Ok, got tired of transcribing... The link below has the 2 questions that I asked. It should stream, but if it doesn't, hit the pause button and let it buffer.
The questions were (paraphrased)
1. How accurate is a single night titration study?
2. Should we be using BiPAP for comfort/compliance?
The answers are quite suprising, especially for BiPAP.
Link Here
This opens a browser window with media player embedded, PM me if you have problems...
Questions I asked at ASAA Lecture
-
wading thru the muck!
- Posts: 2799
- Joined: Tue Oct 19, 2004 11:42 am
Mike,
Thanks for posting the actual recording. The answers were, as you suggest, very interesting and for me also very encouraging. Was that Dr Rapoport answering your questions?
He answered our perenial debate about how to set Bi-level pressures. The method that makes sense to increase comfort doesn't work and the method that works doesn't increase comfort, hence his suggestion that Bi-level machines, as an alternative to CPAP are a failure.
Great questions! ...and what a treat to actually hear the answers. THANKS!
Thanks for posting the actual recording. The answers were, as you suggest, very interesting and for me also very encouraging. Was that Dr Rapoport answering your questions?
He answered our perenial debate about how to set Bi-level pressures. The method that makes sense to increase comfort doesn't work and the method that works doesn't increase comfort, hence his suggestion that Bi-level machines, as an alternative to CPAP are a failure.
Great questions! ...and what a treat to actually hear the answers. THANKS!
Last edited by wading thru the muck! on Mon Apr 04, 2005 7:33 am, edited 1 time in total.
Sincerely,
wading thru the muck of the sleep study/DME/Insurance money pit!
wading thru the muck of the sleep study/DME/Insurance money pit!
-
wading thru the muck!
- Posts: 2799
- Joined: Tue Oct 19, 2004 11:42 am
There's MORE! Yippie! I was facinated and will listen to it many times. It would be great if Dr Rappaprt could post a little column on the forum once a month. Some little tidbit to keep us all going and reassure us that improvements are on the way.
Sincerely,
wading thru the muck of the sleep study/DME/Insurance money pit!
wading thru the muck of the sleep study/DME/Insurance money pit!
Thanks again, Mike. That was very interesting to say the least.
Dr. Rappaport's personal opinion of BiLevel is that it shouldn't really have a role in treating obstructive apnea. Rather, BiLevel should maintain its role in treating central apnea. Yes, I was also surprised to hear that!
Dr. Rappaport did later emphasize that anyone receiving successful therapy with BiLevel should not change their PAP therapy, however.
Dr. Rappaport's personal opinion of BiLevel is that it shouldn't really have a role in treating obstructive apnea. Rather, BiLevel should maintain its role in treating central apnea. Yes, I was also surprised to hear that!
Dr. Rappaport did later emphasize that anyone receiving successful therapy with BiLevel should not change their PAP therapy, however.
-
seanconnery
- Posts: 120
- Joined: Sun Jan 09, 2005 7:48 pm
- Location: British Columbia, Canada
Thanks for this - your digital literacy is commendable!
What I heard was that what I need to understand is a lot more than I thought I knew by being part of this forum. Although wonderful and full of knowledge, a lot of information needs critical scrutiny because the opinions and recommendations are based solely on personal, lay opinion. This information by others in this forum is really valuable, but when I began to hear of strong and repetitive recommendations for this and that these last two months, I began to accept them too, not realizing that a little knowledgeble may be a dangerous thing.
What is our goal in our XPAP compliance? For me, when I started, it was two-fold:
a) front of the house: feeling great in the morning, and productive throughout the day, and earning a good night's sleep, and living a little longer, and,
b) back of the house: collect the data that supports the feeling in a) for others (doctor, RT, insurance), and now me (software, monitoring, being responsible for my health through knowledge and information)
The answer session put into light what PAP makers have as a huge burden: to use the best and current research, respond to users' feedback, employ the talents of engineers, designers, respond to the medical community (which is conservative, secretive, and is wary of innovation), adhere to regulatory bodies, process the product through patent office, adhere to production timelines, be a profit centre, etc. By the time the XPAP comes to market, it is rendered obsolete because of newer emerging data from all these areas. What I find interesting is how a mfg. decides that 'comfort' becomes an addtional criteria, rises to the top of the priority list and causes unintended consequences and newer problems. Seems that defining the real problem is key and requires the knowledge and experience of someone like Dr. R, who seems very knowledgeable in the fields of the autonomic system and how to couple the 'machine' with the human body.
I learned a lot here - my thanks
What I heard was that what I need to understand is a lot more than I thought I knew by being part of this forum. Although wonderful and full of knowledge, a lot of information needs critical scrutiny because the opinions and recommendations are based solely on personal, lay opinion. This information by others in this forum is really valuable, but when I began to hear of strong and repetitive recommendations for this and that these last two months, I began to accept them too, not realizing that a little knowledgeble may be a dangerous thing.
What is our goal in our XPAP compliance? For me, when I started, it was two-fold:
a) front of the house: feeling great in the morning, and productive throughout the day, and earning a good night's sleep, and living a little longer, and,
b) back of the house: collect the data that supports the feeling in a) for others (doctor, RT, insurance), and now me (software, monitoring, being responsible for my health through knowledge and information)
The answer session put into light what PAP makers have as a huge burden: to use the best and current research, respond to users' feedback, employ the talents of engineers, designers, respond to the medical community (which is conservative, secretive, and is wary of innovation), adhere to regulatory bodies, process the product through patent office, adhere to production timelines, be a profit centre, etc. By the time the XPAP comes to market, it is rendered obsolete because of newer emerging data from all these areas. What I find interesting is how a mfg. decides that 'comfort' becomes an addtional criteria, rises to the top of the priority list and causes unintended consequences and newer problems. Seems that defining the real problem is key and requires the knowledge and experience of someone like Dr. R, who seems very knowledgeable in the fields of the autonomic system and how to couple the 'machine' with the human body.
I learned a lot here - my thanks
-
rested gal
- Posts: 12881
- Joined: Thu Sep 09, 2004 10:14 pm
- Location: Tennessee
Thank you VERY much for all the work, Mike - and for asking those great questions at the meeting. Also, thanks for the hint about hitting "pause" to allow buffering. That worked! I was able to listen to the entire answer without a hitch on good old slowww dialup. Thank you, thank you!!
I'm still surprised by Dr. R's view of bi-level machines not having a role in treating obstructive sleep apnea. It did sound at first like he was talking more about bi-level ST's when he spoke of bi-levels breathing for you, even though I didn't catch if he qualified it as BiPap ST....using a timed mode to kick in for central apnea patients. Perhaps he meant that was the bi-level's original purpose? I never could quite gather whether he meant "breathing for the patient" via a Timed mode was what the first bi-level was invented for or whether it was first invented for exhalation comfort to try to enhance compliance. I hadn't really thought of bi-levels as "breathing for you" anyway. At most, I thought of the ones with ST mode as just kicking or nudging with the timed switch - trying to jumpstart the patient out of a central apnea. I didn't think of it as "breathing for you" in a hospital ventilator sense. But, as Dr. R. said, it's a complicated subject and would have taken too much time to go into fully, so perhaps he was using some shortcut phrases.
Perhaps I'm still confused about how sleep lab titrations work, but what Dr. Rappoport said about a person being titrated at 10, and having the exhalation of the bi-level set at 10.... doesn't seem to quite jive with how Titrator explained bi-level titrations. If Dr. Rappoport was speaking only of eliminating the apneas at 10, yes. But I thought Ted (Titrator) said that after eliminating the apneas at, say, 10, the titration continues on upward until hypopneas and other things are also eliminated. In that case, the titrated pressure would be higher than what is used to stop apneas only. And in that case, the bi-level would make sense....with the lower exhalation pressure still serving to keeping the throat open (preventing apneas) AND giving relief from the fully titrated higher pressure that was needed to eliminate hypopneas, flow limitations, snores. Perhaps I still don't understand bi-level titration. I'm no doctor!!
A previous topic that contains Titrator's explanation of how a sleep lab titrates for the two pressures of a bi-level machine:
Sat Jan 01, 2005 subject: ahi numbers
It was amusing to hear the way Dr. Rappoport worked carefully around not mentioning any manufacturer by name. For example, not speaking of which manufacturer's brand he had been associated in developing, nor mentioning a manufacturer (Respironics) for having introduced the first bi-level machine under the trademark name, "BiPap".
Again, thank you, Mikesus, for providing great reports and cool audio from the lecture! Very, very interesting. Fun to hear!
I'm still surprised by Dr. R's view of bi-level machines not having a role in treating obstructive sleep apnea. It did sound at first like he was talking more about bi-level ST's when he spoke of bi-levels breathing for you, even though I didn't catch if he qualified it as BiPap ST....using a timed mode to kick in for central apnea patients. Perhaps he meant that was the bi-level's original purpose? I never could quite gather whether he meant "breathing for the patient" via a Timed mode was what the first bi-level was invented for or whether it was first invented for exhalation comfort to try to enhance compliance. I hadn't really thought of bi-levels as "breathing for you" anyway. At most, I thought of the ones with ST mode as just kicking or nudging with the timed switch - trying to jumpstart the patient out of a central apnea. I didn't think of it as "breathing for you" in a hospital ventilator sense. But, as Dr. R. said, it's a complicated subject and would have taken too much time to go into fully, so perhaps he was using some shortcut phrases.
Perhaps I'm still confused about how sleep lab titrations work, but what Dr. Rappoport said about a person being titrated at 10, and having the exhalation of the bi-level set at 10.... doesn't seem to quite jive with how Titrator explained bi-level titrations. If Dr. Rappoport was speaking only of eliminating the apneas at 10, yes. But I thought Ted (Titrator) said that after eliminating the apneas at, say, 10, the titration continues on upward until hypopneas and other things are also eliminated. In that case, the titrated pressure would be higher than what is used to stop apneas only. And in that case, the bi-level would make sense....with the lower exhalation pressure still serving to keeping the throat open (preventing apneas) AND giving relief from the fully titrated higher pressure that was needed to eliminate hypopneas, flow limitations, snores. Perhaps I still don't understand bi-level titration. I'm no doctor!!
A previous topic that contains Titrator's explanation of how a sleep lab titrates for the two pressures of a bi-level machine:
Sat Jan 01, 2005 subject: ahi numbers
It was amusing to hear the way Dr. Rappoport worked carefully around not mentioning any manufacturer by name. For example, not speaking of which manufacturer's brand he had been associated in developing, nor mentioning a manufacturer (Respironics) for having introduced the first bi-level machine under the trademark name, "BiPap".
Again, thank you, Mikesus, for providing great reports and cool audio from the lecture! Very, very interesting. Fun to hear!
-
rested gal
- Posts: 12881
- Joined: Thu Sep 09, 2004 10:14 pm
- Location: Tennessee
-
rested gal
- Posts: 12881
- Joined: Thu Sep 09, 2004 10:14 pm
- Location: Tennessee
Ahh...thank you, Mike. I'd agree that C-Flex (and presumably Soft-X, although I've never tried an Invacare cpap machine) gives a very nice drop on exhalation comfort level for people using pressures under, say 14. But when you get up into higher pressures C-Flex doesn't get the "comfort" job done.
While testing my Aura mask, I switched my autopap to operate in straight cpap mode at 20, with C-flex on its greatest relief number, "3". You might as well have been asking a sparrow to fly straight into a hurricane. C-flex did NOT work well up at a pressure like that. Not only did it feel like almost no drop in pressure at all when I exhaled, it also cut off the exhalation wayyyy too soon - less than halfway through.
People who have to endure high pressures (which I personally would define as 16 or more, but, heck, it's all relative and everyone's pressure tolerance varies) would definitely get far more comfort and have far better compliance from bi-level machines than from any kind of C-Flex, SoftX feature on a straight cpap machine.
I'm not even getting into the possibility of another kind of relief by using an autopap. Sticking just with bi-level vs cpap with C-Flex. Which I think is what Dr. Rappoport was discussing. It would be interesting to know if he would still maintain that bi-level machines have no place in treating obstructive sleep apnea for patients who are prescribed pressures of, say 17 or 18 or 19, and who have difficulty exhaling. Would he recommend CPAP with C-Flex over a bi-level machine for them?
I guess I keep wondering about this since he sounded so adamantly opposed to the idea of bi-level machines to treat obstructive sleep apnea...period. No qualifying what upper pressure limit, if any, he had in mind in his preference for C-Flex or SoftX features as being better comfort/compliance measures than a bi-level for OSA sufferers. Interesting.
If I were prescribed a very high pressure, and if my sleep disorder were such that I'd be spending most of my night "up there" (so that an autopap wouldn't be of much help), I'd sure want a bi-level machine - a BiPap. Not C-Flex. C-Flex is wonderful down at reasonable pressures. But it would not be my choice at all if I needed high pressure much of the time. Whew.
While testing my Aura mask, I switched my autopap to operate in straight cpap mode at 20, with C-flex on its greatest relief number, "3". You might as well have been asking a sparrow to fly straight into a hurricane. C-flex did NOT work well up at a pressure like that. Not only did it feel like almost no drop in pressure at all when I exhaled, it also cut off the exhalation wayyyy too soon - less than halfway through.
People who have to endure high pressures (which I personally would define as 16 or more, but, heck, it's all relative and everyone's pressure tolerance varies) would definitely get far more comfort and have far better compliance from bi-level machines than from any kind of C-Flex, SoftX feature on a straight cpap machine.
I'm not even getting into the possibility of another kind of relief by using an autopap. Sticking just with bi-level vs cpap with C-Flex. Which I think is what Dr. Rappoport was discussing. It would be interesting to know if he would still maintain that bi-level machines have no place in treating obstructive sleep apnea for patients who are prescribed pressures of, say 17 or 18 or 19, and who have difficulty exhaling. Would he recommend CPAP with C-Flex over a bi-level machine for them?
I guess I keep wondering about this since he sounded so adamantly opposed to the idea of bi-level machines to treat obstructive sleep apnea...period. No qualifying what upper pressure limit, if any, he had in mind in his preference for C-Flex or SoftX features as being better comfort/compliance measures than a bi-level for OSA sufferers. Interesting.
If I were prescribed a very high pressure, and if my sleep disorder were such that I'd be spending most of my night "up there" (so that an autopap wouldn't be of much help), I'd sure want a bi-level machine - a BiPap. Not C-Flex. C-Flex is wonderful down at reasonable pressures. But it would not be my choice at all if I needed high pressure much of the time. Whew.
-
wading thru the muck!
- Posts: 2799
- Joined: Tue Oct 19, 2004 11:42 am
RG,
I think Dr. R's point regarding Bi-level is that it fails as a substitute for cpap if the goal is to provide more comfort due to the fact that your cpap titrated pressure needs to be used as the EPAP pressure for it to be effective. I know this contradicts what many of us understand to be the method of determining pressure settings on the Bi-level, but he's the Sleep Expert. He clearly stated that the CPAP pressure has to correlate with the lower (EPAP) pressure on the Bi-level if it is to be effective. Taking this as fact, why would providing more pressure provide ANY relief from a pressure that already seems too high. I feel sorry for people given Bi-levels for this reason.
I think Dr. R's point regarding Bi-level is that it fails as a substitute for cpap if the goal is to provide more comfort due to the fact that your cpap titrated pressure needs to be used as the EPAP pressure for it to be effective. I know this contradicts what many of us understand to be the method of determining pressure settings on the Bi-level, but he's the Sleep Expert. He clearly stated that the CPAP pressure has to correlate with the lower (EPAP) pressure on the Bi-level if it is to be effective. Taking this as fact, why would providing more pressure provide ANY relief from a pressure that already seems too high. I feel sorry for people given Bi-levels for this reason.
Sincerely,
wading thru the muck of the sleep study/DME/Insurance money pit!
wading thru the muck of the sleep study/DME/Insurance money pit!
Exactly Muck. It is completely counterintuitive to give someone MORE pressure when they are already having a problem with the LOWER pressure. But some folks feel because of the difference that it is perceived lower so therefore it is a workable therapy.
RG - In the case above where you did the testing, you were in straight CPAP mode. If you are in Auto mode, you are going to get exhalation relief while you are awake (and aware of it) and once you fall asleep, it really doesn't matter.
One of the thoughts that Dr. Rappoport was floating there was this: What if you could make a xpap machine that turned on ONLY after you were asleep? Comfort issues wouldn't be a problem...
Personally I think there would be a problem breathing into a dead mask for a lot of people tho. Plus the water in the heated humidifier would really get a chance to get warm and then cause an arousal but I see where he was going with it. Once you are asleep, the pressure change for most people isn't a problem... So, in that light, an Auto with Cflex would better suit someone for comfort/compliance than a BIPAP.
RG - In the case above where you did the testing, you were in straight CPAP mode. If you are in Auto mode, you are going to get exhalation relief while you are awake (and aware of it) and once you fall asleep, it really doesn't matter.
One of the thoughts that Dr. Rappoport was floating there was this: What if you could make a xpap machine that turned on ONLY after you were asleep? Comfort issues wouldn't be a problem...
Personally I think there would be a problem breathing into a dead mask for a lot of people tho. Plus the water in the heated humidifier would really get a chance to get warm and then cause an arousal but I see where he was going with it. Once you are asleep, the pressure change for most people isn't a problem... So, in that light, an Auto with Cflex would better suit someone for comfort/compliance than a BIPAP.