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CPAP pressure changes
Here's an interesting study out a few months ago which showed that weather changes, particularly atmospheric pressure lowering can increase obstructive events. These results are similar to studies that where performed in high elevation.
It just goes to show that your effective xPAP pressure needs to be constantly changing, since the "real" AHI is also changing, depending on the weather, nasal allergies, nasal congestion issues, what and when you just ate, sleep position, etc. I've always been a little suspicious about eyeballing one constant pressure setting based on an entire night's reading. More reason to use autoPAPs more frequently, but that's another major discussion in itself.
It just goes to show that your effective xPAP pressure needs to be constantly changing, since the "real" AHI is also changing, depending on the weather, nasal allergies, nasal congestion issues, what and when you just ate, sleep position, etc. I've always been a little suspicious about eyeballing one constant pressure setting based on an entire night's reading. More reason to use autoPAPs more frequently, but that's another major discussion in itself.
Views: 52
Replies to This Discussion
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Permalink Reply by BeeAsleep on
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I use an APAP. (ResMed S8 Autoset II with an EPR of 2). My pressure setting from the sleep study was 12 for 29 events an hour. Most nights the pressure readings are 10.5-ish to 11.8 -ish. I do wake up when the events happen. I can see what time it is when I wake up, and I see the event reflected in the software program the next day. Wouldn't it be better to set it at a straight 12 and be done with it? I am interested in your thoughts on this. Much thanks!
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Permalink Reply by Steven Y. Park, MD on
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I see your logic in this. The key is to experiment and be mindful of what happens. Setting it at 12 at a constant pressure may be an option, but again, experiment. You should also run it by your sleep doctor to see what he or she thinks.
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I am lucky, I do have a board certified sleep doctor. He did mention moving my APAP to a straight 12 as an option. My therapy seems to be working, with the numbers anyway. Always less than 5 . I just don't like waking up every night over and over at the same time. I will tinker..... and make sure he is ok with my tinkering. Thanks. b
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Permalink Reply by Banyon on
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There is a CPAP user who travels heavily and feels sure his sleep apnea is worse when he is in cities with high humidity. I believe it is the case in Seattle that barometric pressure and humidity level are inversely correlated. I wonder if the study controlled for humidity levels?
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j n k said:Anything that makes my nasal passages swell makes me have to crank up my pressure a few cm. When I can breathe easily, 12/8 does me just fine. Throw a handful of ragweed at me during the day, and I am a 14/10 man. Give me a cold virus on top of that, and I'm gonna be a 16/12 easy.
Banyon, I wonder if he tends to spend more time in AC in the high humidity locations, making the lack of humidity more the issue than the humidity? Just a thought.
As for his experience, I don't know. His observation only brought up the question of whether the study Dr. Park referenced controlled for outdoor humidity or humidity in the controlled environment of the sleep lab or both.
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Permalink Reply by Judy on
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Oooh! Dr Park! You instigator, you! *wicked grin* Advocating APAPs. Tsk, tsk, obviously you are NOT a favorite of the local DME suppliers!
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Permalink Reply by Dan Lyons on
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I hate to say this, but this information is 9th grade science.
If a person owns a barometer, or for that matter, watches the weather on TV, they should have heard the meteorologist give the local barometric pressure.
Everything is oriented off of the air pressure at sea level, or 29.92 in Hg.
Barometric pressure is constantly changing, hence in meteorological world; there are high-pressure and low-pressure areas (remember the L’s and H’s on the maps?). With these variants in the pressure also come changes in the density of the air itself - humidity.
With the advent of environmental controls inside structures or living environments, these variables can swing wildly from one local to another.
The phases of the moon also effect the air pressure resulting is wide swings.
If the adjustment for current air pressure were not an important factor, then why have the manufacturers placed data corrections in the setups for altitude?
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Permalink Reply by Mike on
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i agree that pro active experimentation is key to success with CPAP, at least as things stand now. I also respect Dr. Park for advocating additional use of autoPAPs -- controversial stand.
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Just to clarify, I'm not advocating routine use of APAPs. There are situations when it's a good option. Just like everything else in life, it depends on your situation. As for the pressure issue, as Dan pointed out, any basic CPAP machine self calibrates to the set pressure. There must be something else going on that causes xPAPs not to work as well in high altitudes or lowered pressures. One possibility is that the relative rapid lowering of atmospheric pressure can irritate the nose, causing congestion, with lowers the effective pressure, even if the pressure is constant (upstream from the nose). If you think about it, you're not really measuring the true pressure in the throat. Also, if your true AHI changes due to these weather changes (or sleep position, and even sleep stages), then a constant pressure is not the most ideal. So in theory, an APAP should be able to adjust to these changes based on your real time AHI.
As for the APAP issue, there are two ends to the spectrum: not enough people are being considered for APAP, whereas some people are using it unnecessarily. It's a tough call, and unfortunately, there won't be a consensus for a while. We know in in some European countries, CPAP compliance and usefulness is very high, with the vast majority on regular CPAPs. Ultimately, it's the level of pre-CPAP counseling, preparation, follow-up and support that determines if you can benefit from your xPAP machine. Once you've gone down the checklist of things to try, then an APAP is another option. For some people (like Mike), it'll work great, but there will also be others where APAP doesn't make much difference. I see both ends.
What's also important is that the xPAP machine have full data reporting capabilities, and this should be standard in all models. This is something that I strongly recommend, with the information being readily accessible to the patient if they want it. I think you'll have to agree that if the sleep community did a much better job of counseling and support, more people would be able to benefit from regular CPAP machines and the APAP machines would be reserved for certain predefined situations. In this era of medical fiscal responsibility, this makes sense. Focus on the basics first. I also wish that there are better set guidelines as to who gets APAP—right now it's pretty arbitrary.
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Ahhhhhh, Dr Park!!! If only MORE in the sleep profession believed this way and acted accordingly!!! *sigh* You are one of my true heroes for the quoted statements alone!!
Steven Y. Park, MD said:
... Just to clarify, I'm not advocating routine use of APAPs. There are situations when it's a good option. Just like everything else in life, it depends on your situation. ... If you think about it, you're not really measuring the true pressure in the throat. ... As for the APAP issue, there are two ends to the spectrum: not enough people are being considered for APAP, whereas some people are using it unnecessarily. ... We know in in some European countries, CPAP compliance and usefulness is very high, with the vast majority on regular CPAPs. Ultimately, it's the level of pre-CPAP counseling, preparation, follow-up and support that determines if you can benefit from your xPAP machine. ... What's also important is that the xPAP machine have full data reporting capabilities, and this should be standard in all models. This is something that I strongly recommend, with the information being readily accessible to the patient if they want it. I think you'll have to agree that if the sleep community did a much better job of counseling and support, more people would be able to benefit from regular CPAP machines and the APAP machines would be reserved for certain predefined situations.
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isn't the problem the very thing that you cited, that the insurance companies pay out the same amount either way to the DME irrespective of whether it's an APAP machine or CPAP machine? That way the incentive is for the DME to increase its margin by providing the cheaper machine, which is the straight CPAP. Now, if the insurance companies were on top of this issue, they would in fact provide the reverse incentive: make the APAP cheaper than the straight CPAP -- that way the DMEs would be incentivized to provide the APAP to all patients over the straight CPAP, thereby providing the "insurance" you speak of in the case of cutting out a NPSG or two, which right then and there saves the insurance company thousands of $$$s. I'm not advocating one way or another. Just pointing out the financial logic at play.
j n k said:Hmmm.
Actually, these days, doesn't an APAP cost only about $75 more than a full-data CPAP (according to internet prices comparing an Elite II to an AutoSet II)? So wouldn't it be worth every penny of that for every patient, even if most run the APAP in straight CPAP mode 99.9% of the time? Couldn't that $75 for titrate capability be considered a sort of "insurance" against the possibility of "needing" a new NPSG, with all the associated costs, office visits, and waits for openings at already crowded sleep centers? To my way of thinking, that would be the very definition of fiscal responsibility, now and in the future, industry-wide.
Aren't APAPs the same insurance code as CPAPs? So doesn't insurance pay out the same amount either way?
APAPs for all patients, I say, even if they are mostly run in CPAP mode for the majority.
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well said. i think we might also shift some of the blame to the manufacturers as well as the insurance companies and DMEs --- i.e., there's enough blame to go around: the manufacturers could lower the prices they charge DMEs on the APAPs to the point that the APAPs are cheaper than the CPAPs. then we'd see a lot of changes. given economies of scale and how far they're coming with the automation technology in these units, I see that as a pretty realistic scenario. of course, i might get some push-back trying to get the CFO of Respironics to come around to that way of thinking ;-)
j n k said:That's my point exactly, Mike. If a doc goes ahead and writes the Rx for an APAP every time, why would insurance care? In fact, that should make insurance happier because of the potential savings. But most docs remember the old days when APAPs were cutting-edge technology and much more expensive than CPAPs, so most, if not all, assume they would get in trouble for writing APAP Rx's all day.
When I asked my sleep doc to write my Rx for an APAP, his answer was: "Insurance often won't pay for it." Why does he think that? I don't know. He wrote "patient may use an APAP" on the Rx. Why? I assume it is fear. Fear of whom? And again, why?
I think it must all be one big misunderstanding among all the parties in the "transaction." That's all I can figure.
I think that Dr. Park, by the way, is exactly right in every point he makes above, and he summarizes the primary issues perfectly. I am only using the subcontext of the statements to point out what I believe to be an industry-wide misunderstanding that is, as usual, about money. Dr. Park has obviously found some effective ways to get around those misunderstandings. And as Judy points out, more doctors need to learn the things Dr. Park has learned and is willing to say 'out loud' in a way that other doctor's should learn from.
jeff
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