Do I Need a Titration Test?

[Ansan]

Hi everyone,

I am an American living in Korea and finally decided to see a sleep specialist due to concerns from my girlfriend that I wasn't breathing during my sleep. Unfortunately, my Korean national health insurance coverage does not cover sleep disorders so I have to pay everything out of pocket. I had a USD$7 consultation with the doctor who recommended I undergo a $700 overnight sleep study. I just completed the study last night and the results were an AHI of 90- ouch!

They said I have severe sleep apnea and that I will need to come back in 3 weeks to undergo the overnight titration study at a slightly reduced cost of $600. In the meantime, they rented me an APAP machine for the next 3 weeks at a cool $200. The doctor said that the APAP machine should eliminate about 70% of my apneas but that my results will be much better with a CPAP set-up right after the titration study.

I am already out almost $1,000 and I haven't even bought my own machine yet which they are selling for between $1,300-$1,500.

Here are my concerns:
1) Do I really need to spend another $600 for a titration study when APAP basically eliminates the need?
2) My results showed an AHI of 96 when I sleep on my back but only 40 when I sleep on my side. Won't APAP be better for me since I change sleep positions?
3) I have been losing weight (15 pounds) but have about another 70 pounds to go. Won't steady weight loss over time interfere with the CPAP settings they recommend from the overnight titration study?

Sorry for all of the newbie questions, but I don't want to waste money if I don't have to. On a side note, tonight will be the first time I ever use an APAP machine, so I am really curious how I will feel tomorrow. Hope it goes well! Thanks

[Julie]

Hi - Apap will eliminate the need only if you use good software and know how to interpret the results - which we can certainly help you with if you keep in close touch until things are stable. If you're in a position to do that, great. Do you have any idea which machine and model you're slated to get? Most of us choose those, based on recommendation and our own 'research' (there are really not many decent choices in the end and we can certainly recommend the few) and hopefully you'll be able to do the same. And btw, you can use various tricks to stay off your back altogether, though once on Apap, it may not matter as much. When giving us the machine details (if you can get them) try to include all printing on the top, and (if you use a humidifier) after emptying the water, turn the machine over and add all figures there as well, because telling us it's a "ResMed (or Respironics) Auto" is not enough - there are very many models with that designation.

[Ansan]

Hi Julie,

Thanks for getting back to me so quickly. The machine I am renting for the next 3 weeks is a "ResMed S9 AutoSet" with the "H5i" humidifier. Because the Korean prices are double of what I am seeing from the states, I am going to buy my machine from a US website and have my mom send it over to avoid the high customs tax.

So if I understand you correctly, the titration study will be a waste of time and money if I buy a decent APAP machine?

[grayghost4]

The S9 Autoset is a very good machine and is compatable with Sleepyhead software.
So you will be able to monitor what is happening with your therapy
This site will give you a lot of information and there is a link to sleepyhead there

https://sleep.tnet.com/main

this page will give you link to sleepyhead:
https://sleep.tnet.com/resources/sleepyhead

[Julie]

Well... I don't like to say it would be a complete waste, but if you can communicate often and closely here, you probably don't need the formal set-up... Are you sure your lab test said you 'only' have obstructive apnea and not any other related stuff like more than a few waking and falling-asleep centrals? Or possibly UARS, RERA, etc? If you could post a copy of the results here it would help us to advise... Imgur.com is a good place to put your pix (it'll explain how) and then post a link to this thread.

What about masks? They're usually the #1 issue for newbies and can make or break your Cpap experience... any idea what they're proposing for you to use? Have you been noted to mouth breathe once asleep? It also can make a difference to therapy. You can look at Cpap.com's mask array - best variety and prices out there - to get some idea of what's new, popular, ratings, pix, etc. etc.

[Deep Sleep]

So if I understand you correctly, the titration study will be a waste of time and money if I buy a decent APAP machine?

Not necessarily. The titration study saves you a lot of time and it certainly may save you money if it comes to light you need a bilevel (VPAP or BiPAP) machine over the basic mono-level APAP.

[Sircadian]

Many of us have learned through the help we received here. Feel my care now is better than anything the 'establishment' was providing.

Just need to put a little time into reading and become knowledgeable enough to run software (Sleepyhead) that monitors machines that are fully data capable. If you have a data capable device now (rental), it is accumulating data that could be useful for setting the pressure on the machine your mom sends. You will have to learn how to d/l the software and post a couple screen shots with the graphs that show what the auto is doing ..... for a few nights. Easily doable, g'luck and post your questions if you go this route.

Edit: now see a few of us posted at the same time , ignore repeated info.

[englandsf]

With a pretty high AHI I would try and do the study to rule out any other sleep problems.

But in the meantime concentrate on getting a good mask fit and feel and ask what starting pressure range your S9 will be set up with. Be wary if it's 4-20. Come back here if it is

Good luck, remember you NEED CPAP - it will literally extend your life. The weightless will help but with your AHI (similar to mine) you're probably on it for life. I know I am.

[Ansan]

Wow, thanks for all of the great advice and support. It seems like you all have a nice little community here. I've gone ahead and uploaded my sleep test results to Dropbox if anyone cares to take a look. The numbers still don't really mean that much to me yet as I still need to educate myself much more about this condition.
https://www.dropbox.com/sh/872wgi7rvjff ... seRQa?dl=0

Could someone explain why my doctor said that the APAP machine I rented would only provide 70% relief from my sleep apnea but a CPAP machine calibrated after my titration test should provide almost 100% relief? Perhaps I am being a touch paranoid, but I can see how lucrative it is for the doctor to conduct overnight sleep/titration tests at $700 for each patient. I'm worried that he is overselling CPAP (instead of APAP) because it gives him a steady cashflow of having patients conduct a new titration test every couple of months. If however there are legitimate therapeutic reasons as to why according to my particular test results CPAP would be superior to APAP, then I will happily follow the doctor's advice.

[Pugsy]

The titration sleep study wouldn't be a total waste of time and money but it is possible to do what you want to do without it as long as you don't have any complicating factors pop up with the addition of cpap therapy.
The one potential complication that we have to think about is some people develop central apneas as a response to cpap pressures but the chances of that happening are not horribly high. Somewhere around 10 to 15% of cpap users depending on who you believe. If that happens then a different machine might be needed.
2 to 3 weeks on the loaner rented S9 AutoSet would show the centrals if that should happen. Cross that bridge if and when you need to.

Did you know that all the apaps come with a cpap mode available? Yep..they do. If for some reason you determine that you prefer cpap mode all you have to do is switch it over to cpap mode. No need to buy another machine in that regard.
Using APAP to get to the same success rate as cpap RX provided from a titration study is easy...not difficult if you know what you are doing and it doesn't take a rocket scientist to figure it out. Just takes a little education on your part and some time here so you understand what you are seeing on the machine's data.

[Pugsy]

A word about in lab titration sleep studies...in a perfect world they work out great and we come out of them with a spot on number that should fix all our problems. Unfortunately we don't always get a perfect world and stuff happens that prevent that one night in a foreign bed can't always deliver spot on recommendation for any number of reasons.

Example...I had an in lab sleep titration and I slept so poorly that I didn't get but a handful of minutes of REM sleep where my OSA is worse and where I happen to also need a lot more pressure than when in non REM sleep. So I came out of the sleep study with a RX for cpap 8 cm. Yeah, works great in non REM sleep but in REM sleep things go to hell real fast....I found with my APAP (purchased on on my own) that sometimes I need pressures over 15 cm in what is probably REM sleep.
Let's see....I could use over 15 cm pressure all night long on a cpap mahcine or I could use an apap at around 9 minimum and let it go to 20 (have seen 18 & 19) when needed....duh...guess what my choice was.
If I had more REM during the titration study this might have been found out but I only got 6 minutes of REM and that's not enough to really see where the pressure needs went.

My thoughts....you have to buy a machine anyway...go get the APAP that you want (and the ResMed Autoset would be a great choice) and try figuring out the pressure on your own with the APAP....should you run into trouble you can always have the titration study later....it can be plan B on the back burner for now.

[grayghost4]

I have a S9 vauto machine I will ship to your mother.

the vauto is resmed name for the Bipap machine, it can be set to cpap if it turnes out that is better for you or used as an auto.

http://chicago.craigslist.org/nwc/hab/4994200725.html

[yaconsult]

You've already gotten great advice. I'll just add that the sponsor of this site cpap.com has some of the best prices available for brand new machines - definitely compare them to any other prices you find.

For used machines sold with a warranty secondwindcpap.com is the recommendation.

But note that you will need a prescription from a doctor to buy from any of them. This may be your problem - if the doctor is unwilling to give you a prescription without you having the titration first. I think you could make an excellent case that you are going to buy a data-capable machine and are involved with an online support community and will monitor your results with the SleepyHead software. But it's possible that the doctor will say, no titration, no prescription. What will you do then?

Any doctor can write a cpap prescription - even your GP. Or maybe you have a former doctor in the US that you could send a copy of the sleep study to and he would be willing to write you a prescription?

Or, you could buy a machine from one of the known posters here who sometimes sell machines. That would take care of the prescription issue.

[Julie]

Grayghost has already offered an S9 auto...

[hyperlexis]

Do you need it? Ideally, yes. It will save a lot of guess work and time, frankly. If you can afford it or get it done less expensively or get the government insurance or something to cover it then try to exhaust all your options first. Even maybe travel to a nearby country and see if they can do things for less?

An auto machine does not really eliminate the need for a titration study -- it helps but does not eliminate it. Many people are given auto machines that are set wide open 4-20 (for apap). My machine was set this way and it wasn't great. So with an apap machine set wide open then every single night the machine has to start at the lowest level, then wait until you start having apneas, then ramp up and down, over and over and over. This roller coaster ride does not lead to restful sleep. On newer PR APAPS (60 series) they have a special "OptiStart" setting that tracks your pressure needs over 30 hours and adjusts the future starting pressure as appropriate. So that can sort of help self-titrate things and tighten up the pressures. Not perfect but better than other apaps that re-set every night back to the lowest number. For me my DME looking at my numbers adjusted things higher than my original prescription, as did the optistart system, to start at 7. Eventually once I did get a titration study, they found I actually needed to be at around 12. So that's my new start number.

So basically, if you can, get the titration study. Otherwise perhaps consider the respironics machine. Barring that prepare to make a lot of adjustments over the next few months.