Can Patients with OSA Titrate their own Pressure

[Mikesus]

The topic said self titrate, not self diagnose. The idea is that if you send someone home with an auto, you could avoid a kilobuck sleep study.

[Zees Pleez]

As far as diagnosis, it seems like they could do some kind of at home screener. Years ago I was given an audio recroding device by an ENT that (according to him) diagnosed mild apnea. He did the laser uvula surgery that did nothing but mask a symptom, but that's another story. Are there any such devices that are reasonably reliable?

I think self titration is a slam dunk, especially done the way it was in teh French study, where the docs saw daily reports.

[-SWS]

Diabetics are often taught to self-titrate. Why not apneics, then?

[Joe A]

Mikesus:

My diagnostic study was a split night study. I was diagosed and titrated in the same study. It's the same price as a titration study. If the current wisdom is to do two studies, one for diaganosis and one for titration...then yes....you can save thousands if renting an APAP with software for a week. The only question/coment I have is that CPAP is not for everyone. During the two titration studies I have had....they tried like heck to titrate me on a single level device, but it failed miserably! APAP is a self titrating CPAP...it is not a bilevel machine. Those that really need BiPAP will be improperly titrated with an APAP.

That's why I say...have a split night study...if CPAP is for you, it sounds like APAP may be better. If you are a BiLevel user, then an APAP won't treat you. People who have mixed Centrals/OSA are usually titrated with BiPAP on a very wide spread like say 16/10. Folks like me with several blockages need high pressure, so BiPAP with a spread of 4 works. APAP would likely have me at 14-16CM most of the night.

[wading thru the muck!]

Joe A,

Do you know what percentage of xPAP users are using a biPAP? I'm curious relative to your previous post what the likelyhood of someone self titrating with an auto-pap ultimately needing a biPAP. My guess is a large majority of xpap users do not have any condition that would warrant the use of a biPAP.

Those of us on this forum in favor of self titration are targeting the large group of people with mild to moderate OSA who because of financial concerns related to the high cost of a lab titration have avoided getting treated. The medical community needs to be practical about the reality of facing medical costs of multiple thousands of dollars. If this can be avoided in a relatively safe manner then why not support it. In my case, even the copays were a significant investment. For many people it is not a just a choice of whether on not to spend the money, it's just not possible.

[Zees Pleez]

My diagnostic study was a split night study. I was diagosed and titrated in the same study. It's the same price as a titration study. If the current wisdom is to do two studies, one for diaganosis and one for titration...then yes....you can save thousands if renting an APAP with software for a week.

Mine was supposed to be split if possible, but I ran into complications with protocol. My apnea was getting worse as the night wore on; it wasn't constant. So the tech decided to run right up to the limit - protocol says 1:30 AM is the latest he can start CPAP for titration. He got the equipment ready and was about to come in when I dropped into REM. Another point in their protocol is never wake a patient in REM unless it is absolutely necessary. He said they are very picky about protocol and the detailed report allows him no flexability. It would have shown down to the second when he woke me and what stage of sleep I was in. Had I known that auto titration was an option I would have done that next. It was only by chance that I found out that the DME did it. I ask my doctor if he would write a prescription for APAP and he did - with no pressures specified. The DME interpreted that as a request for a 5 night titration study. When they finished that, he wrote another and specified a range.

[Mikesus]

Mikesus:

My diagnostic study was a split night study. I was diagosed and titrated in the same study. It's the same price as a titration study. If the current wisdom is to do two studies, one for diaganosis and one for titration...then yes....you can save thousands if renting an APAP with software for a week. The only question/coment I have is that CPAP is not for everyone. During the two titration studies I have had....they tried like heck to titrate me on a single level device, but it failed miserably! APAP is a self titrating CPAP...it is not a bilevel machine. Those that really need BiPAP will be improperly titrated with an APAP.

That's why I say...have a split night study...if CPAP is for you, it sounds like APAP may be better. If you are a BiLevel user, then an APAP won't treat you. People who have mixed Centrals/OSA are usually titrated with BiPAP on a very wide spread like say 16/10. Folks like me with several blockages need high pressure, so BiPAP with a spread of 4 works. APAP would likely have me at 14-16CM most of the night.

Those that need BIPAP are:

Conditions Frequently Treated with Bilevel Devices &/or NPPV
Now, physicians typically use bilevel therapy to treat a broad range of conditions, including some conditions that require 24-hour ventilatory support.
o Respiratory muscle dysfunction (CO2 >45 mm Hg)
o previous poliomyelitis
o muscular dystrophies
o myopathies
o Neurological disorders (CO2 >45 mm Hg)
o neuropathies
o bilateral diaphragmatic paralysis
o spinal cord injury
o brainstem lesions
o primary alveolar hypoventilation
o Chest wall deformity (CO2 >45 mm Hg)
o scoliosis
o thoracoplasty
o Upper airway disorders
o severe OSA
o obesity hypoventilation
o Lung disease (CO2 >52 mm Hg)
o COPD
o cystic fibrosis
o bronchiectasis
o Acute respiratory failure (CO2 >52 mm Hg)
o hypercapnic respiratory failure
o hypoxemic respiratory failure

Bilevel therapy is not typically prescribed for OSA patients; however, OSA patients who require high treatment pressures, OSA patients that can not tolerate exhaling against the set pressure of CPAP or OSA patients that have another respiratory condition like underlying lung disease (COPD) may be candidates for bilevel therapy.

Note it says SEVERE OSA and that it is not typically prescribed for OSA patients. With the auto machines that do not respond with pressure increases for centrals, and with the advent of Cflex, the use of Bipap for comfort will more than likely change. (In other words insurance companies will figure out that people can get the same if not better treatment from an Auto with Cflex as they could with a Bipap, and only reimburse for bipap if you have an underlying respiratory issue. (as listed above)

[Joe A]

Mikesus:

My case was severe with an average of 42 events per hour, the pressures needed were high enough to warrant the prescription of Bi Level device plus I was found to be a mouth breather.(Something that a machine can't tell you.)

My only concern is that an Autopap doesn't adress things like mouth breathing, or restless leg syndrome, or mixed centrals and OSA(Typically adressed with Bi PAP at a wide spread.) Again, your argument that these cases are not typical, and that most with OSA can be titrated with CPAP therapy is valid, as well the argument that those without insurance can't plunk down 4,000 bucks for a sleep study.

Seems that this Remstar APAP with C-Flex is kind of a an autotitrating BiPAP....Are the chosen comfort levels an absolute pressure drop, or are they a percentage?

[wading thru the muck!]

Joe A,

The C-flex feature has no correlatated cm h2o pressure drop it. Respironics is careful to avoid this correlation. I use one of these machines and at 10cm or less the highest C-flex setting makes the expiratory pressure seem to disappear. They do admit that the Auto with C-flex machine is a good alternative for people switched to bipap because they could not tolerate a high fixed pressure.

Auto machines do address mouth breathing by reporting these large leaks on the collected data. I can always tell when I've opened my mouth to breathe, just from the software.

[Joe A]

WTTMuck:

Does the data collection software come standard with the machine???

[derek]

I'll answer for Muckman,
No - it is Encore Pro from Respironics: $199 from cpap.com
(My review of Encore Pro should be published here in the next day or so, Johnny is working hard at getting it ready.)
derek

[chrisp]

Here is some information about mouth breeders.

Mouth breathing is a symptom of other conditions. Deviated Septum, Food or airborn Allergies, Poor housekeeping. A humidifier is essential. The reason many mouth breathe is due to drying out of the nasal mucosa. The blood vessels expand in an attempt to hydrate the nose. This expansion closes off the airway. You open your mouth to breathe.

Excellent article about autos and how to get effective therapy.

http://www.sleepreviewmag.com/Articles. ... d=S0309F04

Cheers,

Chris

[nodding off]

APAP is not a substitute for good medical advice and diagnosis, however with a little understanding of your situation and some common sense you can get excellent results from it. I suffer from severe OSA (AHI =94) and found that without my min being set at at least 9 I was getting way too many hypopneas. I don't worry about too high a titration. The machine gives me only what I need on that end. It's the lower end of the spectrum that I find makes the difference in my AHI. With a tightly controlled lower range APAP gives me much more comfortable therapy than CPAP. I view lab titration as a guide, but only that. You are sleeping in an unnatural environment for one night only. I feel that an APAP with a properly set minimum pressure will do a far better job of providing the titration you need, which will vary from day to day.

[jdschooler]

After reading all of the data posted on this topic and having a great deal of experience exercising differential diagnosis in critical situations in the field one thing comes to mind.

The cardinal rule in medicine is "Above all do no harm." As medical professionals (those of us that are), we need to weigh the risks and benefits of diagnositc procedures and treatment of our differential diagnosis. I can run a 12 Lead EKG to further confirm a heart attack in a patient I know is having one. But, the extra time I spend is costing the patient myocardial cells. I can go straight to treatment that I know may save the patient if they are having a heart attack but won't harm them if they aren't.

I find the same with auto titration. If the diagnosis is confirmed in sleep study. Auto titration at home may be more effective given the fact that the patient is sleeping in their home, their bed, and normal situation. For that patient the auto titration may be infact more accurate than the multiple titration studies done in strange surroundings with wires, and different bed, pillows, and such. And the auto will not go higher than necessary, as a result no more pressure than needed, so no more harm than without the therapy. Any central Apnea's would have been seen in the initial study and taken into account when treatment plan was laid out.

Just my 2 cents.

[chrisp]

Thats correct jeff,

Also. Modern Auto units are designed to avoid centrals or at least not cause them by increasing pressure. Can a plain cpap do this ? No. So that arguement doesn't hold water either.

Remember , Follow the money.


Cheers,

Chris