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Permalink Reply by sleepycarol on November 23, 2009 at 5:33pm

Mike has another site that he is building and it would be so helpful if we all took the time to add reviews to that site so that it will help people judge which providers to use.

Okay a question for Saz---

When I can't breathe I go into a major panic attack. I can not have my nose covered with anything that slows down or hinders my breathing. I can't cover my face with a sheet or blanket, can not hold my nose to duck under water, even a shower hitting me in the face even momentarily sends me into a panic. So if I have the feeling I can't breathe at 4 cm I sure am not going to be able to tolerate it for the approximately 2 minutes you indicate that it would take to increase the pressure to 6 cm, and if 6 is still too low, then another 2 minutes for it to increase to 8 -- that would seem like a life time. I was prescribed a pressure of 8 cm to 12 cm on my apap. 8 cm was still giving me a sensation of not having enough air so I reset the machine to start at 9, more tolerable for me. I know there has to be others that experience what I do, so starting at 4 cm sets them up for failure at the very beginning in my opinion. If she had a sleep study and her pressure was titrated at 14 cm it makes no sense at all to start at a 4 cm in my opinion, a lower pressure agreed would be helpful, but not a 4/6 cm. I am just a patient and not a professional so the above is just my own opinion.

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Permalink Reply by Saz RPSGT on November 23, 2009 at 6:52pm

I understand where you are coming from.

What did you do prior to using CPAP? You didn't breathe and you went into major panic attack mode...right?

So the 10 minutes it takes for the AutoCPAP to ramp up is insignificant. Keep in mind, Christine said that she is using her AutoCPAP for diagnostic purposes, it's not her machine. It's being borrowed to dial in on her appropriate pressure.

You are describing your AutoCPAP as being used on a permanent basis, not for diagnostic purposes. In the context of your use, absolutely it should be used with a more narrow window like you describe. In your case there is no diagnostic purpose for you to "suffer" through lower pressures.

So back to Christine. Lab protocol for accredited labs is for night technicians to increase the pressure for clear sleep disorder breathing events, for snoring, and for excessive leg movements. Once sleep appears consolidated you keep increasing after you see samples of supine sleep with REM. The night technician is just trying to get samples of many possible optimal pressures.

With the above in mind, Christine is in a typical situation. It's clear she needs CPAP, but the optimal pressure isn't clear from the night of the sleep study. One okay looking pressure appeared to be 14cmH20. Just so Christine doesn't suffer every night the doctor gives her CPAP at 14cmH20 and will tweak it if she is having a tough time, or until she can get a take home AutoCPAP titrating study to zero in on the best static pressure. (there a usually long waits for these take home tests, so it usually takes awhile).

With the above in mind, it's very likely that the night technician blew past a pressure that would've been great for Christine. That is why you can't just eliminate the lower pressures for an AutoTitrating CPAP home study. Often the optimal pressure is well below what the patient was initially prescribed.

CPAP titrations are somewhat of an art. It takes a keen eye and patience....and time....to get it right. Often during the night it's a baseline and then CPAP is applied in the middle of the night. This doesn't leave much time for titration even with a deft night technician.

Let me know if that makes sense at all. I think that your concern is a great discussion though. It's getting more into the nuts and bolts of sleep medicine and why treatment progresses way that it is...slow. I think the problem is that nobody explains the purpose of anything.

Instead of telling Christine, "this pressure looked best, but we're not really sure so let me know if it's not working." They say, "here, wear this." A little time in explaining the reasoning behind it goes a long way and alleviates frustration for the patient.

Saz

sleepycarol said:

use.

Okay a question for Saz---

When I can't breathe I go into a major panic attack. I can not have my nose covered with anything that slows down or hinders my breathing. I can't cover my face with a sheet or blanket, can not hold my nose to duck under water, even a shower hitting me in the face even momentarily sends me into a panic. So if I have the feeling I can't breathe at 4 cm I sure am not going to be able to tolerate it for the approximately 2 minutes you indicate that it would take to increase the pressure to 6 cm, and if 6 is still too low, then another 2 minutes for it to increase to 8 -- that would seem like a life time. I was prescribed a pressure of 8 cm to 12 cm on my apap. 8 cm was still giving me a sensation of not having enough air so I reset the machine to start at 9, more tolerable for me. I know there has to be others that experience what I do, so starting at 4 cm sets them up for failure at the very beginning in my opinion. If she had a sleep study and her pressure was titrated at 14 cm it makes no sense at all to start at a 4 cm in my opinion, a lower pressure agreed would be helpful, but not a 4/6 cm. I am just a patient and not a professional so the above is just my own opinion.

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Permalink Reply by Judy on November 23, 2009 at 7:09pm

Great explanations, Saz. At least from my perspective. I suppose we'll know best how christine and sleepycarol see it.

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Permalink Reply by sleepycarol on November 23, 2009 at 7:19pm

Yeah, my machine is an apap.

Okay, I understand I think what you are saying, but when I stopped breathing I was asleep so didn't realize I wasn't breathing, my problem would come in when I was trying to go to sleep -- at the 4 cm/6 cm I would feel like I couldn't catch my breath and then start the panic attack. So I would be unable to go to sleep as i wouldn't be able to tolerate that low of pressure prior to going to sleep.

How is that handled.

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Permalink Reply by Saz RPSGT on November 23, 2009 at 9:09pm

So for your specific needs of using an AutoCPAP on a nightly basis you would want the starting pressure to be above where you would have a panic attack.

AutoCPAPs are becoming more frequently used at home since the price of them is coming way down. I mention this because about 1-2 years ago they were only prescribed for home use when a patient was REM specific (drastic increase in pressure needs when in REM sleep) and they couldn't tolerate being on a really high pressure that was just needed for REM sleep.

Example: Consolidated sleep achieved during NREM sleep at 10cmH20. Consolidated sleep achieved during REM sleep at 15cmH20. It used to be that you would have to be on 15cmH20 the whole night even though a typical night you are only in REM for 25% of the time. With the AutoCPAP you can have your lower pressure be 10cmH20 when that is all that is required for consolidated NREM sleep, but when you enter REM it will increase up to 15cmH20 that is required. (If 10cmH20 starting is too high for someone then the RAMP feature is still available). You can also see here that there is going to be some poor REM sleep waiting for the machine to increase to the appropriate pressure. One reason a static pressure is better if you can tolerate it.

A patient being REM specific is not uncommon at all. I would almost say that it's expected.

A patient like Christine who is using an AutoTitrating CPAP for diagnostic purposes (of finding an optimal pressure) would have to suffer through the pressures where she is potentially feeling starved for air. If it's to the point no pressure can be found she would be sent out for another trial with a range of 8-20cmH20. I've never sent a patient back out with a diagnostic autoCPAP because they couldn't get to sleep. They eventually do sleep (after 20 minutes of perceived misery)and we get excellent data.

Let me know if that did or didn't answer your question.

Saz

sleepycarol said:

Yeah, my machine is an apap.

Okay, I understand I think what you are saying, but when I stopped breathing I was asleep so didn't realize I wasn't breathing, my problem would come in when I was trying to go to sleep -- at the 4 cm/6 cm I would feel like I couldn't catch my breath and then start the panic attack. So I would be unable to go to sleep as i wouldn't be able to tolerate that low of pressure prior to going to sleep.

How is that handled.

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Permalink Reply by Saz RPSGT on November 23, 2009 at 9:17pm

At this point they are using it for different purposes though. I would expect Christine to hate it if she requires a higher pressure. It's going to take awhile for her to get to an appropriate pressure. If she only requires 8 or 10cmH20, it'll basically feel like a ramp.

Carol should be loving it since it's set for her therapeutic pressure range and should be somewhat comfortable (no air starvation feeling) right when she turns it on.

By the way sleepycarol, you never mentioned the web address for Mike's new website.

Saz

Judy said:

Great explanations, Saz. At least from my perspective. I suppose we'll know best how christine and sleepycarol see it.

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Permalink Reply by sleepycarol on November 23, 2009 at 9:30pm

Saz,

I have been on my machine since August of 2007. I would not go without my machine for any amount of money. I would have to dig out my sleep study for really accurate numbers but if I remember right I was scheduled for split study but only slept only a little 2 hours so I had to go back for the titration study. The night of the titration study I slept around four hours. I was originally scripted a "smart cpap" with a pressure range of 8 - 12 cm.

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Permalink Reply by sleepycarol on November 23, 2009 at 9:40pm

This is a work in progress and I hope Mike doesn't get mad for me putting a link here:

http://www.sleepsearch.com

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Permalink Reply by RockRpsgt on November 23, 2009 at 10:03pm

Jason what I do not understand is why you would throw all the data from the titration study out the window? I understand the "hysteresis effect" and i understand that there are many reasons why even a seasoned tech might overtitrate. the titration is supposed to be one night snapshot of the pt on PAP. Why not use that data along with the APAP data to help triangulate Christine's optimal pressure? I see no need to reset to ground zero. If she was originally titrated to 14 why not start her new APAP diagnostic evaluation at a range of 7 to 17. Why ignore the data you already have? Why wouldn't the team in question look at the AHI of each individual pressure from the titration study to help figure out a better range? The faster we can show an improvement in sleep efficiency, the more likely the pt is to comply with the therapy. This to me defeats that purpose.

i do agree that it all starts with pt education.

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Permalink Reply by sleepycarol on November 23, 2009 at 10:06pm

I appreciate Rock and Saz taking time to explain things. This has been an educational thread and I have learned some things.

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Permalink Reply by Saz RPSGT on November 24, 2009 at 12:19am

Most of what I wrote about was for Christine's personal situation.

Why not reset to ground zero for Christine? Her pressure setting from the titration night is 14. It takes the Auto very little time to get there.

I routinely give patients a pressure sample at 5cmH20, and a mask leak check at 12cmH20. If at 5cmH20 they make a comment that they feel starved for air, I set them up for 8cmH20 (or higher based on history) to a range of 20cmH20. 7cmH20 is only 2cmH20 from where I would begin. That's about 2-3 minutes more of disrupted sleep with a start of 5cmH20. Why cap a patient at 17cmH20 in your example. Some people really do require and love 20cmH20 and higher. I let the machine do its job.

I don't feel that this is ignoring previous data, but adding to it. 5 nights of 4-6 hours of sleep and it's plenty of data.

All I have to do is explain how to put the mask on, since I fit it for them. Function of the machine. What their expectations should be for the night, that it won't be perfect initially. Stress that mask and mouth leaks are important to minimize. They're given either a FFM or a chinstrap and urged to use heated humidity. As you know, it doesn't take but 20-30 minutes to educate someone enough that they can take over our jobs! ;^)

One of my other facilities just ran a patient that had a 3 hour baseline. Great consolidated sleep from 5-11cmH20. They blew past that range in about 40 minutes. Yup...10 minute samples when they have 5 hours to get this person titrated. I understand 15-20 minutes increases with clear OSA, but this was supine, consolidated, and 7cmH20 even had REM. The night tech is an RPSGT and an RRT. I've been working with her for about 6 years. I have no idea what she was seeing, but mistakes happen. I say just let the patient know what to expect and let the machine do its job.

You bring up something though. I'd love to see the data from Christine's Sleep Study! That way I wouldn't be pulling these comments out of my who-ha.

Patient education patient education patient education. Why do some professionals hold onto the information like it's their first born?

Saz

Sorry for the rambling. Long day.

Rock Hinkle said:

Jason what I do not understand is why you would throw all the data from the titration study out the window? I understand the "hysteresis effect" and i understand that there are many reasons why even a seasoned tech might overtitrate. the titration is supposed to be one night snapshot of the pt on PAP. Why not use that data along with the APAP data to help triangulate Christine's optimal pressure? I see no need to reset to ground zero. If she was originally titrated to 14 why not start her new APAP diagnostic evaluation at a range of 7 to 17. Why ignore the data you already have? Why wouldn't the team in question look at the AHI of each individual pressure from the titration study to help figure out a better range? The faster we can show an improvement in sleep efficiency, the more likely the pt is to comply with the therapy. This to me defeats that purpose.

i do agree that it all starts with pt education.

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Permalink Reply by RockRpsgt on November 24, 2009 at 2:22am

Saz your way is the way it is supposed to be done. I just think that limiting the range even a little is going to be better for the pt. Using Christine as an example. She is already used to a pressure of 14cm. Our own (at least mine) experiences tell us that she is probably not going to do well at a lower pressure. Now you add those negative thoughts and uncomfort to a lonely dark room and that time becomes an eternity. Six minutes of uncomfort could seem like an hour. Christine may well be a ball of anxiety ready to explode.

Why could you not look at the titration data and say for example that Christine's AHI was 10 at 5cm. Now we are using the data to fine tune the auto range. We know that 5cm is not going to help her so why are waisting time by collecting data from that pressure. We have already proven to the doc, christine, and the insurance company that:

1-She has apnea
2-It can and at one point was probably close to being corrected at 14cm
3-Christine will benefit from PAP therapy due to the above.

When I chose my range I did so by halfing the distance to the max (20), and min (0) to come up with 7-17cm. Why not 7cm? Statistics, her titration, and the fact that she is already used to 14cm tell us that 4,5, and 6cm are probably not going to work. My plot all lies on the word probably, but it is a risk I am willing to take for pt comfort.

Lets look at the top end of my range now which was 17cm. Why not 17cm. If she was titrated to 14cm originally do you really think that she is going to be much over that. More than likely without any drastic changes to her weight, or overall health her pressure needs are going to be lower. I feel that 17 is a pretty good number. If her needs go over that you will be able to tell in your data. More than likely if her pressure needs are 20 the machine is going to hit 17. At this time and her sleep efficiency is going to increase even if just a little. Now if you go the other way and say for some reason the machine titrates itslef to 18 while her needs are actually 10. Now her efficeincy is going to decrease along with our chances at getting her to comply.

Like I said i see your point. I also understand the protocol. I just believe that the longer we keep the pt from optimal titration the greater the chance that we may lose them. This is a very interesting topic. Thanks for the convo Saz.

On a personal note go to the library and quit pulling facts out of your who-ha. There has got to be a better way to store data. Get a flash drive or smething. ;-)

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