An APAP Shootout (sort of) on Academic Journal

[SamCurt]

I want to search medical literature on articles about APAP, and found some weird articles.

This is the first one of the two I want to summarize; it's from the medical journal Chest which carried many respiratory articles. OK, since this is a medical journal I wonder if you can read it free; but public libraries usually have a Proquest account and you can read the full text there.

The following is a summarization of the publication and does not represent my views.

Title of publication: Bench Evaluation of Flow Limitation Detection by Automated Continuous Positive Airway Pressure Devices

by Frederic Lofaso, Gillbert Desmarais, Karl Leroux, VIncent Zale, Redouane Fodil, Daniel Isabey, Bruno Louis.

Conflict of interest: All writers declared they have no conflict of interest.

Summarization of Content:

Flattened respiratory waves (as you can see below) are commonly recognized as a predictor of subtle obstruction and since they herald snoring, hyponea and apnea, CPAP should intervene. Clinically it has been proven CPAP level that removes such flattening improves sleep quality. So how APAPs do in detecting and removing APAP?

APAPs tested:

• GoodKnight 418P
• GoodKnight 420E
• ResMed Autoset Spirit
• Respironics Remstar Auto
• Breas PV10i

Method:



A http://www.michiganinstruments.com/resp-ttl-dual.htm provides the respiratory wave; it is then modified by a flow rate generator which modify waves to the desired form. This modified respiratory wave is then used as the input of an APAP and its output pressure is modified.

Two sets of waves are produced:



A: These are simulated flattened waves. The number after the R is the height of the wave NOT flattened, so an R100 is equal to a normal breath wave. The testing waves are run for 15 mins, and 20 mins of normal waves are applied between tests.

B: NG: Normal wave as described by Dr. G.
G1: Flow limited wave as described by Dr G.
NC: Normal wave as described by Dr C.
FFLC: False Flow limitation cycle described by Dr C.
C1, C2: Flow limited waves as described by Dr C.
Otherwise the time is same as A.

Results:

Brea: After 5 minutes, the set was auto-triggered to rise to maximum pressure within 340s.

Respironics: Doesn't seem to respond to the waves; pressure increased by 1.4cmH2O over 160s and goes back to initial in 60s, cycled every 540s even with flattened waves.

Others: seemed to respond better but unable to detect all flattened waves. See the following picture:



However, ResMed and the GoodKnights differ in how they apply pressure; RedMed increased pressure steadily up to the maximum, while the GoodKnights increased by a 0.3cmH2O step after they detected the flattened wave.

Some discussions from the writers:

Resmed shown the best sensitivity but that does not mean the best since doctors' strategy differ. Overlap occurs normal people and people with obstruction; normal people might have flattened waves; and people with apnea does not consistently exhibit flattened waves. Hence, over- and hyper-sensitivity might be a problem for any APAP.

Future APAPs would more likely to be customizable to different patient subtypes, and manufacturers should disclose their algorithms so that doctors may tweak the APAPs for patients, especially when different APAPs, using the same flow limtation algorithm, differs so much in sensitivity and response...

_________________

CPAPopedia Keywords Contained In This Post (Click For Definition): 420E, respironics, resmed, CPAP, auto, APAP

[greyhound]

I hope DrBandage reads this and can interpret it (I know s/he's not a pulmonary specialist) for the rest of us.

[GoofyUT]

Thanks for taking the time to share this with us.

This is but one of several "iron lung" studies that appear in the medical literature. The question is whether the results derived from the use of a mechanical breathing simulator have any bearing when an APAP is hooked up to a real, live person whose breathing is, because we are human, irregular and varies throughout the night and if affected by so many factors. A large, controlled study using lots of actual patients hooked up to a variety of different auto-titrating PAPs and measuring their responses objectively is LONG overdue, and would be very useful.

But here's the ESSENTIAL point that you did make and share with us:

Future APAPs would more likely to be customizable to different patient subtypes, and manufacturers should disclose their algorithms so that doctors may tweak the APAPs for patients, especially when different APAPs, using the same flow limtation algorithm, differs so much in sensitivity and response...

This is PRECISELY why I so stridently urge folks considering and prescribed auto=titrating PAP to TRY AS MANY DIFFERENT MACHINES AS POSSIBLE. INSIST ON IT!!! The algorithms are that different and provide very different responses for each individual. Its SO important to find the machine that provides the best response for YOU. Brand loyalty simply doesn't work in this arena.

As I've said before, you wouldn't buy a suit sight unseen and without trying it on, would you? Well, this is a matter of YOUR HEALTH! Why accept a device as critical as an APAP without insisting on the ability to "try it on" for a few nights to ensure that it gives you the response that you need better than its competitors can?? Accept nothing less!

Cheers!

Chuck

[WillSucceed]

GoofyUT wrote:

This is PRECISELY why I so stridently urge folks considering and prescribed auto=titrating PAP to TRY AS MANY DIFFERENT MACHINES AS POSSIBLE. INSIST ON IT!!! The algorithms are that different and provide very different responses for each individual. Its SO important to find the machine that provides the best response for YOU. Brand loyalty simply doesn't work in this arena.

I could not agree with you more. I have been encouraging folk to trial every machine possible before committing hard-earned dollars since I started posting on this forum almost 2 years ago. I learned, through trialing 3 different manufacturer's APAP's, that while all of the machines have the potential to provide good treatment, any of us might find (as I did) that one machine does not "fit" us as well as others or, that one machine simply seems to treat us significantly better than the others.

Daring to suggest that folk trial machines in addition to the Respironics line-up has ruffled the feathers of some. As such, I have taken some heat from the I-use-Respironics-because-it-has-C-FLEX-and-it-HAS-to-be-the-best-machine-in-the-whole-wide-world-golly-gee crowd.

The bottom line is that each of us has specific treatment needs and we owe it to ourselves to trial as many machines as possible so that we get the best treatment, and not let ourselves be swayed by anyone else's opinion.

I remember how vulnerable I felt when I was first diagnosed, how much I wanted to get good treatment, how much I looked to this forum to teach me what I needed to know (thanks, Rested Gal and SWS), and how aggressively some folk argued for one machine or the other. I think that when we provide information to new users that is objective (if that is possible), balanced, informative and supportive WITHOUT be rabid about the particular machine that we are using for our own treatment, we are truely doing the best that we can. This business of "I use a certain machine therefore you must use the same machine" stuff only supports ego, not health.

[SamCurt]

Actually there was another APAP algorithm shootout in the same issue of the same journal, and the editorial was also on these two articles.

I would try to summarize the editorial, but not the second shootout since the latter has funded by a company related to Weinmann (manufacturer of SOMNOplus masks and SOMNOsmart APAPs).

[Slinky]

Yeah, but, its all well and good to say try as many brands and types of xPAP machines. Getting our DME suppliers to concur and provide is an ENTIRELY DIFFERENT MATTER.

So far, it appears that a good majority of the DMEs have their favorite bare bones PAPs and their favorite brand machines they want to place w/us. My DME supplier uses a bare bones machine for fitting masks. No way to check leak rate on the LED screen whilst fitting masks. The only autopap they have for a loaner, they don't have a humidifier for. Not even a passover humidifier to loan (they billed $135 for two weeks rental, whereas they bill $135 a month for my Resmed S8 Elite).

No way will they supply a Resmed auto loaner, their philosphy is they "loaned" me a Respironics auto and an auto is an auto. My sleep pulmo didn't script a specific brand of auto and I don't know that that would even be honored since it is a temporary loaner.

The really sad part about my rental loaner experience is that the auto never had a fair chance during that two weeks. The first couple of nights were w/o humidifier, the next two nights I went w/o, then several nights w/a passover humidifier which wasn't much better than w/o a humidifier at all and the FINALLY a fellow PAPper loaned me a HC 100 heated humidifier and I had 3-4 good nights - and then the darn cat caused me to drop my CL2 mask and broke the hard plastic elbow. I had a tell of a hime getting a new elbow from my DME. Only to get home and lose a couple more nights of fair trial for the auto when I realized that when the cat grabbed the headgear causing me to drop the CL2 and break the elbow she had also gotten a claw in the nasal cushion and it was leaking like a sieve. Had to resort to another size cushion which didn't fit waiting for the DME to order in another cushion for me and by the time the new cushion came in I had to return the auto. So out of some 2 1/2 weeks w/the auto I had 3-4 nights to give it a "fair" (?) try and I got good sleep and results those 4 nights. Naturally, most of the problems arose on a weekend. Don't it figure?

So, w/o a willing DME how does one go about trying various brand and types of xPAP?

[WillSucceed]

I went to 3 different suppliers to try 3 different APAP's. It was a big pain in the butt, but worth it.
Best of luck to you.

[capt]

WillSucceed, I definitely agree with your recommendation! One thing I have noticed is that the suppliers here in Canada seem much easier to deal with, when it comes to trying different masks and machines compared to the U.S. suppliers. Here in Calgary I can easily get a machine or mask for at least a weeks trial. That is not the experience I have seen my father have in Ohio.

[GoofyUT]

[quote="Slinky"]Yeah, but, its all well and good to say try as many brands and types of xPAP machines. Getting our DME suppliers to concur and provide is an ENTIRELY DIFFERENT MATTER.

So far, it appears that a good majority of the DMEs have their favorite bare bones PAPs and their favorite brand machines they want to place w/us. My DME supplier uses a bare bones machine for fitting masks. No way to check leak rate on the LED screen whilst fitting masks. The only autopap they have for a loaner, they don't have a humidifier for. Not even a passover humidifier to loan (they billed $135 for two weeks rental, whereas they bill $135 a month for my Resmed S8 Elite).

No way will they supply a Resmed auto loaner, their philosphy is they "loaned" me a Respironics auto and an auto is an auto. My sleep pulmo didn't script a specific brand of auto and I don't know that that would even be honored since it is a temporary loaner.

The really sad part about my rental loaner experience is that the auto never had a fair chance during that two weeks. The first couple of nights were w/o humidifier, the next two nights I went w/o, then several nights w/a passover humidifier which wasn't much better than w/o a humidifier at all and the FINALLY a fellow PAPper loaned me a HC 100 heated humidifier and I had 3-4 good nights - and then the darn cat caused me to drop my CL2 mask and broke the hard plastic elbow. I had a tell of a hime getting a new elbow from my DME. Only to get home and lose a couple more nights of fair trial for the auto when I realized that when the cat grabbed the headgear causing me to drop the CL2 and break the elbow she had also gotten a claw in the nasal cushion and it was leaking like a sieve. Had to resort to another size cushion which didn't fit waiting for the DME to order in another cushion for me and by the time the new cushion came in I had to return the auto. So out of some 2 1/2 weeks w/the auto I had 3-4 nights to give it a "fair" (?) try and I got good sleep and results those 4 nights. Naturally, most of the problems arose on a weekend. Don't it figure?

So, w/o a willing DME how does one go about trying various brand and types of xPAP?

[Slinky]

Unfortunately, I only have a choice of 3 DME providers due to my secondary insurance. And, other DMEs say once you've started via Medicare w/one provider you can't switch until the capped rental is completed. I can't find anything at the Medicare site regarding this and a phone call got me a person who said they couldn't provide me w/that information. Say what? I switched to this second DME before the first DME billed Medicare since the first didn't provide the machine my script called for. The third said its too late to switch to them now.

[GoofyUT]

Then, I guess that you're screwed, right???? WRONG!!!!

I admire your activism in attempting to switch DMEs to get the servcie and equipment that you felt that you needed. But, if you've reached their famous brick-wall, SCREAM!! Ask to speak to the boss. If that doesn't work, scream at your insurance. If that doesn't work, call the State insurance commission and the State board that regulates DMEs. if that doesn't work, call your regional office of CMS (Centers for Medicare and Medicaid Services; the Federal agency that runs Medicare). If that doesn't work, call the Office of the Inspector General (OIG) of CMS, in DC.

And, if your insurance switches or you have the opportunity to change DMEs in the future, INTERVIEW THEM in advance and select the one that will give you the treatment and trial opportunities that you require.

But don't walk away with your tail between your legs simply because the DME said no. WE are the patients. The sleep docs and the DMEs work for US. Its OUR health that is at stake.

[Slinky]

Well, that's pretty much what I've been trying to do but being new to all this I'm kind of feeling my way. And I don't enjoy being confrontational. Altho I did a pretty good job of that the first month or so that I was on PAP therapy (red-face). I was so exhausted I was a real witch and couldn't even stand myself!!

I prefer to know the rules and regs so that I know I have a leg to stand on when picking my "fights".

[greyhound]

And those of us without DME insurance riders have no way to try out multiple APAPs. So, try before you buy sounds good in theory, but doesn't always work in the real world.

[GoofyUT]

I know that its exhausting. The DMEs COUNT on that, and most folks just slink (no pun intended!!)away with their tails between their legs accepting what they've been dispensed without question, because of this. I do admire your pluck Judy, and you've done FAR more than 99% of the xPAP patients out there to get what you need.

As a state gov't healthcare administrator, I can tell you that private vendors in the community are VERY scared about the prospect of having a State agency looking into them and so, they are very responsive to complaints that raise the prospect of some State official giving them a call. And, I KNOW that State agencies are VERY concerned when CMS calls us when a consumer complaint has gotten to them, and we SCURRY to get those complaints resolved quickly.

So above all else, never forget how important your health is to you, and demand what you need to protect it, knowing full well that there is a LOT of "juice" on your side.

Chuck

[sleepergal]

I won't buy a cpap or apap machine that doesn't give me detailed treatment and results information, period. As long as Respironics allows the software to be sold to the patient and Resmed doesn't, I'll purchase Respironics equipment and not Resmed. Resmed may be the better machine for some, but as long as they maintain their current "no software to patients" policy, I'll pass. I suspect that the improved compliance, attention to leaks, mask results, etc. that I achieve with full access to the Respironics software greatly outweighs any potential benefits I might achieve by a different algorithm.

Where, oh where, are the studies on the benefits of educating and equipping patients to take responsibility for their own treatment, under the minimally required supervision of medical professionals?