This is my big chance. Which machine?

[RipVW]

In my personal experience the APAP sounds great but rarely delivers the optimal pressure that was found during a pt's titration.

You're "experience" is inconsistent with the plethora of scholarly literature regarding APAP, certainly inconsistent with my (and many others!) experience with sleep study versus APAP titration. Where did you go to school?!

Rip,

Now I have to agree with PolyMar about, "the APAP sounds great but rarely delivers the optimal pressure that was found during a pt's titration".

The sleep lab rarely finds the optimal pressure.

Rooster

"New research comparing the results of two obstructive sleep apnea (OSA) diagnosis and treatment protocols—traditional and a “simplified" protocol—and their respective costs shows that a simplified program using experienced nurses, home ambulatory diagnosis and auto-titrating continuous positive airway pressure (CPAP) machines to titrate CPAP pressures is not inferior to the traditional model which relies on specialist physicians and sleep studies."
From: http://www.sleepreviewmag.com/sleep_rep ... -18_03.asp

And from another study:
CONCLUSIONS: A clinical pathway utilizing PM and APAP titration resulted in CPAP adherence and clinical outcomes similar to one using PSG.
From: http://www.ncbi.nlm.nih.gov/pubmed/18853940

And another:
Overall compliance was better in the ambulatory CPAP compared with the PSG group (median, 6 vs 5.4 hours/night).
After 3 months, there was no difference in the apnea-hypopnea index on CPAP between the 2 groups.
ESS, Sleep Apnea Clinical Score, and Sleep Apnea Quality of Life Index scores were similar.
ESS and Sleep Apnea Quality of Life Index improved for more than 3 months in both groups, except in 1 person with Cheyne-Stokes respiration.
There was no difference in CPAP between the PSG and ambulatory groups.
62% of patients in the PSG reported a preference for home management vs 6% of those in the ambulatory group preferring laboratory management.
The authors recommended using a clinical algorithm for patients with high probability of obstructive sleep apnea and PSG for those who do not respond to CPAP or do not meet criteria for high probability.
From: http://www.medscape.com/viewarticle/552035

And:
A recent study suggests that treatment of OSA with auto-nCPAP initiated at a patient’s home is effective and reliable.
From: http://www.sleepreviewmag.com/issues/ar ... -11_03.asp

And:
Home oximetry may be as good as polysomnography for predicting response to treatment of obstructive sleep apnea, according to the results of a study published in the Jan. 15 issue of the American Journal of Respiratory & Critical Care Medicine.
From: http://cme.medscape.com/viewarticle/498040

And:
In the initial management of patients with a high probability of obstructive sleep apnea, PSG confers no advantage over the ambulatory approach in terms of diagnosis and CPAP titration. The ambulatory approach may improve adherence to treatment. When access to PSG is inadequate, the ambulatory approach can be used to expedite management of patients most in need of treatment.
From: http://www.eclipsconsult.com/eclips/art ... 08)70713-8

[elg5cats]

[quote][/quote]what in the world is going on in that avatar?

KoKo the featured kitty got a sleep blanket when she came home. Seventeen years later, the blanket is a ragged blanket with holes and frazzed ends! KoKo loved her blanklie and would slip under blanket and play through the holes......so the avatar is a picture of KoKo playing under her sleep blanket. It's an official postal stamp also! Thanks for asking!

[SharkBait]

Business is business everyone is just trying to eat.

Yes, some more than others apparently.

Seems like the larger problem to me is the insurance companies.

And you just go along with that... and attempt to maximize your profits by giving patients the cheapest equipment possible.

In my previous blog I was trying to communicate the fact that I try and provide exactly the blower my pt wants and needs. We often take hits in this department financially and in fact the standard blower we supply goes well beyond reasonable and necessary(We use ResMed Escape II's w/ EPR: Respironics M-Series with C-Flex, Bi-Flex Auto's; VPAP Auto 25's and Auto SV's), but like I also previously stated all individuals involved in my organization are on PAP or one if not several of their loved ones are. I am not the one purchasing your health insurance, you the people are and so I think you as well have some level of responsibility to fight the well oiled, money grubbing machine we call insurance. When all is said and done it is very apparant that many patients on this forum do not feel they received a fair deal when working with their DME company, and again that is why you must do research. I promise that not everyone is out to take advantage of the pt, I know I certainly am not. But if insurance is only willing to pay a supplier $300 for a $1000 piece of equipment DME wholesale price then is it fair to ask the DME company to eat the $700, no it's not, thats a sure fire way to bankrupt your business. Suppliers and the sleep industry do try to fight insurance protocols on a regular basis yet the problem continues. Why should they agree to pay a supplier more when so many people are buying and utilizing insurance everyday with out complaints. The way to fight the problems if through professional petitions as well as pt petitions, oh and make sure you elect the proper people into office-maybe eventually we will get a elected PAP official who understands.

I certainly don't advocate anyone taking a loss. Perhaps the way to approach it is take what the insurance company pays, and then show the customer what each machine will cost them. The barebones machine is free, the APAP is nnn dollars, and everything in between... So without gigging the customer and still maintaining a fair profit for the business, the customer is given a choice. How did that not become the de facto approach?

[PolyMar]

Actually that is the exact model that is taught when attending DME seminars. Speakers often reference the plain walker for free or the shiny chrome rolling walker for $$$ additional. DME companies with a great business model will often have show rooms where you can see the bare bone piece of equipment next to the shiny BMW like equipment. To be fair with a patient and to maximize profit and compatability DME companies are often encouraged to have a showroom set up to display all levels of equipment.

[PolyMar]

In my personal experience the APAP sounds great but rarely delivers the optimal pressure that was found during a pt's titration.

You're "experience" is inconsistent with the plethora of scholarly literature regarding APAP, certainly inconsistent with my (and many others!) experience with sleep study versus APAP titration. Where did you go to school?!

Rip,

Now I have to agree with PolyMar about, "the APAP sounds great but rarely delivers the optimal pressure that was found during a pt's titration".

The sleep lab rarely finds the optimal pressure.

Rooster

"New research comparing the results of two obstructive sleep apnea (OSA) diagnosis and treatment protocols—traditional and a “simplified" protocol—and their respective costs shows that a simplified program using experienced nurses, home ambulatory diagnosis and auto-titrating continuous positive airway pressure (CPAP) machines to titrate CPAP pressures is not inferior to the traditional model which relies on specialist physicians and sleep studies."
From: http://www.sleepreviewmag.com/sleep_rep ... -18_03.asp

And from another study:
CONCLUSIONS: A clinical pathway utilizing PM and APAP titration resulted in CPAP adherence and clinical outcomes similar to one using PSG.
From: http://www.ncbi.nlm.nih.gov/pubmed/18853940

And another:
Overall compliance was better in the ambulatory CPAP compared with the PSG group (median, 6 vs 5.4 hours/night).
After 3 months, there was no difference in the apnea-hypopnea index on CPAP between the 2 groups.
ESS, Sleep Apnea Clinical Score, and Sleep Apnea Quality of Life Index scores were similar.
ESS and Sleep Apnea Quality of Life Index improved for more than 3 months in both groups, except in 1 person with Cheyne-Stokes respiration.
There was no difference in CPAP between the PSG and ambulatory groups.
62% of patients in the PSG reported a preference for home management vs 6% of those in the ambulatory group preferring laboratory management.
The authors recommended using a clinical algorithm for patients with high probability of obstructive sleep apnea and PSG for those who do not respond to CPAP or do not meet criteria for high probability.
From: http://www.medscape.com/viewarticle/552035

And:
A recent study suggests that treatment of OSA with auto-nCPAP initiated at a patient’s home is effective and reliable.
From: http://www.sleepreviewmag.com/issues/ar ... -11_03.asp

And:
Home oximetry may be as good as polysomnography for predicting response to treatment of obstructive sleep apnea, according to the results of a study published in the Jan. 15 issue of the American Journal of Respiratory & Critical Care Medicine.
From: http://cme.medscape.com/viewarticle/498040

And:
In the initial management of patients with a high probability of obstructive sleep apnea, PSG confers no advantage over the ambulatory approach in terms of diagnosis and CPAP titration. The ambulatory approach may improve adherence to treatment. When access to PSG is inadequate, the ambulatory approach can be used to expedite management of patients most in need of treatment.
From: http://www.eclipsconsult.com/eclips/art ... 08)70713-8

So it sounds like you definitely favor getting rid of the sleep lab and techs/technologists. Are you a disgruntled doc or a disgruntled pt? What type of sleep labs are you utilizing that are not finding optimal pressures? Are the labs AASM acredited?

My company has 6 sleep labs located around a very large metropolitan area (3 of these labs are research labs located at local hospitals), all sleep studies are run by RPSGT's and supervised by either a nuerologist or pulmonologist boarded in sleep. The person running the study does their part, another scores the study and the superivising physician recommends the final pressure. By using the previous model we find we rarely have a study where an optimal pressure is not found - if a pressure is not found it is because the patient was recommended for a CPAP titration and they are suffering from Complex Apnea which requires the pt performing an additional test to assure the complex condition is treated properly and that the patient receives the best patient care possible. It should always be the doctor recommending the final pressure as he/she is the one signing the script.

I assume your favor of APAP titrating is for patients suffering from simple OSA cases and not complex patients, or at least I hope. It seems as though there are a lot of people pushing APAP who are not taking into account complex apnea patients suffering form cheyne stokes, seizures, CSA, etc. Do you have a lab you trust to see your complex pts? I feel as though many people slander the sleep lab model and turn potential patients off from visiting the sleep lab by speaking in absolutes or almost absolutes. That is why I am passionate about rebuffing the APAP model. I know from having run the studies myself that often when I see patients who are on APAP (set-up by other companies or themselves) I frequently see the patient in REM rebound for a large portion of their study indicating they are being deprived of REM sleep on their auto, as well as SWS.

I appreciate all of the links you posted, however I will have to agree to disagree with you.

[Paul56]

Wow ...... why don't we just throw up a rope and the lynch the guy, after all he's an RT and we all know that RT's are no-good, good for nothings that only want to sleep with our daughters and steal our fortunes after we die prematurely from improperly treated sleep apnea.

The tone around here seems a bit harsh.

I for one welcome an alternative view from the "dark side" as long as it isn't couched in absolutes and professional arrogance. If someone strays too far from our accepted beliefs there are civilized ways of challenging, correcting or ignoring them.

Each of us are experts on our own personal experiences and benefit from the collective wisdom of the group; let's embrace an opportunity to learn from and educate a professional in the field who can provide valuable insights from exposure, diagnosis, and treatment of a huge number of patients and a glimpse of the internal machinations occurring in our niche of the healthcare industry.

We're wearing masks, not hoods.

Paul

Hi Paul,

Some of us, dare I say perhaps the majority of us, have had bad experiences with the DME... and I am definitely no exception.

I have been dealing with VitalAire of St. Laurent on Industrial. They are pleasant folks to deal with but the policies and attitude are something else.

When I was initially getting fitting for a machine the whole point for the RT seemed to be to achieve the sale quickly as possible despite the fact I was supposed to be on a 3-week trial.

The first machine supplied was not fully data capable, so while some therapy was delivered we had no idea if that therapy was achieving good results.

The second machine supplied was fully data capable but they set the pressure too low. I only discovered this by the time I had returned all the way back here to Aylmer. Fortunately with assistance of the good folks here at cpaptalk I was able to correctly set the loaner machine myself and avoid the trip back out there again.

Mask choices? Hahaha! There were NO mask choices. I was shown the Quattro and that was it... no opportunity to try any other masks to see how I did with them. When asked, she simply had a very long pause while she stared at the floor and finally said: "Lets talk about this next week."

Follow-up? What follow-up? There is NONE. Once they had my cheque and I was out the door that was it... yer on yer own baby!

And then there are the ridiculous prices they charge. $320 for a Quattro for example.

My DME experience is very mild compared to some others.

So, when someone from a DME comes into the forum here I"m very skeptical... because my experience has been that patient care comes AFTER DME profits & sales.

Just my two cents.

[PolyMar]

Wow ...... why don't we just throw up a rope and the lynch the guy, after all he's an RT and we all know that RT's are no-good, good for nothings that only want to sleep with our daughters and steal our fortunes after we die prematurely from improperly treated sleep apnea.

The tone around here seems a bit harsh.

I for one welcome an alternative view from the "dark side" as long as it isn't couched in absolutes and professional arrogance. If someone strays too far from our accepted beliefs there are civilized ways of challenging, correcting or ignoring them.

Each of us are experts on our own personal experiences and benefit from the collective wisdom of the group; let's embrace an opportunity to learn from and educate a professional in the field who can provide valuable insights from exposure, diagnosis, and treatment of a huge number of patients and a glimpse of the internal machinations occurring in our niche of the healthcare industry.

We're wearing masks, not hoods.

Paul

Hi Paul,

Some of us, dare I say perhaps the majority of us, have had bad experiences with the DME... and I am definitely no exception.

I have been dealing with VitalAire of St. Laurent on Industrial. They are pleasant folks to deal with but the policies and attitude are something else.

When I was initially getting fitting for a machine the whole point for the RT seemed to be to achieve the sale quickly as possible despite the fact I was supposed to be on a 3-week trial.

The first machine supplied was not fully data capable, so while some therapy was delivered we had no idea if that therapy was achieving good results.

The second machine supplied was fully data capable but they set the pressure too low. I only discovered this by the time I had returned all the way back here to Aylmer. Fortunately with assistance of the good folks here at cpaptalk I was able to correctly set the loaner machine myself and avoid the trip back out there again.

Mask choices? Hahaha! There were NO mask choices. I was shown the Quattro and that was it... no opportunity to try any other masks to see how I did with them. When asked, she simply had a very long pause while she stared at the floor and finally said: "Lets talk about this next week."

Follow-up? What follow-up? There is NONE. Once they had my cheque and I was out the door that was it... yer on yer own baby!

And then there are the ridiculous prices they charge. $320 for a Quattro for example.

My DME experience is very mild compared to some others.

So, when someone from a DME comes into the forum here I"m very skeptical... because my experience has been that patient care comes AFTER DME profits & sales.

Just my two cents.

Sounds like you definitely had a bad experience. I think it is important for everyone to know you can choose your own DME company, call around and check out the place before you commit to be a customer, same as the sleep lab. Once you have a referral and a script you can go anywhere you want.

P.S. Not only do I help run a DME company but I am also an RPSGT and a PAP user. Perhaps it would be pertinant to ask the people you will potentially be working with what there link is to the PAP world, then you can choose to do business with them or not.

[RipVW]

"PolyMar" (aka Bluebonnet_Gal, aka thetylerose)
So it sounds like you definitely favor getting rid of the sleep lab and techs/technologists. Are you a disgruntled doc or a disgruntled pt? What type of sleep labs are you utilizing that are not finding optimal pressures? Are the labs AASM acredited?
I appreciate all of the links you posted, however I will have to agree to disagree with you.

Hmm. Don't recall saying anything about "getting rid of sleep labs . . ." Sorry you misunderstood. My experience with sleep lab titration was not a good one, since the titrated pressure was way too low. After more than a year of poor results despite my faithful compliance, I found this forum, learned about data, bought the software, card and card reader for my first machine (S8 Elite), and discovered my high AHI average of 12. I purchased my auto machine, it found my optimal pressure, and ever since my AHI has averaged around 0.4. And, most importantly, I feel great since I get good sleep. I'm sure that sleep studies work well for many patients, but I know they just don't produce accurate readings for others (there’s quite a bit of literature to substantiate this fact, too, but I’ll let you do the literature review). Too many folks simply give up and stop using their CPAP therapy rather than taking responsibility for their health, doing some research. I had to find my solution, since my sleep lab did not. Moreover, I tend to trust the research findings that home titration works. Worked for me, works for the participants in many, many studies . . . So, it must not be all wrong. It's okay to disagree. Not sure that it's okay to ignore hard data that has been replicated again and again, though. Have you reviewed any of the studies? Are there aspects of the research methodologies that you think invalidate the findings? Wondering, too, if you can provide us with any peer reviewed medical research reports that support your beliefs regarding the inaccuracy of APAP titration? I know we'd all like to take a look, if indeed it exists.

[Slinky]

PolyMar, I can't fault my sleep lab - it wasn't their fault - or mine - that I was only able to sleep 42 minutes out of 6 hours bed time my first titration. So they brought me back for a second titration. I only slept 98 minutes out of 6 hours bed time the second titration. I was started on CPAP at 6 cms, 30 days later pressure was upped to 7 cms and 30 days after that I insisted on a loaner auto PAP and ended up at 8 cms for about a year before I said enough! CPAP has helped but it hasn't helped enough and 17 months after starting CPAP I had a bi-level titration and was switched to a bi-level.

None the less, I still prefer an in-lab titration for detecting any and all sleep disorders. But sometimes the patient just does NOT get a decent enough sleep for a good titration in-lab due to no one's fault. (Used an Ambien (which helped at home) the second night of titration too!) It wasn't that the bed, room, temperature, etc. was uncomfortable. I think it was just I was too excited that maybe now I was going to be albe to SLEEP.

[ozij]

Polymar,
In addition to some sleep labs being plain unprofessional, the issue brought up by slinky is very important:
Assuming utter professionalism, and total dedication of the sleep lab staff, the "optimal pressure" found during the titration is only optimal for the sleep study conditions.

There are some people for whom a sleep study - a very very very good sleep study - will simply not find the optimal pressure for when they sleep at home. Because the lab environment keeps them from sleeping. Becuase the strange smells from the cpap bother them.... etc.

On my sleep study - all of 2 hours worth of light sleep the tech noted that I kept my mouth shut. Ha! Double Ha! I open mouth something terrible when I relax in my own bed at night.

The basic assumption, that a one night's sleep study can find an optimal pressure for everyone is wrong. I think it's a carryover from the days they discoverd a tracheotomy solved sleep apnea once and for all.

A sleep lab that want's to know of they really found the "optimal pressure" for their patients has to run a study, in which they:

1. Make sure every patient is given a machine that tracks usage and breathing events
2. Contact each patient after a week, 2 weeks, 3 weeks, one month, two months 3 months, 6 months 9 months a year.
3. Read the detailed data from every patient's machine to keep track of the patients':
   • Breathing events
     Leaks
     Hours of usage
4. Note changes in the patients' BP, insuline resistance, medications needed .
5. Note changes in the patients subjective experience.

Without systematic answers to the above, there is no way of knowing if the pressure found in the lab was the optimal pressure to treat a patient's OSA.

We are clearly a self selected group all of whom were motivated to find information about their therapy on the internet, the majority of whom did not get good therapy when they started, nor did they get good advice from the professionals who surrounded them.

And I would hazard to say, practically none of whom were contacted by their sleep lab to confirm whether the pressure found/prescribed was indeed optimal.

O.

[RipVW]

Polymar,
The basic assumption, that a one night's sleep study can find an optimal pressure for everyone is wrong. I think it's a carryover from the days they discoverd a tracheotomy solved sleep apnea once and for all.

And I would hazard to say, practically none of whom were contacted by their sleep lab to confirm whether the pressure found/prescribed was indeed optimal.
O.

Ditto, ozij! After I completed my sleep study, I never heard from my sleep doctor/clinic again. Approaching three years now, still no followup!? I guess they are very busy with new patients ;<)

As Dr. Peter Farrell, CEO & Founder of ResMed, commented:
"If 10% of the population suffers from OSA, how can you build enough sleep labs to handle potentially 30 million people in the United States alone? You couldn’t build enough sleep labs in 100 years."

So, I think sleep labs/techs need not worry about convincing the very few of us who have found this forum and taken responsibility for our own health and CPAP therapy that we would be better off with them—they will always have more patients than they can manage, particularly if they take your advice regarding the comprehensive follow-up protocol your suggest.

[roster]

...... By using the previous model we find we rarely have a study where an optimal pressure is not found .............

How do you know it is the optimal pressure?

You cannot know it is the optimal pressure unless you have a surreptitious way of monitoring the patient's therapy in his own bed over several weeks.

Your statement reeks of typical "medical professional arrogance".

[PolyMar]

Ok guys I get it, down with the sleep lab. This sight is starting to wear me out. I here everything you are saying but I don't think you are hearing me...everything you keep suggesting is exactly what are labs/DME co does, in fact our company was founded by a gentleman who had a very similar experience as you during his sleep study and after care process. I am not intending to be arrogant, only informative and trying to let you know there are places that have heard what the patients suggest and have implimented the suggestions. Our follow-up is so intense some pt's who don't care as much as do get annoyed. We follow up 24 hours after study (and in most cases you have your equipment the same day to finish your titration study), once you are in our DME program you are contacted the first day, third day, tenth day, 30th day and on a monthly basis after that forever . If a pt is having a particularly hard time I will follow up with you every single day if I need to. We offer masks fittings if a pt is having difficulty and will order any mask/equipment a pt wants if we do not already have it. We also have a program where if you like we will contact you according to the pay schedule your insurance has to notify you of eligibility for new equipment and then send it out, no cost to be enrolled only cost incurred is for the actual equipment itself if requested. I appreciate this forum as an educational tool for me as a PAP user and as a professional trying to find out how patients feel and what their needs are. What I don't appreciate is the malicious rock throwing, however I will not let it deter me. I hope this finds everyone doing well!

[plr66]

....there are places that have heard what the patients suggest and have implimented the suggestions. Our follow-up is so intense some pt's who don't care as much as do get annoyed. We follow up 24 hours after study (and in most cases you have your equipment the same day to finish your titration study), once you are in our DME program you are contacted the first day, third day, tenth day, 30th day and on a monthly basis after that forever . If a pt is having a particularly hard time I will follow up with you every single day if I need to. We offer masks fittings if a pt is having difficulty and will order any mask/equipment a pt wants if we do not already have it.

Wow!

[roster]

Ok guys I get it, down with the sleep lab. This sight is starting to wear me out. I here everything you are saying but I don't think you are hearing me...everything you keep suggesting is exactly what are labs/DME co does, in fact our company was founded by a gentleman who had a very similar experience as you during his sleep study and after care process. I am not intending to be arrogant, only informative and trying to let you know there are places that have heard what the patients suggest and have implimented the suggestions. Our follow-up is so intense some pt's who don't care as much as do get annoyed. We follow up 24 hours after study (and in most cases you have your equipment the same day to finish your titration study), once you are in our DME program you are contacted the first day, third day, tenth day, 30th day and on a monthly basis after that forever . If a pt is having a particularly hard time I will follow up with you every single day if I need to. We offer masks fittings if a pt is having difficulty and will order any mask/equipment a pt wants if we do not already have it. We also have a program where if you like we will contact you according to the pay schedule your insurance has to notify you of eligibility for new equipment and then send it out, no cost to be enrolled only cost incurred is for the actual equipment itself if requested. I appreciate this forum as an educational tool for me as a PAP user and as a professional trying to find out how patients feel and what their needs are. What I don't appreciate is the malicious rock throwing, however I will not let it deter me. I hope this finds everyone doing well!

You don't get me. You don't have to "wear yourself out" rattling on and on like that. Just answer the previously posted simple question:

...... By using the previous model we find we rarely have a study where an optimal pressure is not found .............

How do you know it is the optimal pressure?
You cannot know it is the optimal pressure unless you have a surreptitious way of monitoring the patient's therapy in his own bed over several weeks.

........

Understand? A simple question, which, if answered, can give you some credibility that you are currently lacking.