Accuracy and Value of Titration Studies?

[Jay K]

It seems that many on this board believe one's AHI improves as one becomes more acclimated to a CPAP, APAP, or BIPAP machine. Additionally, when one changes masks it seems there is an acclimation period as well. From this, it would also seem to follow that as one changes other aspects of the environment, e.g., the bed one sleeps in, the pillows one uses, this may also affect the AHI results. I myself have seen these effects in my own experience.

So, given all this (and assuming there is at least a reasonable element of truth to it), of what value is a titration study, particularly an initial one when you are in a sleep lab using equipment you have never experienced before, and so forth? Wouldn't the better approach be to conduct a sleep study and then give the patient an auto machine once it is determined he or she has obstructive sleep apnea?

I should add that although I can see some value in using a titration study to set the general pressure ranges on the auto machine, I'm particularly wondering whether such studies are sufficiently accurate to be used to set fixed pressures on CPAP machines.

[jnk]

It seems that many on this board believe one's AHI improves as one becomes more acclimated to a CPAP, APAP, or BIPAP machine. Additionally, when one changes masks it seems there is an acclimation period as well. From this, it would also seem to follow that as one changes other aspects of the environment, e.g., the bed one sleeps in, the pillows one uses, this may also affect the AHI results. I myself have seen these effects in my own experience.

So, given all this (and assuming there is at least a reasonable element of truth to it), of what value is a titration study, particularly an initial one when you are in a sleep lab using equipment you have never experienced before, and so forth? Wouldn't the better approach be to conduct a sleep study and then give the patient an auto machine once it is determined he or she has obstructive sleep apnea?

I should add that although I can see some value in using a titration study to set the general pressure ranges on the auto machine, I'm particularly wondering whether such studies are sufficiently accurate to be used to set fixed pressures on a CPAP machines.

I consider the titration study to be the most valuable and useful part of the entire sleep-medicine dignostic/treatment process, but it doesn't take the place of using the machine and using data over time to perfect the pressure(s).

A good titration study sees what helps a patient in worst-case scenario--supine position during REM. It documents how the patient reacts to the pressure and finds out if limb movements or pressure-centrals are caused. In my case, I fought the pressure in my sleep until the tech flipped me over to bilevel, and I immediately reacted well to it.

A sleep study is a snapshot taken on a non-standard night, but it is still valuable. Having an efficacy-data machine is important too, to see what pressure needs are over the weeks and months to follow. In my opinion, the best treatment isn't a matter of either/or. Good treatment involves a good titration AND tweaking pressure based on data from a home machine. Both.

jeff

[JStaggie]

Well, I think that the fact a sleep titration study is done with full EKG, airflow, and other sensors, not merely with the CPAP machine statistics, that the technician may be able to use the data available to determine a titration such that the variance due to environmental variables is reduced.
That said, the med center that ran my sleep study conducts their studies in four custom hotel rooms at a local hotel rather than in the hospital so that patients are more comfortable. As a business traveller I felt right at home: my study showed that I was asleep in 1.7 minutes after lights out.

[goose]

Jeff's right -- Titration is supposed to be the most important part of the whole shebang.......

Mine was useless!!!! I don't know how they titrated me at the pressure they did, I can't breathe at that low pressure...I was titrated at 5cm.....I'm on an auto at 11-15cm......I thought I was going to suffocate that first night.....
I have done better with my auto machine and encore pro.......

cheers
goose

[Gerald]

I agree with Goose.......

My (3) sleep studies were all but useless......and my successful treatment has been done on my own.

Do the sleep study.....get the script (write it yourself so that is done correctly....have the doctor give you one that matches what you've written)......buy your own equipment......get the software.....and do your own thing.

Gerald

[kteague]

While titrations in the lab are not a guaranteed success, I do see their value for those whose pressure need is higher and may cause centrals, and for those who might have PLMD and have the movements show up upon using the cpap to control their apneas. Granted, this is just a small segment of those diagnosed with OSA, but to that number, it matters a lot.

[JohnBFisher]

... Granted, this is just a small segment of those diagnosed with OSA, but to that number, it matters a lot. ...

And what we - as laymen - do NOT see are the labs and patients to end up dealing with VERY serious conditions. I've talked with my sleep techs who have all recounted times they had to call 911 to transport someone to an emergency room.

Now, while some people have had problems with their titrations most sleep labs do a good job. But it all depends on the lab and the sleep tech involved.

Like everything else, you should actually interview your sleep lab. Check on their credentials. Talk with lab manager. Talk with the sleep techs.

Doing that, I've only had one poor experience. And even that provided an "okay" setting. That lab just failed to highlight the central sleep apneas during sleep onset. While in most situations it is not a big issue ... if those in and of themselves cause you to not sleep, it should be highlighted. That work of that lab kept me from getting effective therapy for at least two years. They've since changed management.

kteague is definitely correct. For anyone dealing with a complex sleep problem a good sleep lab matters a LOT !

[RLAUREN]

JohnBFisher and jnk THANK YOU FOR THE TIME AND WISDOM YOU PUT INTO YOUR ANSWERS.
I am new to whole thing and take it very serious. The more I read, the more I realize that I don't know very much. There is a cause and effect to everything we do, This becomes even clearer after I see all the data that goes into a Titration Study. I think that Sleep Apnea is a big enough risk in my life, that I need a team. I look at myself as the Player/Manager. As a player or a manager I should not be doing things on my own. But as the manager, I should be making sure that all the members are the best at their roles. I can only do that with knowldge. That is why I come here. If a team member,( doctor, or DME or...,) is not doing their job, I do not take over their job, I coach or find a replacement. I will fail myself if I go it alone. A xPAP Machine is a valuable medical piece of equipment. Before I change the play I should make sure the team is there to help make it happen or identify possible risks.

Again, thank you all for making me better Player/Manager. GO TEAM

[DreamStalker]

Also have to keep in mind that accuracy and precision are different. One-night titration studies are generally more precise than using an APAP but not always more accurate than using an APAP over a longer period.

As already mentioned. Titration studies have value and merit for reasons other than accuracy.

[JohnBFisher]

... The more I read, the more I realize that I don't know very much.

... I look at myself as the Player/Manager. As a player or a manager I should not be doing things on my own. But as the manager, I should be making sure that all the members are the best at their roles. I can only do that with knowldge. That is why I come here. If a team member,( doctor, or DME or...,) is not doing their job, I do not take over their job, I coach or find a replacement. I will fail myself if I go it alone. A xPAP Machine is a valuable medical piece of equipment. Before I change the play I should make sure the team is there to help make it happen or identify possible risks.

Again, thank you all for making me better Player/Manager. GO TEAM

Very good analogy!

I always recommend that we should discuss the situation with our medical team. During my last visit, I raised some questions about leaks and my VPAP Adapt SV. I also noted that I did not think my pressure had been set correctly. My doctor was very upset. He knew how much I had gone through to just get the unit I had. He wanted the therapy to be as effective as possible. He did not panic when I noted I knew how to adjust the pressure. He just asked me to set it to the prescibed pressure and track my progress.

So, we discussed what to track, how to track it, and what to bring back to him. I'm having problems with some very unusual pulse oximeter patterns. He's concerned and wants me to track it.

Of course the need to involve the medical team is even more important the more complex and/or life threatening the problem. Someone with cardiac problems using an ASV unit should NOT start changing settings unless they have involved their medical team. Period.

But an otherwise healthy person who has obstructive sleep apnea can set their pressure fairly accurately - even without a data capable unit !! I would still involve my medical team in that situation, but it certainly does not involve as much risk.

[Luc]

It seems that if you have experience with these things, then the advice to interview your sleep team/lab can probably render a more meaningful titration. But this only applies to the few, or so I think. Personally, when I went to my titration, I basically didn't know anything about anything. They hooked me up to those bedamned 50 or so wires, put a mask on me and was told to sleep. Well from 10:00PM to 02:00 AM, I slept all of 11 minutes. The titration was deemed as unsuccessful. If I had gone to the sleep lab with the knowledge I have today , I could've had a much better night. So, no. For me the titration was useless.

Luckily, my doctor put me on an APAP and I was permitted to test it at home. I responded very well and the ideal pressure was obtained after a couple of weeks. True, no one was there to observe my REM or delta waves or check for toe wiggling or snoring or pulse... but what would this have changed. Nothing. The bottom line is my breathing. I say spare us the agony. If OSA is determined first time around, then give us an automatic machine.

[Jay K]

I can certainly see that a good titration study can help determine whether centrals are going to be induced by particular pressures, and so forth, but I haven't seen anything here to suggest a single titration study is a reliable way to set an appropriate fixed pressure on a CPAP machine given the variables I identified in my first post. But isn't that essentially what is being done for those who are given CPAPs rather than APAPs? And I guess following up on this train of thought, with the availability of APAPs isn't it borderline malpractice to give a patient a CPAP based on a single titration study?

I must admit this is more an issue of curiosity than anything else (I have an auto), although the discussion may also be helpful to those who are new to this and getting their first machine (or considering asking to replace a CPAP with an APAP).

[montana user]

I believe a successful titration study is 100% on the sleep techs shoulders! I take great care in doing my titrations, but I have seen many techs who go for long coffee breaks, and could have/should have raised the pressure at least twice while they were gone! During titrations, I make very quick trips for my coffee, bathroom, etc. I dont want to miss any opportunity to raise the pressure if it is needed. someone on here stated they were titrated to 5cm??? Thats the starting pressure! If you walk our of a lab with a pressure of 5cm, either the tech fell asleep, or you could use a dental device instead of CPAP.

I do like the question that was posted though. I always tell my patients that once they get home with their CPAP, they won't have all the wires on them, so hopefully it will be easier to get adjusted once they are home. I feel with a good sleep tech, you can get an accurate titration study. Of course Im a little bias...

[jnk]

A good titration gives you a good start. That's important.

From then on, having an efficacy/leak data machine is the important thing. The best thing about autos is that they give you efficacy/leak data. But a person can self-titrate with a CPAP, too. Even a person without data can self-titrate by how they feel. But having the data from the titration sleep study, especially the pressure charts, can be very useful if figuring out which direction to try with the pressure.

jeff

[Slinky]

jnk, YOU taught me that in-lab titration and fully data capable CPAP are COMPLIMENTARY. The in-lab titration give us a "starting point" (and can detect any of the other some 80 sleep disorders that might be present and coexisting w/OSA) whilst the fully data capable CPAP provides the TRENDS in our sleep and therapy and indicate any changes that MIGHT need to be made.