"Sleep Doctor" doesn't like autopaps

[Miko]

Here's my thought: Patients on APAP NEVER NEED TO HAVE ANOTHER SLEEP STUDY!!! The machine automatically adjusts to the proper pressure. No more retests!!

Oh, but wait....try to get your sleep doc to admit or accept the autopaps results? no, he won't. That's why I LOVED the Resmed's onboard data display. It told me exactly where I was at. In the sleep lab, they couldn't believe I knew what level I was at, considering it was my first tritration.

Then again, that's why we have medicare to cover the overnight sleep study. However, the APAPS will never tell you if you have Resltess Leg Syndrome or Central Apneas.

If I recall correctly, the extra cost of an auto vs CPAP is not justified since, according to the sleep docs **most** people don't benefit with the auto. I could be one of those, but I still want the auto, just the same...especially when I come home in the evening after drinking with the boys.

[Miko]

Guest,

1) I'm with rested gal, do doctors have sleep studies that show a standard cpap, that blows one constant pressure, does not allow you to have apneas?

I suggest this question and all your questions be directed to your sleep doc since they are the experts. I won't be seeing the sleep doc anytime soon. So, if anyone does manage to ask his/her sleep doc these questions, please post back.

[Hugh Jass]

At the risk of being unpopular, I believe it's possible for both sides of the argument to be right, i.e. APAP's prevent apneas automatically, and APAP's don't prevent apneas.

I saw my sleep doc last week complaining that I was still waking up every hour and half, normally during REM stage. She told me that it's possible that the APAP minimum setting may be too low, and wasn't catching everything. She had the minimum changed from 4 to 8, and if I was still waking up during REM, to boost it to 10.

Needless to say, I was disappointed because I can't stand a doctors attitude that if a treatment isn't working, you must need more of it. I mean, how could they possible be wrong, right !

However, she may be right, which causes me to believe that APAP's may be good, but not always as good as we hope to believe.

Here's why I think this.

For the first 10 weeks, my settings were for 4-16 and only once did I go to a 9, and that was for about 2 minutes, (and I suspect as a result of a leak in my mask). My 90% was consistently 5-6 for the 10 weeks.

However, after boosting the minimum to 8 the APAP was now going up to the 12's quite often. My 90% is now 10-11 ! Not only that, I am now sleeping better and not waking up as much.

(I have been 100% compliant since day one, my weight has not changed nor am I taking any medication.)

If the APAP is so smart and can regulate my pressure so well, why was it not able to determine that my ideal pressure was in the 10-11 range, not the 5-6 ?

When it was 5-6, my AHI was anywhere from 3 to 6. Now at the higher minimum pressure it's from .7 to 2.

So my opinion is that an APAP is good, but we can't always assume that all we need to do is plug it in and our apneas will be reduced and/or eliminated since the unit will automatically take care of it.

I suspect, depending on our breathing patterns and our type of SDB, (not SBD ), the APAP may need to be set at a higher minimum pressure to prevent apneas from happening, which regretably means sometimes the Dr. can be right.

I presume many will disagree with my opinion. I'm just relating my experience.

To those who may be discouraged, don't give up simply because you have an APAP and are not feeling better. It may be you need to have a higher minimum setting as was my experience.

FYI, I'm using a Remstar Auto with C-Flex and PB Breeze Mask. (if it wasn't for C-Flex, there's no way I could tolerate pressures of 10-12. Hooray for C-Flex !)

Regards

[-SWS]

I believe it's possible for both sides of the argument to be right, i.e. APAP's prevent apneas automatically, and APAP's don't prevent apneas.

I agree while heartedly, Hugh Jass. AutoPAP, CPAP, BiLevel.... none of these xPAP platforms come close to being infallible! That's why trial and error some times becomes necessary.

[MelMel]

Hi Janelle,

It is often called balance billing. For example, even though the allowable by the insurance is the same for the auto as it is for the standard cpap, the dme will still charge more for the auto than the "straight" cpap. Unfortunately the patient ends up paying the difference. That is the evil in the evil dme.

MM

[chrisp]

MelMel, You are giving away all the Evil DMEs secrets . We will have to place you into protective custody. Or, a nice DME version of the witness protection program. The only position available is a snowshoe salesman in Arizona at the moment .

DMEs all over are pulling their hair out whenever you post their dirty secrets.

MelMel is a nice DME

Cheers,

Chris

[Guest]

I just can't help myself. This stuff is not a national secret...just the things that people who do this everyday know and the average person doesn't. If anyone's dme is on the up and up then there is no reason why a patient cannot know the information I give out.

Be gone evil dmes...BE GONE!!

MelMel

[Liam1965]

\It is often called balance billing. For example, even though the allowable by the insurance is the same for the auto as it is for the standard cpap, the dme will still charge more for the auto than the "straight" cpap. Unfortunately the patient ends up paying the difference. That is the evil in the evil dme.

So how does that work when there's a negotiated "discount price" for the equipment between the DME and the insurance company?

For example, my machine (which can be had from CPAP.COM for approximately $750, everything included except the second mask) has a retail price JUST for the CPAP (no hoses, humidifiers, nothing) from my DME of $1850 or so. The negotiated discount price is something like $1200, but those are the quoted prices for any CPAP, regardless of what you get.

So.... how could they get away with billing me extra for an AutoPAP, if that's the negotiated price they promised Cigna they would charge for a CPAP machine?

Liam, still thinking this DME pricing is shady at best.

[rested gal]

Good points, Hugh Jass. And that's why autopaps give a range to choose from. An autopap's ability to allow tweaking the treatment range to suit each patient is a big plus - whether the best range for any given person is wide or very narrow.

Patients who have the software and the knowledge to find their best range - particularly their best "low" pressure, as you did, Hugh - are ahead of the game....because they are using an autopap. No one knows better than you whether a narrow range around your titrated pressure is letting you sleep better, or whether low pressures work well for you. You've looked at your results and figured out what works best for you. You couldn't have found what suits you best had you been on a simple cpap.

The problem I see with doctors who would say, "See? You get your best results keeping your autopap's low pressure right up at your titrated pressure....you don't NEED an autopap." is this:

On straight cpap, single pressure, no software - what about the patient's pressure needs in the future? Next month? next year? If the patient's conditions change (weight gain, new meds, more collapsible throat with age, new health problems) and symptoms of sleepiness return, what happens? Doctor says, "Well, let's try raising the pressure a notch." What if two or three notches more are needed instead of one? More guessing? What if a person loses weight and fortunately needs less pressure - how will they find out? Doctor sends them off for the hassle of another sleep study titration?

All along, if the patient were on autopap with the upper pressure set several points above the titrated pressure, the machine could be taking care of changing needs. All along, if the patient has an autopap with software, the knowledgeable patient can keep track of what pressure range feels best and works best for them. Trial and error, as SWS said.

Sleeping comfortably at lower pressures is the obvious major attraction of autopap for most people. We've all seen posts that show that's the case for many. However, if keeping the low pressure up at, or near, the titrated pressure results in better sleep, that's where it should be set. The person can still enjoy the assurance of more "ceiling room" being there, with the top pressure, if/when conditions change.

[Miko]

On straight cpap, single pressure, no software - what about the patient's pressure needs in the future? Next month? next year? If the patient's conditions change (weight gain, new meds, more collapsible throat with age, new health problems) and symptoms of sleepiness return, what happens? Doctor says, "Well, let's try raising the pressure a notch." What if two or three notches more are needed instead of one? More guessing? What if a person loses weight and fortunately needs less pressure - how will they find out? Doctor sends them off for the hassle of another sleep study titration?

Exactly...one must always remember that doctors tend to be "reactive" as opposed to proactive. They make their money from you when you visit them, not by keeping you completely healthy. Just like my ex-GP wasn't concerned about my heart, but stated that we will worry about it when the problem happens.

[Dave Hargett]

I just went though something very similar. I’ve been on CPAP 1 ½ years and haven’t felt any better. I recently went to a sleep doc and requested a sleep study, my request was denied, although the doc did schedule a follow up appointment for me.

At my follow up I requested a prescription for an Auto C-Flex, request denied, no reason given.

A few days ago I took delivery of a new Auto C-Flex with software, paid for without going through my insurance, courtesy of the sleep doc.

Using the Auto C-Flex I find my pressure spends a good deal of time at 15/16, my old CPAP prescription was set for 12. Sleep doc stated during my follow up visit, my prescription was correct, even though I was complaining.

I have only used my new Auto C-Flex for 4 nights and I’m waking up feeling refreshed instead of feeling as though I need a nap while getting out of bed every morning.
I haven’t had the headaches I was getting up with every morning for the past four days.

Okay,
Now have you made an appointment with the sleep doctor to show him your sleep data report? To tell him how much better you feel? And if he still blows you off, to tell him that you're firing him and never coming back?

Dave

[hopeful]

It was definitely one of those very mixed experiences - I definitely felt he wasn't being totally honest with me.

I felt he agreed with me at first (everyone should get an Apap out of the box, if nothing more than a temporary to get them going while waiting for a titration appointment), then he became very defensive. What IS it with these people?

Here were his points of concern regarding apap:

1) Apaps have only been around 8-10 years. While that may seem like a long time, there have been no definitive research studies on their efficacy. Cpaps are proven through research to address the problem. In treating live human beings, most doctors go with the tried and true rather than the new stuff that may have unknown side effects.

2) He pointed out that he is only one of many components -- the sleep clinic, the DME, all of whom may get to the patient before they come to the follow up with him. The DME's are theoretically there to provide rentals so that they can respond to changing needs for the discovery period of new patients. So that if that, for example, a patient needs a bi-pap, they can easily switch their rental from the cpap to the bi-level.

3) He pointed out that many doctors remain super-conservative because of the growing tendency for legal recourse, and they want to avoid being sued.

4) Finally, he pointed out that the mechanism the apap used to identify the level of pressure is "crude" (something about the soft pallate). But when I asked him point blank if he didn't trust the apap to be effective, he avoided answering me directly. My brain must been too little to understand all of his deep wisdom (sorry for the nasty tone there, I find hemming and hawing very frustrating).

I'm still sorting out what I think about all of this. I'm still a bit skeptical. While I can understand hesitation to follow fads in medicine, I personally think that translates into "we need to follow the fad of the moment, e.g. cpap." For example, I don't think we really understand the impact of the too much air pressure night after night. My doc seemed to imply the main thing was making sure it didn't go too low. But what if we discover sometime in the future that constant exposure to too high pressure has it's own health risks?

It seems to me the docs are hedging bets here based upon simply doing what everyone else is doing.

I'd be interested to hear what other people think of his comments...

[hopeful]

I found three articles...all very positive on apap. While much of it is medical gobbeldygook the last sentence is in plain English.

http://erj.ersjournals.com/cgi/content/ ... t/12/4/759


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Clinical Trial

CPAP titration by an auto-CPAP device based on snoring detection: a clinical trial and economic considerations
M Berkani, F Lofaso, C Chouaid, M Pia d'Ortho, D Theret, V Grillier-Lanoir, A Harf, and B Housset


This study aimed to assess the ability of an auto-nasal continuous positive airway pressure (nCPAP) device (REM + auto; NPBFD, Nancy, France) to predict the optimal constant nCPAP level. The apnoea/hypopnoea detection facility of the auto-nCPAP device was deliberately disabled and nasal mask pressure vibration detection was the only mode of pressure setting. The auto-nCPAP device was tested on 10 previously untreated patients with obstructive sleep apnoea during a single night, with ambulatory polysomnography performed in a conventional hospital room; the efficacy of the fixed pressure determined by the auto-nCPAP device was assessed by an ambulatory full polysomnography 2 weeks after the initiation of treatment at home. The fixed nCPAP pressure was effective (apnoea/hypopnoea and arousal indices <10 events x h(-1)) in all but two of the 10 patients studied. When the fixed nCPAP pressure was increased by 2 cmH2O in these two patients, sleep and respiration were normalized. Since only 12 ambulatory polysomnographic recordings were used to determine the effective nasal continuous positive airway pressure level, and as the device restored normal breathing and sleep in all 10 patients, it was concluded that this method of nasal continuous positive airway pressure titration may improve cost-effectiveness and reduce waiting lists in sleep laboratories.


Published ahead of print on July 28, 2004, doi:10.1164/rccm.200312-1787OC
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PubMed Citation
Articles by Masa, J. F.
Articles by Montserrat, J. M.

American Journal of Respiratory and Critical Care Medicine Vol 170. pp. 1218-1224, (2004)
© 2004 American Thoracic Society
doi: 10.1164/rccm.200312-1787OC

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Original Article

Alternative Methods of Titrating Continuous Positive Airway Pressure
A Large Multicenter Study
Juan F. Masa, Antonio Jiménez, Joaquín Durán, Francisco Capote, Carmen Monasterio, Mercedes Mayos, Joaquín Terán, Lourdes Hernández, Ferrán Barbé, Andrés Maimó, Manuela Rubio and José M. Montserrat
San Pedro de Alcántara Hospital, Cáceres; Hospital de Valdecilla, Santander; Txagorritxu Hospital, Vitoria; Virgen del Rocío Hospital, Sevilla; Hospital de Bellvitge, Sant Pau Hospital, and Clinic Hospital, Barcelona; General Yagüe Hospital, Burgos; Son Dureta Hospital, and Joan March Hospital, Palma de Mallorca, Spain

Correspondence and requests for reprints should be addressed to Juan F. Masa, M.D., C/ Rafael Alberti 12, 10005 Caceres, Spain. E-mail: fmasa@separ.es

Standard practice for continuous positive airway pressure (CPAP) treatment in sleep apnea and hypopnea syndrome (SAHS) requires pressure titration during attended laboratory polysomnography. However, polysomnographic titration is expensive and time-consuming. The aim of this study was to ascertain, in a large sample of CPAP-naive patients, whether CPAP titration performed by an unattended domiciliary autoadjusted CPAP device or with a predicted formula was as effective as CPAP titration performed by full polysomnography. The main outcomes were the apnea–hypopnea index and the subjective daytime sleepiness. We included 360 patients with SAHS requiring CPAP treatment. Patients were randomly allocated into three groups: standard, autoadjusted, and predicted formula titration with domiciliary adjustment. The follow-up period was 12 weeks. With CPAP treatment, the improvement in subjective sleepiness and apnea–hypopnea index was very similar in the three groups. There were no differences in the objective compliance of CPAP treatment and in the dropout rate of the three groups at the end of the follow-up. Autoadjusted titration at home and predicted formula titration with domiciliary adjustment can replace standard titration. These procedures could lead to considerable savings in cost and to significant reductions in the waiting list.

© 2004 American College of Chest Physicians

Constant vs Auto-Continuous Positive Airway Pressure in Patients With Sleep Apnea Hypopnea Syndrome and a High Variability in Pressure Requirement*
André Noseda, MD, PhD; Chantal Kempenaers, MS; Myriam Kerkhofs, PhD; Stéphanie Braun, MS; Paul Linkowski, MD, PhD and Ernest Jann, MD
* From the Chest Department and the Sleep Laboratory, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium.


Correspondence to: André Noseda, MD, PhD, Chest Department, Hôpital Erasme, Route de Lennik, 808, B-1070 Brussels, Belgium; e-mail: andre.noseda@chu-brugmann.be

Study objectives: Auto-continuous positive airway pressure (CPAP) has been reported to have no more efficacy than constant CPAP in unselected patients with sleep apnea hypopnea syndrome (SAHS). The aim of this study was to evaluate patients judged to be good candidates for auto-CPAP because of a high within-night variability in pressure requirement.

Design: Single-blind, randomized, cross-over study (2 x 8 weeks) to compare auto-CPAP with constant CPAP.

Patients: Outpatients with moderate-to-severe SAHS attending the chest clinic.

Interventions: Patients were equipped at home in the auto-CPAP mode (model GK418A; Malinckrodt; Nancy, France), using a 4- to 14-cm H2O pressure range. Those individuals having a high within-night variability in pressure requirement, assessed at the end of a 14-day run-in period, were included in the cross-over study. Auto-CPAP was compared with constant CPAP (according to a titration night in the sleep laboratory) in terms of compliance, efficacy on apneas (assessed from the pressure monitor), and sleepiness (assessed on the Epworth sleepiness scale).

Measurements and results: Of 90 consecutive patients with SAHS, 27 patients were selected for a within-night variability in pressure requirement exceeding a given threshold. After completion of the cross-over, 24 patients were evaluable. The median percentage of nights the machine was used was 95.5% (range, 45 to 100%) on constant CPAP, and 96.5% (range, 40 to 100%) on auto-CPAP; the median apnea index recorded by the device was 0.40/h (range, 0 to 2.40/h) on constant CPAP, and 0.45/h (range, 0 to 5.80/h) on auto-CPAP (differences not significant). The mean Epworth sleepiness score was significantly (p < 0.01) lower on auto-CPAP (5.1; SD, 2. than on constant CPAP (6.1; SD, 2..

Conclusions: In patients selected for a high within-night variability in pressure requirement, auto-CPAP administered via a GK418A device was equivalent to constant CPAP based on a titration night in the sleep laboratory. Subjective ratings for sleepiness were slightly lower on auto-CPAP.

[hopeful]

This one tested (and validated) the theory that the higher the pressure (above level 10) needed for the patient, the more apap was effective for that patient.

Comparison between Automatic and Fixed Positive Airway Pressure Therapy in the Home
Clifford A. Massie, Nigel McArdle, Robert W. Hart, Wolfgang W. Schmidt-Nowara, Alan Lankford, David W. Hudgel, Nancy Gordon and Neil J. Douglas
Suburban Lung Associates, Elk Grove Village, Illinois; University Department of Medicine, University of Western Australia, Royal Perth Hospital, Perth, Australia; Sleep Medicine Associates of Texas, Dallas, Texas; Sleep Disorders Center of Georgia, Atlanta, Georgia; Case Western Reserve University, Cleveland, Ohio; Gordon and Associates, Berkeley, California; and Department of Medicine, Royal Infirmary, Edinburgh, United Kingdom

Correspondence and requests for reprints should be addressed to Clifford A. Massie, Ph.D., Suburban Lung Associates, 810 Biesterfield Rd., Suite 404, Elk Grove Village, IL 60007. E-mail: clifford.massie@sublung.com

We tested the hypothesis that continuous positive airway pressure (CPAP) use and outcomes can be improved by an autotitrating CPAP device in patients with obstructive sleep apnea–hypopnea syndrome (OSAHS) who require higher CPAP (10 cm H2O or more). In this multisite randomized single-blind cross-over study, 44 patients (mean age, 49 ± 10 years) were randomized to 6 weeks at laboratory-determined fixed pressure and 6 weeks on autotitrating CPAP. Average nightly use was greater in automatic mode (306 versus 271 minutes, p = 0.005); median and 95th centile pressures in automatic mode were lower (p < 0.002). Automatic CPAP resulted in better SF-36 Vitality scores (65 ± 20 versus 58 ± 23, p < 0.05) and mental health scores (80 ± 14 versus 75 ± 18, p < 0.05), but no significant difference in Epworth score (p = 0.065). During automatic therapy, patients reported more restful sleep, better quality sleep, less discomfort from pressure, and less trouble getting to sleep for both the first week of therapy and for the averaged scores for Weeks 2–6 (all p values < 0.006). Patients who require higher fixed CPAP use autotitrating CPAP more and report greater benefit from this therapy.

[rested gal]

Thank you for posting those, Hopeful! I recall reading them, but had not bothered to write down where I had seen them. Have been looking for them ever since the stories about doctors' comments about "autopap" have been appearing. Thank you, thank you!