Ive changed my mind on auto-titrating devices

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MrGrumpy
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Ive changed my mind on auto-titrating devices

Post by MrGrumpy » Wed Feb 03, 2016 10:18 pm

I used to think auto titration was da bomb. Whether it be plain old AutoPap or autoBipap, I used to think "I had to have it." Nothing less than an APAP for me, thank you."

Now, Ive changed my mind on the subject. I think auto titrating devices just complicate things and have begun to see things more the way many sleep specialists see them...a single set pressure is oftentimes the best.

I admit there are exception to this. For folks who have high pressures, auto-titration devices are a Godsend. I mean, there are a lot of folks who just cant tolerate a 15 set CPAP or even BiPap pressure. So maybe setting it at minimum of 10 or 11 and letting it "ride" during the night to 15 and back is the best alternative available.

I also believe Autopaps are very useful in keeping the insurance monkey off your back and preventing some sleep docs from "dumping you" after a few years. After theyve gotten their initial insurance money from that first big sleep study series and gear issuance, some sleep docs gradually fade off because their interest wanes with decreasing financial payment. The autopap keeps everybody honest, or more honest at least. Because it gives you the patient, power. Power to say, "hey man, I set this sucker from 4 to 20 or 4 to 15 and despite my weight loss, it STILL 95th percentiles at 10 or 11." That cleans out a lot of bullshit. I mean, computers dont lie, people and insurance companies oftentimes do lie.

HOWEVER, going back to my original change in tune. I think plain old CPAPs or plain old Bipaps, not the autotitrating ones, give superior overall performance. There is none of this runaway pressure stuff. Less stomach irritation, less sinus irritation, you keep the pressures tighter to exactly what you need, nothing more nothing less. I believe that gives superior clinical effectiveness.

Plus, you are keeping one factor the same...pressure. If YOU CHANGE, say you gain or lose weight or you start drinking booze at night or taking a lot of benzos, its gonna reflect in your AHI for a set pressure. For that, you go back to your sleep doc, say, damn, look at my shitty AHI and I dont feel so hot anymore. My sleep is deteriorating as well. Sleep doc says, "lets re-titrate you for this twenty pound weight gain or weight loss." DONE. And you have a new pressure.
Id be dead by now if I didn't use my CPAP gear every night.

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

Post by Goofproof » Wed Feb 03, 2016 10:33 pm

So your thinking is to blame the auto pap or auto bi pap, for your inability to set the treatment range right. 4 cm to 20 cm is the DUMB DR OR DME, setting range. By zeroing in on a 3 or 4 cm range, you have your cake and eat it too. Learn to monitor the software, and correctly find the pressure, then if you want, change it to your best single pressure. Or you can waste the time and money and let the professionals pull a number out of their hat, maybe they will guess correctly, maybe not. Jim

In any case, your leak rates must be under control to keep the data correct.
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MrGrumpy
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Re: Ive changed my mind on auto-titrating devices

Post by MrGrumpy » Wed Feb 03, 2016 10:37 pm

No, Im talking from the perspective of purely clinical effectiveness.I think a single set pressure, as long as that pressure is your 95th percentile (or 90th for Phillips machines) is the best pressure for most as long as they can tolerate that pressure. Why? Because it destroys most if not all the obstructions, unless you gain weight or you change over time.
Goofproof wrote:So your thinking is to blame the auto pap or auto bi pap, for your inability to set the treatment range right. 4 cm to 20 cm is the DUMB DR OR DME, setting range. By zeroing in on a 3 or 4 cm range, you have your cake and eat it too. Learn to monitor the software, and correctly find the pressure, then if you want, change it to your best single pressure. Or you can waste the time and money and let the professionals pull a number out of their hat, maybe they will guess correctly, maybe not. Jim

In any case, your leak rates must be under control to keep the data correct.
Id be dead by now if I didn't use my CPAP gear every night.

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

Post by Thatgirl » Wed Feb 03, 2016 10:44 pm

I have 0 sleep apnea 95% of the time. The only time I have any is on my back, in REM. Then I'm severely apneic. I'm not gonna ride a pressure of 15 trying to fall asleep on my side in case I roll onto my back during REM at some point.

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

Post by palerider » Wed Feb 03, 2016 10:46 pm

MrGrumpy wrote:No, Im talking from the perspective of purely clinical effectiveness.I think a single set pressure, as long as that pressure is your 95th percentile (or 90th for Phillips machines) is the best pressure for most as long as they can tolerate that pressure. Why? Because it destroys most if not all the obstructions, unless you gain weight or you change over time.
*shakes head*

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Re: Ive changed my mind on auto-titrating devices

Post by big_dave » Thu Feb 04, 2016 1:26 am

I always say try both auto mode and fixed pressure to see what works best. I only care that auto mode works best for me. I don't care what is best in some theoretical sense.

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49er
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Re: Ive changed my mind on auto-titrating devices

Post by 49er » Thu Feb 04, 2016 2:12 am

Hmm,

After my 2015 septoplasty, I had no problems adjusting my pressure to what was necessary. Initially, it was lower and then I had to adjust it upward again due to nasal congestion. Definitely didn't need a titration for that with access to sleepyhead software.

As I previously mentioned, I did have a titration in 2014 as I stupidly let someone talk me into doing it. But I felt it was a waste of time and very aggravating.

MrGrumpy wrote:I used to think auto titration was da bomb. Whether it be plain old AutoPap or autoBipap, I used to think "I had to have it." Nothing less than an APAP for me, thank you."

Now, Ive changed my mind on the subject. I think auto titrating devices just complicate things and have begun to see things more the way many sleep specialists see them...a single set pressure is oftentimes the best.

I admit there are exception to this. For folks who have high pressures, auto-titration devices are a Godsend. I mean, there are a lot of folks who just cant tolerate a 15 set CPAP or even BiPap pressure. So maybe setting it at minimum of 10 or 11 and letting it "ride" during the night to 15 and back is the best alternative available.

I also believe Autopaps are very useful in keeping the insurance monkey off your back and preventing some sleep docs from "dumping you" after a few years. After theyve gotten their initial insurance money from that first big sleep study series and gear issuance, some sleep docs gradually fade off because their interest wanes with decreasing financial payment. The autopap keeps everybody honest, or more honest at least. Because it gives you the patient, power. Power to say, "hey man, I set this sucker from 4 to 20 or 4 to 15 and despite my weight loss, it STILL 95th percentiles at 10 or 11." That cleans out a lot of bullshit. I mean, computers dont lie, people and insurance companies oftentimes do lie.

HOWEVER, going back to my original change in tune. I think plain old CPAPs or plain old Bipaps, not the autotitrating ones, give superior overall performance. There is none of this runaway pressure stuff. Less stomach irritation, less sinus irritation, you keep the pressures tighter to exactly what you need, nothing more nothing less. I believe that gives superior clinical effectiveness.

Plus, you are keeping one factor the same...pressure. If YOU CHANGE, say you gain or lose weight or you start drinking booze at night or taking a lot of benzos, its gonna reflect in your AHI for a set pressure. For that, you go back to your sleep doc, say, damn, look at my shitty AHI and I dont feel so hot anymore. My sleep is deteriorating as well. Sleep doc says, "lets re-titrate you for this twenty pound weight gain or weight loss." DONE. And you have a new pressure.

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

Post by MrGrumpy » Thu Feb 04, 2016 11:41 am

I told you man, stay out of my posts.

palerider wrote:
MrGrumpy wrote:No, Im talking from the perspective of purely clinical effectiveness.I think a single set pressure, as long as that pressure is your 95th percentile (or 90th for Phillips machines) is the best pressure for most as long as they can tolerate that pressure. Why? Because it destroys most if not all the obstructions, unless you gain weight or you change over time.
*shakes head*
Id be dead by now if I didn't use my CPAP gear every night.

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

Post by MrGrumpy » Thu Feb 04, 2016 11:46 am

Im not saying APAPs dont have their uses. I already said if you have high pressures, oftentimes an APAP is a Godsend because a lot of people just cant tolerate high pressures. So if your 95th percentile is 15, but you cant tolerate past 10 or 11 without experience stomach irritation or constant mask leaks, setting the minimum as 10 or 11 and topping it at 15 is the way to go. You do what you gotta do to get the job done.

BUT...IF YOU CAN TOLERATE PRESSURE....and there ARE THOSE THAT CAN, quite a few btw, set single pressures I now believe are the best.

APAPs and autoBipaps are best for those who 1) their weight changes frequently, 2) those that have booze problems or take a lot of sedating meds, prescription or OTC and 3) for those unfortunate few who just cant tolerate much pressure but do have OSA. I mean, an APAP set wide open 4-20 is better than nothing, but IMO, not by much.
Id be dead by now if I didn't use my CPAP gear every night.

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

Post by Stormynights » Thu Feb 04, 2016 12:07 pm

4-20 isn't going to work for anyone long term. It is just a test not therapy. An auto can be set to straight pressure and if you have issues you can switch back to apap instead of having a new study done. A lot of us use and love apap. YMMV

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Re: Ive changed my mind on auto-titrating devices

Post by ClayL » Thu Feb 04, 2016 12:25 pm

When I was last due for a new machine I asked my sleep doc about an auto CPAP. He said he usually had good results with fixed pressure and didn't think it was necessary but he did prescribe an auto but asked me to use it in auto mode for a month and then switch to fixed for a month and send him the Sleepyhead results. In my case there was almost no difference between the two but the auto was slightly better so I left it in auto mode. A couple of years later my AHI was often somewhat higher than before. The machine seemed like it was lagging too far behind the apneas so I set it to fixed mode and the AHI got consistently better. It has been a couple of years and I have left it in the fixed mode - AHI is still good - 1.89 average for the last 12 months.
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Gasper62
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Re: Ive changed my mind on auto-titrating devices

Post by Gasper62 » Thu Feb 04, 2016 12:33 pm

I'll throw my APAP away immediately ! What were all those learned engineers thinking ? (also shakes head )

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

Post by HoseCrusher » Thu Feb 04, 2016 2:01 pm

I am not a robot.

For me each day is a little different from the previous day. This implies that my sleep needs vary from night to night.

Also I like to be a comfortable as possible.

Looking at my data I see a variation in the pressures used to keep my airway open. While it is possible to take an average and get average therapy, I prefer to have the machine respond to my needs and then back off a little.

A problem arises when people don't understand how to set the range of pressures. I have data for the median, 95%, and maximum pressures. The first time you use a machine it may be set 4 - 20 which is basically wide open. After a few nights you can review your data and narrow that range down. After a few weeks you start to get a decent picture of what the machine is providing.

In my case I was initially set up with the 7 - 18 pressure range. I ran into problems with the machine running away to the upper pressure following a leak that occurred as I rolled over. Ignoring the data from those nights where leaks pushed the maximum pressure to the maximum I found that most nights my maximum was around 12 or a little over. I set my maximum to 13. No more problems with the machine chasing leaks.

Now I looked at the median value to get an idea of the low end of the range. Looking over a month of data my median is a little over 10. Using this information I set my low pressure to 9.

Now that I have my pressure range adjusted to fit my needs I can monitor it to see if any adjustments are needed.

The up side to using a pressure range is that you only use the higher pressures when they are needed. It is a little easier to breath against lower pressures and I am all for a little extra comfort. In addition if you occasionally need a little higher pressure it is available.

The down side is that you are being subjected to a range of pressures throughout the night. Some may find this less than perfectly restful.

If you set a single pressure and need a little more you are out of luck. If you need a little less you are also out of luck.

It all comes down to your data. If your median, 95%, and maximum numbers are all the same, you don't need a range. If they are different a range of pressure may provide better and more comfortable therapy.

Edit to add that if you set a single pressure your median, 95%, and maximum numbers will all be the same. To see if there is a range you need to set a range of pressures and review your data.

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Michelle-OH
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Re: Ive changed my mind on auto-titrating devices

Post by Michelle-OH » Thu Feb 04, 2016 2:20 pm

I would happily trade you machines to get an auto!

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

Post by GettingBetter » Thu Feb 04, 2016 2:36 pm

It is good to see everyone is different, unique and completely right in their viewpoint.

We need to be open to changes as needed and not heels-dug-in determined that there is only one way to a great night's sleep.

Thanks Mr. Grumpy, I'm looking at my data a little differently now. I am automated right now on pressure settings. I don't know if my brain function and just plain wakefulness was adequate to contemplate setting a static pressure on my machine for the last three months. Since I had problems following recipe instructions and sequencing out the tasks required to prepare for a meeting - I feel pretty confident that I probably should leave my pressure settings in the hands of faceless engineers right now and maybe as I regain some mental acuity, I can start fiddling with the pressure.