Curious...How many of you are running APAP vs. Constant Pressure?

[Lucky7]

There seems to be a fair amount of "debate" between auto titration vs running a constant pressure. The argument for constant seems to be preventing events before they happen.

How many of you run

1. APAP
2. CPAP
3. APAP with a tightened up pressure range?

And, what's your rationale for each?

[Jimmy Lotus]

I'm running APAP from 9-13 cms and it's been working out really well for me. Not sure if 9-13 counts as a "tightened-up" range. I ran without EPR for the first night and it was disastrous.

[Pugsy]

The argument for constant seems to be preventing events before they happen.

The same argument could be made for using auto adjusting pressures....the key is to have that minimum pressure set to prevent the bulk of obstructive apnea events from ever happening and let the machine increase the pressure if needed for some outlier reason...like position change or REM stage sleep differing pressures needs.

My OSA is 5 time worse in REM only...and sometimes I might need 6 to 8 cm more pressure just during REM.
To use a fixed pressure that prevents EVERYTHING I would have to use around 15/16 cm all night long.
REM is about 20 % of the night on a good night. Why in the hell would I want to use 15 cm all night just for that 20% of the time when around 8 or 9 cm does a good job the rest of the night? I have my minimum set so that the machine can get to where it needs to be in able to deal with the REM pressure needs.

The main reason that auto adjusting pressures get a bad rap is because people think that they can use the factory defaults with the minimum starting pressure being 4 and let the machine figure it out....doesn't work that way unless someone is lucky enough to need maybe 8 cm to deal with everything. They blame auto adjusting for wide open failing and expect the machine to work miracles.

And a "tight range" means nothing if a person never reaches that max setting anyway....but it seems to make people feel better.

[LSAT]

Mine is 12/20.....I average 13 and the highest I get is about 16.5

[djont57]

APAP...because it works best for me. Yes, I have tried CPAP.

[Lucky7]

"The main reason that auto adjusting pressures get a bad rap is because people think that they can use the factory defaults with the minimum starting pressure being 4 and let the machine figure it out....doesn't work that way unless someone is lucky enough to need maybe 8 cm to deal with everything."

You know (hopefully I can find it again) but I read an interesting paper the other that indicated that 9cm H20 is about "right" for a majority of people (with a normal distribution) around it. I thought it was a decent argument for 9-20 as default, instead of 4-20. I'll see if I can find it and post the link.

Also, I had oximetry on the other night and...I'll post a screenshot later of that....unflagged RERA's coupled with desats. So, I somewhat understand why people thing the algo's aren't as good as they could be.

[lazarus]

APAP 8-20.

To way too many docs, the phrase "using APAP" means 4-20. That is because that is how manufacturers originally advertised APAP. But patients in forums quickly discovered as an online community that raising the minimum to within one or two cm of what a person needs to prevent obstruction often greatly lowers AHI and gives a combination of all the benefits of APAP and all the benefits of straight CPAP simultaneously--giving the best sleep.

There are, of course, exceptions to every rule of thumb, so one approach does not fit all. Nevertheless, exceptions seem to be relatively rare, based on the anecdotes of what I've read online from PAP-therapy users. Despite what the YouTube entertainers may say to grab newbie eyeballs.

Unfortunately, docs and manufacturers are not good at learning from patients.

The primary point, though, is that the phrase "using APAP," or "running APAP," means different things to different people, so the comparisons of APAP to CPAP are meaningless without very clear definitions for success and for therapy approaches and for patient phenotypes.

The closely-related bottom line for self-pressure-tweaking patients is "do whatever gives YOU the lowest AHI and the best sleep over time." And don't depend on your medical team to figure that out for you; your quality of sleep and quality of life naturally mean much more to you than to them.

[Pugsy]

You know (hopefully I can find it again) but I read an interesting paper the other that indicated that 9cm H20 is about "right" for a majority of people (with a normal distribution) around it. I thought it was a decent argument for 9-20 as default, instead of 4-20. I'll see if I can find it and post the link.

So.....what would you have someone who never, ever went above 8 cm be using?? You think that it is a good idea to force you to use a setting just because the majority used that setting? What if the "majority" seemed to need 13 cm and you only needed 8 cm?

I don't like it when everyone gets the settings because "the majority did well with so and so".
There are just too many variables among people in general to make such a blanket statement.

None of this stuff is set in stone because we are all individuals with differences in so many things....

The default settings are just what they say they are but they aren't intended to never be altered nor is the machine designed to only be used wide open forever. The medical people are supposed to follow up with an evaluation of those default settings by actually reviewing all the data available and making a more of an educated decision as to therapy needs. Many years ago most of us had to go to a sleep lab for the titration sleep study to find optimal pressures but now post Covid it's not the case so much any more. News flash...even the in lab titration studies didn't always get it right.
They didn't for me.

What's the "BEST" therapy? Is it cpap or apap or bipap??? None of the above.

The BEST therapy (or best mask) is whatever works for YOU the individual....not what works well for some guy next door or on this forum or just because it works well for the majority.

I tell people to try both modes (fixed or auto adjusting) if they wish and they decided what seems to work best for them.
Some do better on fixed...some do better with auto adjusting...you don't ever know unless you try.

[Miss Emerita]

I was diagnosed with moderate obstructive apnea but see almost complete elimination of obstructive events with an EPAP of just 5. My sleep is pretty fragile, so I used fixed pressures just to eliminate one possible source of disruption. I use PS of 5 because it did wonders for flow limitations. Again, with PS for FLs I am just trying to avoid potential disruptions.

As so many others have said, what works for one person may make no sense for another. I think a data-informed readiness to experiment is vital in finding what works best for each person.

[Lucky7]

"I don't like it when everyone gets the settings because "the majority did well with so and so".
There are just too many variables among people in general to make such a blanket statement."

No, hey I totally get where you are coming from here.

Here's that paper I mentioned:

https://diposit.ub.edu/dspace/bitstream ... 712108.pdf

The (interesting bits, I think anyway) that dovetails with what Larazarus suggested above "8-20cm"

"Given that individually titrating CPAP is not a life-threatening issue and is not of
critical importance to achieve a radical improvement in the patient’s health, it is reasonable
to think about alternative simplified procedures leading to similar therapeutic effectiveness.
Hence, based on the new data presented herein and based on conceptual assumptions, we
propose that in case that personalized CPAP titration may impede or substantially delay
treatment, CPAP should be initially prescribed at 9 cmH2O to all recently diagnosed OSA
patients who would normally be eligible for this treatment, and that in case the patient
still manifests residual symptoms, then a visit to the healthcare staff would be needed to
modify the CPAP settings. To further reduce the burden to health systems, particularly
in low-resource settings, it could also be possible to ask the patient to adjust the CPAP
setting (within a safety preset range) depending on symptoms and comfort. In fact, such a
patient-empowering procedure has proven its worth in a seminal study that surprisingly
has seen no continuation and further validation despite the promising results [12].
3. Data on Conventionally Prescribed CPAP in OSA
Analysis of the actual distribution of CPAP pressure settings in clinical practice provides the required justification for the proposed alternative procedure. Figure 1 shows
information usually not provided in the literature and consists of the histogram of the
actual pressure settings for nasal CPAP retained for treating 16,780 unselected patients who
underwent conventional CPAP titration in the area of Catalonia, Spain. These data reveal
that the mean (±SD) of CPAP pressures retained for the treatment of this large cohort of
patients was 9.3 ± 1.7 cmH2O, and constitute pressure settings that are remarkably similar
to those reported in many research studies involving smaller numbers of patients who were
selected/excluded according to specific criteria [13,14]. Most interestingly, the real-life data
in Figure 1 indicate that 67.4% of patients are treated with CPAP values within a range
of 8–10 cmH2O, i.e., differing by only ±1 cmH2O from the mean of 9 cmH2O. Moreover,
in an additional 19.0% of patients—i.e., those treated with CPAP settings of 7 (8.2%) or
11 cmH2O (10.8%)—a CPAP pressure of 9 cmH2O would represent a difference of only
±2 cmH2O from the pressure settings selected through personalized titration. Thus, after
individualized and labor-intensive and expensive CPAP titration, 86.4% of OSA patients
are treated with nasal pressure settings within the range of 9 ± 2 cmH2O

Bolsters Lazarus's idea of setting min at 8cm....ish....8ish. And let the machine handle the variations.

Lots of other interesting other tidbits in the paper about how nobody gets titrated in a lab today (they make a good point about how resource intensive it is, now that I think about it)

[Lucky7]

APAP 8-20.

To way too many docs, the phrase "using APAP" means 4-20. That is because that is how manufacturers originally advertised APAP. But patients in forums quickly discovered as an online community that raising the minimum to within one or two cm of what a person needs to prevent obstruction often greatly lowers AHI and gives a combination of all the benefits of APAP and all the benefits of straight CPAP simultaneously--giving the best sleep.

There are, of course, exceptions to every rule of thumb, so one approach does not fit all. Nevertheless, exceptions seem to be relatively rare, based on the anecdotes of what I've read online from PAP-therapy users. Despite what the YouTube entertainers may say to grab newbie eyeballs.

Unfortunately, docs and manufacturers are not good at learning from patients.

The primary point, though, is that the phrase "using APAP," or "running APAP," means different things to different people, so the comparisons of APAP to CPAP are meaningless without very clear definitions for success and for therapy approaches and for patient phenotypes.

The closely-related bottom line for self-pressure-tweaking patients is "do whatever gives YOU the lowest AHI and the best sleep over time." And don't depend on your medical team to figure that out for you; your quality of sleep and quality of life naturally mean much more to you than to them.

Very well said, I appreciate the thoughtful response Spot on about docs, and not depending up on your medical team. Unfortunately eh?

I showed my doc OSCAR and he was like "wow, this is really cool". I have to admit I was a bit nervous about it, but I know him pretty well and in retrospect I was probably nervous for no reason.

[Lucky7]

I'm running APAP from 9-13 cms and it's been working out really well for me. Not sure if 9-13 counts as a "tightened-up" range. I ran without EPR for the first night and it was disastrous.

Love your T-Shirt, that's great

[chunkyfrog]

Auto was exactly what I needed.
I was stuck with single pressure for 9 months, and the aerophagia was
HELLACIOUS!
I may have eventually quit cpap if there was no auto.

[CPAP-A-MUST]

Cannot use APAP…woke me up several times a night in brief spurts. Once I fine turned my fixed pressure, it made all the difference. My OSA is mild and my pressure is 9.2. It has been perfect the last two years.

[Lucky7]

Auto was exactly what I needed.
I was stuck with single pressure for 9 months, and the aerophagia was
HELLACIOUS!
I may have eventually quit cpap if there was no auto.

Thank for your input