to communicate most effectively. while video like youtube does take up a lot of bandwidth, new technologies are being deployed all the time to keep up with the need. where there's demand, there will be service providers who arise to meet the demand. one of the good things about our free market society.

Judy said:

I'm going to make a suggestion: Watch WHICH Reply To This you use - or delete the whoe long repetive posts included in the upper Reply To This. Its a terrible waste of bandwidth or whatever you call it to include almost the entire thread in your reply to a thread. And this bandwidth or whatever you call it is NOT free, it is costing SOMEONE to keep this forum afloat and available.
Speaking of which - the internet is running out of "space" and they expect "brown outs" to start in 2010. This is mostly due to YouTube and another site I didn't recognize gobbling up so much internet space. And the powers that be want the health care industry to start maintaining medical records online??? And the financial industry wants us to pay our bills online? Manage our finances online???

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Permalink Reply by RockRpsgt on May 2, 2009 at 8:47pm

Sorry Judy sometimes you just get so caught up in the sport of the debate!

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Permalink Reply by Mike on May 2, 2009 at 11:11pm

i apologize if this has been brought up already, but i think there's some merit to both sides of this argument. On the one hand, I'm with Duane that these machines are too "dumb" as they stand right now. Think about it: the machine doesn't know until it's too late -- until you already have had the apnea event -- that it needs to up the pressure. It's purely reactive, not proactive. But on the other hand, I think the future of auto-adjusting machines is bright -- i can see the day in the not too distant future when they displace CPAP altogether. I think that day will have arrived when the APAPs are smart enough to detect on a breath-by-breath basis what is going on with airflow, and to raise the pressure proactively to eliminate the apnea before it occurs. The machines sort of have to predict the future, and react just in time to save the patient any arousal. Or are there machines out there that already do that and I'm just not giving them enough credit?

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Permalink Reply by RockRpsgt on May 2, 2009 at 11:49pm

Not sure Mike. I think that would be a question for Rock Conner. They might have something via the respiratory side. I would be very interested to find out.

Thanks everyone who participated or will continue to participate in this post! All in fun and education.

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