Hey, you experts exactly HOW do you perform lab titrations?
Hey, you experts exactly HOW do you perform lab titrations?
I have been wondering about this...
Can you sleep techs, lab techs tell us exactly how you perform your titrations during a sleep study?
When you put the mask on the patient, then you go back to your control room, how does all this work?
What sort of machine do you use? How do you manually raise the pressures? How long does it take to dial in the perfect number?
How many events will you see before you get to your magic number if you can find one? Does it take hours? minutes?
I picture the wizard of oz behind the curtain when you all are doing this!
Please do tell how it all works!
I never had a lab titration, so I am very curious!
thanks!
elena
p.s. anyone else have any questions about sleep study titrations, please hop on here!
Can you sleep techs, lab techs tell us exactly how you perform your titrations during a sleep study?
When you put the mask on the patient, then you go back to your control room, how does all this work?
What sort of machine do you use? How do you manually raise the pressures? How long does it take to dial in the perfect number?
How many events will you see before you get to your magic number if you can find one? Does it take hours? minutes?
I picture the wizard of oz behind the curtain when you all are doing this!
Please do tell how it all works!
I never had a lab titration, so I am very curious!
thanks!
elena
p.s. anyone else have any questions about sleep study titrations, please hop on here!
_________________
Mask: Swift™ FX Nasal Pillow CPAP Mask with Headgear |
Humidifier: S9™ Series H5i™ Heated Humidifier with Climate Control |
Additional Comments: sleep study: slept 66 min in stage 2 AHI 43.3 had 86 spontaneous arousals I changed pressure from 11 to 4cm now no apap tummy sleeping solved apnea |
- Big Daddy RRT,RPSGT
- Posts: 250
- Joined: Wed Apr 28, 2010 5:46 pm
- Location: Jackson, Michigan
Re: Hey, you experts exactly HOW do you perform lab titrations?
Elena88: Can you sleep techs, lab techs tell us exactly how you perform your titrations during a sleep study?
When you put the mask on the patient, then you go back to your control room, how does all this work? Well after talking to your patient you try to determine the best mask for them, sensitive skin?, mouth breather?, sinus problems?, side sleeper?, facial abnormalities? etc then you have to take the time to try different masks until you find a comfortable mask that minimizes leaks.
What sort of machine do you use? We use the Resperonincs Omni Lab as it has CPAP,BIPAP, ST, Auto-SV all in one.
How do you manually raise the pressures? You monitor airflow and chest movement, oxygen saturation, for respirattory events/desats, if you note any of these you typically increase the pressure by 1 or 2 cmH2O depending on patient tolerence, we also wait 15-20 minutes between changes to allow the patient to adjust to the new pressure.You have a control on the computer screen to remotely make the changes without entering the room.
How long does it take to dial in the perfect number? Sometimes you find a very well tolerated pressure that eliminates most respiratory events and arousals in an hour or two, other times it takes all night. Sometimes the patient must return for an additional night if it was determined they needed a specialty machine like an Auto-SV or BiPAP ST.
How many events will you see before you get to your magic number if you can find one? Well you try not to overtitrate, so you will tend to move slowly, after 15-20 minutes of so if you see more than two or three respiratory events/snoring/desats you will usually increase the pressure. The goal is to get the patient to "normal" (AHI<5) but if you starting with an AHI 0f 8 or 9 you probably need it lower than that, however if you start with an AHI of 100 you'll probably feel great. Ultimately the goal is the fewest number of respiratory events and the fewest number of arousals.
Does it take hours? minutes? Usually hours depending on patient response/toleration.
I picture the wizard of oz behind the curtain when you all are doing this!
Please do tell how it all works!
I never had a lab titration, so I am very curious!
thanks!
elena
p.s. anyone else have any questions about sleep study titrations, please hop on here!
When you put the mask on the patient, then you go back to your control room, how does all this work? Well after talking to your patient you try to determine the best mask for them, sensitive skin?, mouth breather?, sinus problems?, side sleeper?, facial abnormalities? etc then you have to take the time to try different masks until you find a comfortable mask that minimizes leaks.
What sort of machine do you use? We use the Resperonincs Omni Lab as it has CPAP,BIPAP, ST, Auto-SV all in one.
How do you manually raise the pressures? You monitor airflow and chest movement, oxygen saturation, for respirattory events/desats, if you note any of these you typically increase the pressure by 1 or 2 cmH2O depending on patient tolerence, we also wait 15-20 minutes between changes to allow the patient to adjust to the new pressure.You have a control on the computer screen to remotely make the changes without entering the room.
How long does it take to dial in the perfect number? Sometimes you find a very well tolerated pressure that eliminates most respiratory events and arousals in an hour or two, other times it takes all night. Sometimes the patient must return for an additional night if it was determined they needed a specialty machine like an Auto-SV or BiPAP ST.
How many events will you see before you get to your magic number if you can find one? Well you try not to overtitrate, so you will tend to move slowly, after 15-20 minutes of so if you see more than two or three respiratory events/snoring/desats you will usually increase the pressure. The goal is to get the patient to "normal" (AHI<5) but if you starting with an AHI 0f 8 or 9 you probably need it lower than that, however if you start with an AHI of 100 you'll probably feel great. Ultimately the goal is the fewest number of respiratory events and the fewest number of arousals.
Does it take hours? minutes? Usually hours depending on patient response/toleration.
I picture the wizard of oz behind the curtain when you all are doing this!
Please do tell how it all works!
I never had a lab titration, so I am very curious!
thanks!
elena
p.s. anyone else have any questions about sleep study titrations, please hop on here!
_________________
Mask: Mirage Quattro™ Full Face CPAP Mask with Headgear |
Humidifier: S9™ Series H5i™ Heated Humidifier with Climate Control |
Additional Comments: 13-20cmH2O,EPR of 1,Humidifier at 3, Climate line at 75 degrees,Chinstrap,Tubing cover |
I am on a life quest for the perfect night's sleep...Keep trying...Good sleep can blow!
Re: Hey, you experts exactly HOW do you perform lab titrations?
Hey Big Daddy,
thank you so much! That is absolutely facinating! I can see that you really need some time to perform the titration, because the patient
has to get used to each pressure..
Also, of course it makes sense that you would have at your fingertips EVERY machine function to use, just in case.. It must make you feel pretty
darn good to be helping people feel so much better, and even saving lives!
Good on you!
Thank you for pulling back the "wizard of oz" curtain, so we know whats really going on back there!
thank you so much! That is absolutely facinating! I can see that you really need some time to perform the titration, because the patient
has to get used to each pressure..
Also, of course it makes sense that you would have at your fingertips EVERY machine function to use, just in case.. It must make you feel pretty
darn good to be helping people feel so much better, and even saving lives!
Good on you!
Thank you for pulling back the "wizard of oz" curtain, so we know whats really going on back there!
_________________
Mask: Swift™ FX Nasal Pillow CPAP Mask with Headgear |
Humidifier: S9™ Series H5i™ Heated Humidifier with Climate Control |
Additional Comments: sleep study: slept 66 min in stage 2 AHI 43.3 had 86 spontaneous arousals I changed pressure from 11 to 4cm now no apap tummy sleeping solved apnea |
Re: Hey, you experts exactly HOW do you perform lab titrations?
I've often wondered why my report came back with the phrase
no obstructions were observed at 6cm but 7cm was required to achieve the appropriate REM stage sleep.
I thought the pressure eliminates the obstruction I don't understand how pressure can change REM stages
I loved my titration study as I've never felt as good as I did the day after. But I'm working on it
no obstructions were observed at 6cm but 7cm was required to achieve the appropriate REM stage sleep.
I thought the pressure eliminates the obstruction I don't understand how pressure can change REM stages
I loved my titration study as I've never felt as good as I did the day after. But I'm working on it
- Big Daddy RRT,RPSGT
- Posts: 250
- Joined: Wed Apr 28, 2010 5:46 pm
- Location: Jackson, Michigan
Re: Hey, you experts exactly HOW do you perform lab titrations?
The theory is that your still having very mild hypopneas that go unnoticed with the recording technique being used. If you used an intra-esophageal pressure transducer you would probably see the events but that involves a catheter through your nose and down your throat, try to sleep like that!Uncle_Bob wrote:I've often wondered why my report came back with the phrase
no obstructions were observed at 6cm but 7cm was required to achieve the appropriate REM stage sleep.
I thought the pressure eliminates the obstruction I don't understand how pressure can change REM stages
I loved my titration study as I've never felt as good as I did the day after. But I'm working on it
So instead we do increased pressure trial, the current pressure eliminates obvious resp events but you continue to have arousals or just go a very long time without any REM, more pressure or less, try more until you make it better or worse, then less pressure until you make it better or worse. It's as much science and it is an art, using set scoring rules but also using what we would call tech intuition. Auto CPAP is great technology but it can't do that.
Thats why the lab determined pressure is sometimes different than an auto cpap determined pressure. Neither is better than the other, what matters is how you feel after a full night of sleep on that particular pressure. Some do better on Auto some do better on a set pressure, very patient dependant. If you still feel poorly on your lab pressure try auto, feel poorly on auto maybe you need an in the lab cpap titration. I hope this helps your understanding.
_________________
Mask: Mirage Quattro™ Full Face CPAP Mask with Headgear |
Humidifier: S9™ Series H5i™ Heated Humidifier with Climate Control |
Additional Comments: 13-20cmH2O,EPR of 1,Humidifier at 3, Climate line at 75 degrees,Chinstrap,Tubing cover |
I am on a life quest for the perfect night's sleep...Keep trying...Good sleep can blow!
Re: Hey, you experts exactly HOW do you perform lab titrations?
I wish I had been at your place! I was handed a nasal mask, no questions, no fitting, nothing. I asked about a full-face since I am a mouth breather and they said no.Big Daddy RRT,RPSGT wrote: When you put the mask on the patient, then you go back to your control room, how does all this work? Well after talking to your patient you try to determine the best mask for them, sensitive skin?, mouth breather?, sinus problems?, side sleeper?, facial abnormalities? etc then you have to take the time to try different masks until you find a comfortable mask that minimizes leaks.
But while you are explaining, please explain this part:
SLEEP EFFICIENCY: He was studied for 381 minutes. He slept for 282 minutes for a low sleep efficiency of
74.0%.
SLEEP ARCHITECTURE: Sleep latency was long at 34 minutes. REM latency was long at 125 minutes.
Stage awake 20.09%. Stage I 2.2%. Stage II 64.5%. Stage m 9.3%. Stage REM 11.3% Review of the sleep
histogram shows poor sleep efficiency with wake after sleep onset.
Does that mean I slept 74% of the time studied and that it took me 34 minutes to go to sleep? 125 minutes to get to REM? and that I wake up after finally getting to sleep?
Re: Hey, you experts exactly HOW do you perform lab titrations?
Ok now this is really interesting info. I was titrated using an APAP, not manual titration. Based on that they told me my pressure range was 7 to 10 cm and to start at 7cm CPAP (because this sleep doc did not believe in giving APAP as a treatment device). I now do best on 10.5 cm. I wonder, if they had done a manual titration, whether they would have seen that at 10.5 cm my AHI was the same as the lower pressures but my sleep stages and REM sleep were better at this higher pressure. Interesting food for thought!Big Daddy RRT,RPSGT wrote: So instead we do increased pressure trial, the current pressure eliminates obvious resp events but you continue to have arousals or just go a very long time without any REM, more pressure or less, try more until you make it better or worse, then less pressure until you make it better or worse. It's as much science and it is an art, using set scoring rules but also using what we would call tech intuition. Auto CPAP is great technology but it can't do that.
Thats why the lab determined pressure is sometimes different than an auto cpap determined pressure. Neither is better than the other, what matters is how you feel after a full night of sleep on that particular pressure. Some do better on Auto some do better on a set pressure, very patient dependant. If you still feel poorly on your lab pressure try auto, feel poorly on auto maybe you need an in the lab cpap titration. I hope this helps your understanding.
Thanks for starting this thread Elena
PR System One APAP, 10cm
Activa nasal mask + mouth taping w/ 3M micropore tape + Pap-cap + PADACHEEK + Pur-sleep
Hosehead since 31 July 2007, yippie!
Activa nasal mask + mouth taping w/ 3M micropore tape + Pap-cap + PADACHEEK + Pur-sleep
Hosehead since 31 July 2007, yippie!
- montana user
- Posts: 292
- Joined: Sat Nov 21, 2009 2:23 am
- Location: Helena Montana
Re: Hey, you experts exactly HOW do you perform lab titrations?
Big daddy said it all, just want to re enforce that a titration can be very hard, trying to use CPAP, then maybe trying some bi-level, then possibly back to CPAP with some oxygen bleed in. There is alot that can go into a titration. This is one of the hardest things to teach a new sleep tech how to do. A good sleep tech will be very aggressive and try eveerythign he can to get you the best settings and most comfortable settings. I am afraid though this is where alot of people have bad experiences. No one takes the time to find the right masks, they don't pay attention and under titrate or over titrate. It can be very frustrating for me when I can not find the right pressure before the patient wakes up. Good thread and good question!!! Thank you for asking our side of things, were not all bad guys..lol
Re: Hey, you experts exactly HOW do you perform lab titrations?
What the other technologists said is right on the money. I'll chime in with this... It's very important that you get a good mask fit and that it is comfortable. If your tech is only offering one mask, you should insist on trying some others. Also, you should show up with an open mind. If you say you are a mouth breather and only want to use a full face, you may be making things worse for yourself. I know that certain people are true mouth breathers. But, I've noticed that many people with sleep apnea tend to breathe through their mouths. This is because they are not getting enough air through the nose....anyway, check out http://www.sleepandcpap.blogspot.com "Mouth Breathing Myth" for more info on that.
Here is a link to a sample of a xPAP Titration Protocol/ Flow chart: http://www.respironics.com/UserGuides/B ... 042977.pdf
Enjoy!
Here is a link to a sample of a xPAP Titration Protocol/ Flow chart: http://www.respironics.com/UserGuides/B ... 042977.pdf
Enjoy!
For commentary from a 10 year Sleep Technologist visit my blog at: Recent Topics: Picture of the new baby/ Switching to Swift FX
http://www.sleepandcpap.blogspot.com
http://www.cpapmaskreview.blogspot.com
http://www.facebook.com/sleepandcpap
http://www.sleepandcpap.blogspot.com
http://www.cpapmaskreview.blogspot.com
http://www.facebook.com/sleepandcpap
Re: Hey, you experts exactly HOW do you perform lab titrations?
Very interesting, thanks for taking the time to explain that. I had my APAP set to 7cm to 9cm for the longest time and all my events were 90 centrals, no AIs.Big Daddy RRT,RPSGT wrote:The theory is that your still having very mild hypopneas that go unnoticed with the recording technique being used. If you used an intra-esophageal pressure transducer you would probably see the events but that involves a catheter through your nose and down your throat, try to sleep like that!Uncle_Bob wrote:I've often wondered why my report came back with the phrase
no obstructions were observed at 6cm but 7cm was required to achieve the appropriate REM stage sleep.
I thought the pressure eliminates the obstruction I don't understand how pressure can change REM stages
I loved my titration study as I've never felt as good as I did the day after. But I'm working on it
So instead we do increased pressure trial, the current pressure eliminates obvious resp events but you continue to have arousals or just go a very long time without any REM, more pressure or less, try more until you make it better or worse, then less pressure until you make it better or worse. It's as much science and it is an art, using set scoring rules but also using what we would call tech intuition. Auto CPAP is great technology but it can't do that.
Thats why the lab determined pressure is sometimes different than an auto cpap determined pressure. Neither is better than the other, what matters is how you feel after a full night of sleep on that particular pressure. Some do better on Auto some do better on a set pressure, very patient dependant. If you still feel poorly on your lab pressure try auto, feel poorly on auto maybe you need an in the lab cpap titration. I hope this helps your understanding.
After my septoplasty and turbinate reduction surgery I'd thought i'd try a lower pressure so i went to 4cm. To my surprise the S9 used 4cm - 4.5cm for over 70% of the night, but i do not recall any dreaming. Also 4 cm is very hard to breath in with if i get the slightest bit of congestion. I think i'll go back to 7cm as my lower end.
I agree that a titration requires a lot of skill and effort. Maybe I should tip my titrator before i start my next titration study
Re: Hey, you experts exactly HOW do you perform lab titrations?
Naw, just take your tech a plate of homemade fudge or homemade cookies or a homebaked apple pie. Some kind of eating goodie.
_________________
Mask: Quattro™ FX Full Face CPAP Mask with Headgear |
Additional Comments: PR SystemOne BPAP Auto w/Bi-Flex & Humidifier - EncorePro 2.2 Software - Contec CMS-50D+ Oximeter - Respironics EverFlo Q Concentrator |
Women are Angels. And when someone breaks our wings, we simply continue to fly.....on a broomstick. We are flexible like that.
My computer says I need to upgrade my brain to be compatible with its new software.
My computer says I need to upgrade my brain to be compatible with its new software.
Re: Hey, you experts exactly HOW do you perform lab titrations?
Yes,on our tour of the facility when the tech showed us the control room, there was a nice little buffet going on back there!
_________________
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Additional Comments: 14/8.4,PS=4, UMFF, 02@2L, |
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- Big Daddy RRT,RPSGT
- Posts: 250
- Joined: Wed Apr 28, 2010 5:46 pm
- Location: Jackson, Michigan
Re: Hey, you experts exactly HOW do you perform lab titrations?
Yes, Yes, Yes, Yes, you understand.djr1215 wrote:I wish I had been at your place! I was handed a nasal mask, no questions, no fitting, nothing. I asked about a full-face since I am a mouth breather and they said no.Big Daddy RRT,RPSGT wrote: When you put the mask on the patient, then you go back to your control room, how does all this work? Well after talking to your patient you try to determine the best mask for them, sensitive skin?, mouth breather?, sinus problems?, side sleeper?, facial abnormalities? etc then you have to take the time to try different masks until you find a comfortable mask that minimizes leaks.
But while you are explaining, please explain this part:
SLEEP EFFICIENCY: He was studied for 381 minutes. He slept for 282 minutes for a low sleep efficiency of
74.0%.
SLEEP ARCHITECTURE: Sleep latency was long at 34 minutes. REM latency was long at 125 minutes.
Stage awake 20.09%. Stage I 2.2%. Stage II 64.5%. Stage m 9.3%. Stage REM 11.3% Review of the sleep
histogram shows poor sleep efficiency with wake after sleep onset.
Does that mean I slept 74% of the time studied and that it took me 34 minutes to go to sleep? 125 minutes to get to REM? and that I wake up after finally getting to sleep?
_________________
Mask: Mirage Quattro™ Full Face CPAP Mask with Headgear |
Humidifier: S9™ Series H5i™ Heated Humidifier with Climate Control |
Additional Comments: 13-20cmH2O,EPR of 1,Humidifier at 3, Climate line at 75 degrees,Chinstrap,Tubing cover |
I am on a life quest for the perfect night's sleep...Keep trying...Good sleep can blow!
- Big Daddy RRT,RPSGT
- Posts: 250
- Joined: Wed Apr 28, 2010 5:46 pm
- Location: Jackson, Michigan
Re: Hey, you experts exactly HOW do you perform lab titrations?
Tips and food to bribe the sleep tech? You are my kind of patients!
_________________
Mask: Mirage Quattro™ Full Face CPAP Mask with Headgear |
Humidifier: S9™ Series H5i™ Heated Humidifier with Climate Control |
Additional Comments: 13-20cmH2O,EPR of 1,Humidifier at 3, Climate line at 75 degrees,Chinstrap,Tubing cover |
I am on a life quest for the perfect night's sleep...Keep trying...Good sleep can blow!
Re: Hey, you experts exactly HOW do you perform lab titrations?
*wicked grin* What can I tell ya? I'm not very domesticated but I have this recipe for EZ Apple pie that even "I" can make and its darn good! Unfortunately, my favorite sleep tech wasn't a regular at my sleep lab so he didn't get a "treatie" yet but when and if I run into him again you can bet your bippy he will get an EZ Apple pie!!!
And the neat part is the hardest part of making this pie is the coring and peeling of the apples!!!! No kidding! (Hey, when I say even "I" can make it, you HAVE to know it is easy). Heck, it took me years to learn to make No-Fail Fudge that didn't fail.
You treatta me good, I treatta you good. We both be happy. (And if not careful will get fat).
And the neat part is the hardest part of making this pie is the coring and peeling of the apples!!!! No kidding! (Hey, when I say even "I" can make it, you HAVE to know it is easy). Heck, it took me years to learn to make No-Fail Fudge that didn't fail.
You treatta me good, I treatta you good. We both be happy. (And if not careful will get fat).
_________________
Mask: Quattro™ FX Full Face CPAP Mask with Headgear |
Additional Comments: PR SystemOne BPAP Auto w/Bi-Flex & Humidifier - EncorePro 2.2 Software - Contec CMS-50D+ Oximeter - Respironics EverFlo Q Concentrator |
Women are Angels. And when someone breaks our wings, we simply continue to fly.....on a broomstick. We are flexible like that.
My computer says I need to upgrade my brain to be compatible with its new software.
My computer says I need to upgrade my brain to be compatible with its new software.