Ive changed my mind on auto-titrating devices

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
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Hang Fire
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Re: Ive changed my mind on auto-titrating devices

Post by Hang Fire » Mon Feb 08, 2016 10:10 pm

MrGrumpy wrote:a single set pressure is oftentimes the best
Doesn't seem to prevent stupid attacks.

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archangle
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Re: Ive changed my mind on auto-titrating devices

Post by archangle » Tue Feb 09, 2016 9:50 am

Sheriff Buford wrote:
archangle wrote: Used properly, there is no disadvantage to the patient.
I humbly disagree. There's not many people that feel the same using straight cpap vs autopap. Second, I think the reason (as I have stated before) is the amount of time a autopap takes to respond to an event can be the culprit. Short as it is... your are clearly experiencing an event, waiting for the machine to respond. During this time you are experiencing minimum therapy without the needed pressure to deal with the event.

Sheriff
I don't understand your statement. APAPs can be set to function in CPAP mode. If that is what works best for the patient, that's the proper way to use an APAP.

I'd like to see everyone started out with an APAP, even if the doctor thinks manual CPAP is the right idea. That way, if problems develop later (or the patient gets another doctor), the APAP option is available to try. The cost difference of an APAP vs. a good CPAP machine is so small, it's well worth it.

I suspect even most people on fixed pressure CPAP would do better with a minimum pressure set at or slightly below their current setting and at least a few points higher pressure for the max to take care of bad nights.

As for waiting for the event, unless the minimum pressure is set too low, most modern machines will start ramping the pressure up when they detect flow limitations, even before actual apneas happen. Doesn't always work right for everyone, but it's a lot better than many people think.

I do believe that 4-20 auto setting very rarely counts as "used properly," except maybe for an initial trial.

I do think that it's very common that APAP's are NOT "used properly." In particular, I think many of them have the minimum pressure set too low.

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Re: Ive changed my mind on auto-titrating devices

Post by MrGrumpy » Tue Feb 09, 2016 4:12 pm

Bingo. You understand the point Im trying to make to these people. If you are using CPAP with a single pressure thats properly titrated, it PREVENTS events from even occurring in the first place.

Sheriff Buford wrote:
archangle wrote: Used properly, there is no disadvantage to the patient.
I humbly disagree. There's not many people that feel the same using straight cpap vs autopap. Second, I think the reason (as I have stated before) is the amount of time a autopap takes to respond to an event can be the culprit. Short as it is... your are clearly experiencing an event, waiting for the machine to respond. During this time you are experiencing minimum therapy without the needed pressure to deal with the event.

Sheriff
Id be dead by now if I didn't use my CPAP gear every night.

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archangle
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Re: Ive changed my mind on auto-titrating devices

Post by archangle » Tue Feb 09, 2016 4:57 pm

MrGrumpy wrote:Bingo. You understand the point Im trying to make to these people. If you are using CPAP with a single pressure thats properly titrated, it PREVENTS events from even occurring in the first place.
Well then, why don't we just put everyone on 20 cmH2O pressure and prevent all those apenas?

Fixed pressure vs. APAP may cause unnecessary aerophagia, mouth leaks, mask leaks, patient discomfort, difficulty breathing, difficulty falling asleep, etc. Most importantly, it may lead to an increase in CPAP dropouts who give up and quit the therapy.

CPAPers, especially newbies, don't like higher pressures. This may tend to lead to lower than optimal pressures. An APAP, properly set up will adjust as needed.

Proper manual CPAP titration requires monitoring and adjustment of the pressure up or down as the patient's needs changes. That may be an unnecessary expense. Many the doctors are slackers who don't bother to do it. Without frequent monitoring and adjustment, you won't be properly titrated for long.

Far too often, manual CPAP titration is based on one night's study in a strange bed, wired up, sleeping in the wrong position, nervous, not sleeping at your usual time, bad sleep, no REM sleep, etc. Your needs may be different at home or change over time or even from night to night. While you can re-titrate based on the data a good manual CPAP generates, most of the medical mafia doesn't bother.

Manual CPAP may have more potential to induce central apnea.

Even if "properly" titrated, you may not get as effective therapy with a manual CPAP as with an APAP. The APAP's tend to react to flow limitations and snoring and ramp up to reduce it. This may not show up in your normal manual CPAP titration.

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Re: Ive changed my mind on auto-titrating devices

Post by MrGrumpy » Tue Feb 09, 2016 5:22 pm

Because hardly anybody requires a pressure of 20, except for morbidly obese, 600 lb people at the bariatric clinic. Which I suspect strong some on this forum fit into.

Besides that, most people have a pressure much lower than 20 that nips most events before happening. For example with me, before my tonsillectomy, a set pressure of 10 eliminated most events.

archangle wrote:
MrGrumpy wrote:Bingo. You understand the point Im trying to make to these people. If you are using CPAP with a single pressure thats properly titrated, it PREVENTS events from even occurring in the first place.
Well then, why don't we just put everyone on 20 cmH2O pressure and prevent all those apenas?
Id be dead by now if I didn't use my CPAP gear every night.

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Sheriff Buford
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Re: Ive changed my mind on auto-titrating devices

Post by Sheriff Buford » Thu Feb 11, 2016 5:57 am

archangle wrote:
Sheriff Buford wrote:
archangle wrote: Used properly, there is no disadvantage to the patient.
I humbly disagree. There's not many people that feel the same using straight cpap vs autopap. Second, I think the reason (as I have stated before) is the amount of time a autopap takes to respond to an event can be the culprit. Short as it is... your are clearly experiencing an event, waiting for the machine to respond. During this time you are experiencing minimum therapy without the needed pressure to deal with the event.

Sheriff
I don't understand your statement. As for waiting for the event, most modern machines will start ramping the pressure up when they detect flow limitations, even before actual apneas happen.
Nope... Resmed has a 9 second delay before responding. During an actual event... that's 9 seconds of the effects of an event before the machine can respond.

Sheriff

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Re: Ive changed my mind on auto-titrating devices

Post by Sheffey » Thu Feb 11, 2016 9:50 am

Sheriff Buford wrote:Nope... Resmed has a 9 second delay before responding. During an actual event... that's 9 seconds of the effects of an event before the machine can respond.

Sheriff
The ResMed S9 responds way beyond the simple view you present. If set properly, with the minimum within 6.0, or so, cm of maximum needs, it prevents most apneas. This is because it not only responds to apneas, but also to inspiratory flow limitations and snoring, both of which almost always precede apneas. So the S9 definitely is responding before apneas begin.

One example which is typical of my experience. My initial sleep study results showed an obstructive AHI of 75, consisting of mostly apneas. Many of my apneas were greater than 90 seconds duration.

When given a machine that was set at 10 cm, my AHI was consistently in the range of 35 with many long apneas.

Now with some self-titrating using the wonderful S9 AutoSet, I get results typical of what I had Tuesday night.
Machine pressure settings min 12, max 20
95% pressure 16.9
Max pressure 18.6
AHI - 0.00
HI - 0.23
The machine ranged all the way to 18.6 cm from 12.0 cm and prevented all apneas and all but two hypopneas. The S9 algorithm rocks!

If you are happy with your therapy from straight CPAP settings, I won't try to convince you otherwise.

But you might do a disfavor to newbies by making false statements about APAP machines.
Sheffey

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Re: Ive changed my mind on auto-titrating devices

Post by ChicagoGranny » Thu Feb 11, 2016 9:53 am

Sheffey wrote:Machine pressure settings min 12, max 20
95% pressure 16.9
Max pressure 18.6
AHI - 0.00
HI - 0.23
Fantastic results, Sheffey!

I also have widely ranging pressure needs and find the ResMed S9 AutoSet controls my apnea very well, usually under 2.0 AHI.

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Sheriff Buford
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Re: Ive changed my mind on auto-titrating devices

Post by Sheriff Buford » Thu Feb 11, 2016 10:40 am

Sheffey wrote:
Sheriff Buford wrote:Nope... Resmed has a 9 second delay before responding. During an actual event... that's 9 seconds of the effects of an event before the machine can respond.

Sheriff
The ResMed S9 responds way beyond the simple view you present. If set properly, with the minimum within 6.0, or so, cm of maximum needs, it prevents most apneas. This is because it not only responds to apneas, but also to inspiratory flow limitations and snoring, both of which almost always precede apneas. So the S9 definitely is responding before apneas begin.

One example which is typical of my experience. My initial sleep study results showed an obstructive AHI of 75, consisting of mostly apneas. Many of my apneas were greater than 90 seconds duration.

When given a machine that was set at 10 cm, my AHI was consistently in the range of 35 with many long apneas.

Now with some self-titrating using the wonderful S9 AutoSet, I get results typical of what I had Tuesday night.
Machine pressure settings min 12, max 20
95% pressure 16.9
Max pressure 18.6
AHI - 0.00
HI - 0.23
The machine ranged all the way to 18.6 cm from 12.0 cm and prevented all apneas and all but two hypopneas. The S9 algorithm rocks!

If you are happy with your therapy from straight CPAP settings, I won't try to convince you otherwise.

But you might do a disfavor to newbies by making false statements about APAP machines.
My goodness, Sheffey, stand down! My apologies, I was wrong. The delay is 10 seconds not 9. If you look at the Clinical manual on page 8 or the S9 VPAP clinical manual - page 9, the Resmed algorithm has a 4 second delay (for expiratory pauses), then takes 6 seconds for the CSA detector to begin and detect the apnea type (central or obstructive). Then the machine starts to ramp up and treat the apnea. A few years back, I called Resmed (I wrote the name of Wayne... next to my copy) to confirm this statement. This was the way he explained it to me. He said the machine has this delay to keep the machine from responding to our natural breath interruptions, turning over in bed, coughs, sniffs, etc... If the machine responded to every respiratory interruption, the machine would go into "hay-wire" mode all night.

If you also look at page 23 in the S9 VPAP clinical manual, Resmed defines an apnea when "the respiratory flow decreases more than 75% for at least 10 seconds", while a hypopnea is when the respiratory flow decreases to 50% for at least 10 seconds." There again... the 10 second delay.

I can send you a copy of these manuals if you send me your email.

We request newbies to read the clinical manual. I have read it many times and I always pick up something new... every time I read it. Maybe you need to look it over. Better yet, if you disagree, call Resmed and tell them they are wrong.

Sheriff

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Re: Ive changed my mind on auto-titrating devices

Post by MrGrumpy » Thu Feb 11, 2016 10:58 am

I rest my case...

Even I did not know that technical fact. I know these auto machines I use have a delay before they actually respond to an event. Nine seconds is way too long to respond to an event. Now I know why my sleep doctors IRL keep hammering me, "these auto devices are sometimes useful for diagnostic reasons and also for people who have really high pressures, but they dont respond fast enough to knock out all the stuff so you feel well during the daytime."

Sheriff Buford wrote:
archangle wrote:
Sheriff Buford wrote:
archangle wrote:

I don't understand your statement. As for waiting for the event, most modern machines will start ramping the pressure up when they detect flow limitations, even before actual apneas happen.
Nope... Resmed has a 9 second delay before responding. During an actual event... that's 9 seconds of the effects of an event before the machine can respond.

Sheriff
Id be dead by now if I didn't use my CPAP gear every night.

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Re: Ive changed my mind on auto-titrating devices

Post by MrGrumpy » Thu Feb 11, 2016 11:04 am

A ten second delay? My goodness no wonder I feel so rotten. I used to feel good when my minimum pressure was constantly set at my titrated CPAP pressure of 10.

If you can tolerate it, straight CPAP is the best. I have decided that after years of using an APAP in near straight CPAP mode and feeling good. And then having to revert to using my APAP in "wide open mode." Aint no way in hades Im believing these auto devices are fast enough. Good for diagnosis? Yeah. Good for giving you a lot of data? Yeah. Better than nothing? Yeah. But not good enough for making you feel truly well

Sheriff Buford wrote:
Sheffey wrote:
Sheriff Buford wrote:Nope... Resmed has a 9 second delay before responding. During an actual event... that's 9 seconds of the effects of an event before the machine can respond.

Sheriff
The ResMed S9 responds way beyond the simple view you present. If set properly, with the minimum within 6.0, or so, cm of maximum needs, it prevents most apneas. This is because it not only responds to apneas, but also to inspiratory flow limitations and snoring, both of which almost always precede apneas. So the S9 definitely is responding before apneas begin.

One example which is typical of my experience. My initial sleep study results showed an obstructive AHI of 75, consisting of mostly apneas. Many of my apneas were greater than 90 seconds duration.

When given a machine that was set at 10 cm, my AHI was consistently in the range of 35 with many long apneas.

Now with some self-titrating using the wonderful S9 AutoSet, I get results typical of what I had Tuesday night.
Machine pressure settings min 12, max 20
95% pressure 16.9
Max pressure 18.6
AHI - 0.00
HI - 0.23
The machine ranged all the way to 18.6 cm from 12.0 cm and prevented all apneas and all but two hypopneas. The S9 algorithm rocks!

If you are happy with your therapy from straight CPAP settings, I won't try to convince you otherwise.

But you might do a disfavor to newbies by making false statements about APAP machines.
My goodness, Sheffey, stand down! My apologies, I was wrong. The delay is 10 seconds not 9. If you look at the Clinical manual on page 8 or the S9 VPAP clinical manual - page 9, the Resmed algorithm has a 4 second delay (for expiratory pauses), then takes 6 seconds for the CSA detector to begin and detect the apnea type (central or obstructive). Then the machine starts to ramp up and treat the apnea. A few years back, I called Resmed (I wrote the name of Wayne... next to my copy) to confirm this statement. This was the way he explained it to me. He said the machine has this delay to keep the machine from responding to our natural breath interruptions, turning over in bed, coughs, sniffs, etc... If the machine responded to every respiratory interruption, the machine would go into "hay-wire" mode all night.

If you also look at page 23 in the S9 VPAP clinical manual, Resmed defines an apnea when "the respiratory flow decreases more than 75% for at least 10 seconds", while a hypopnea is when the respiratory flow decreases to 50% for at least 10 seconds." There again... the 10 second delay.

I can send you a copy of these manuals if you send me your email.

We request newbies to read the clinical manual. I have read it many times and I always pick up something new... every time I read it. Maybe you need to look it over. Better yet, if you disagree, call Resmed and tell them they are wrong.

Sheriff
Id be dead by now if I didn't use my CPAP gear every night.

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Not Fade
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Re: Ive changed my mind on auto-titrating devices

Post by Not Fade » Thu Feb 11, 2016 3:11 pm

Sheffey wrote:Machine pressure settings min 12, max 20
95% pressure 16.9
Max pressure 18.6
AHI - 0.00
HI - 0.23
Excellent results, Sheffey. I also use an APAP to cover a wide range of pressure needs, although not quite as wide as yours. If I were stuck with using a straight CPAP, the constant high pressure would make my life miserable. In fact, I start out on prescribed straight CPAP pressures - terrible results.
Sheffey wrote:But you might do a disfavor to newbies by making false statements about APAP machines.
It seems a couple of users have stuck their noses too deep into the machine manuals to understand how beautifully the algorithms work.

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Re: Ive changed my mind on auto-titrating devices

Post by palerider » Thu Feb 11, 2016 4:30 pm

Sheriff Buford wrote:The delay is 10 seconds not 9. ... If you also look at page 23 in the S9 VPAP clinical manual, Resmed defines an apnea when "the respiratory flow decreases more than 75% for at least 10 seconds", while a hypopnea is when the respiratory flow decreases to 50% for at least 10 seconds." There again... the 10 second delay.
it's not a 10 second delay, the machine doesn't even recognize something as an apnea or hypopnea until after 10 seconds because it doesn't count as an apnea until after 10 seconds, medical definition.

second, as explained elsewhere, no machine will increase pressure DURING an apnea, for a variety of reasons, 1) it'd take a LOT of pressure, very suddenly and that WOULD wake you up, 2) it might have the effect of ramming a plug into the drain, so it'd be even harder for your body to open up your airway, and think of the shock to the lungs if you did have something going up to crazy pressures to try and blow open a closed airway, suddenly you'd get a WHAM in the lungs... no, much better to ease the pressure up afterwards, much more peaceful, more restful.

now, as far as single pressure being better, it's only better if you crank the pressure way up to where it handles every possible eventuality, on your back, during rem, with your head at a funny angle... a level of pressure that you don't need the other 95% of the night, so then you've got more mask leaks, and maybe more bloating because you're being overinflated for the majority of the night.

Pugsy liked to say that she'd HATE a cpap, because she needed 18cm for a little while during rem, and about 9cm for the rest of the night. she, of course, had tried, the constant pressure of 18, and hated it. but slept great on a properly tuned auto.

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Re: Ive changed my mind on auto-titrating devices

Post by Sheriff Buford » Thu Feb 11, 2016 5:08 pm

As I am now an autopap user, I have always advocated an autopap user to TRY straight cpap on occasion and a cpap user to occasionally try autopap. Go with the therapy that provides the best numbers, comfort and most of all, the mode that makes you FEEL BETTER. I used to always FEEL better using straight cpap. But now, my acid relux is better-controlled using autopap, so that's my story. To me, someone who says full face masks are better than any other mask, autopap is better than cpap and tennis shoes are better than cowboy boots are doing a diservice to the forum members... especially newbies.

Sheriff

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Re: Ive changed my mind on auto-titrating devices

Post by chunkyfrog » Thu Feb 11, 2016 5:48 pm

Sheriff Buford wrote:As I am now an autopap user, I have always advocated an autopap user to TRY straight cpap on occasion and a cpap user to occasionally try autopap. Go with the therapy that provides the best numbers, comfort and most of all, the mode that makes you FEEL BETTER. I used to always FEEL better using straight cpap. But now, my acid relux is better-controlled using autopap, so that's my story. To me, someone who says full face masks are better than any other mask, autopap is better than cpap and tennis shoes are better than cowboy boots are doing a diservice to the forum members... especially newbies.

Sheriff
I totally agree, Officer! We are all different, and the "one size fits all" paradigm is a massive disservice.

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