help me understand auto titration

[HPM]

I use a 6 year old machine with no extras such as exalation relief or data capable. I'm currently using a loaner for a download because I have been feeling symptomatic. The dr increased my pressure from 10 to 11 to see if it helps but I could hardly tolerate it, mask leaked all the time and it felt like too much air and I felt even worse. So after a week, the pressure was changed back to 10 and will continue the 30 day download period. THe loaner has c flex for exahaltion relief and that really helps me, especially since I use nasal pillows.Before it felt like I was breathing against a wall. I have read here about an auto titration and inquired about it and was told the doctor "doesn't like" the auto adjusting machines. So, I guess I'm saying that during the down load, I have to stay at the single fixed pressure and wait 30 days to see what works. It seems like the auto thing would be more helpful and help me feel better quicker by getting to the right pressure. Is it too much for me to insist that this download be done with an adjustable machine.
-- I also am looking into getting a new machine and have more questions for later--

[Alshain]

Many doctors don't like auto-titration because they feel that if your study/titration at the lab worked, then it isn't necessary. Personally (with no evidence of this) I believe that some doctors believe they take away from possible studies, which would obsolete their sleep lab and reduce their income. Basically an APAP monitors your number and length of events and gradually increases the pressure Rx after events occur in order to minimize them the rest of the night. There are pitfalls here though. It starts over at the minimum pressure every time you turn off the machine. If you need the higher pressure, constantly restarting at a lower pressure is troublesome. In my opinion APAP should be used on a temporary basis to determine your needs and then switched off (into normal CPAP mode). It can be turned on every once and a while to confirm it's still working.

APAP is nice but not entirely necessary. If you can get a machine that you can monitor the data yourself you can tweak it on a manual CPAP every night until you find a good setting, this does require you to make your own changes, which your doctor will not like at all.

[Pugsy]

What machine are you using presently during this 30 day period?

If you can't stand to go from 10 to 11 cm...what would you do with an auto machine that thought you need 14 or more? That is what auto machines do. If you leak, they will increase the pressure just to try to fix the leak. It can't be set on 4 to 20 and expect the machine to miraculously zero in on the perfect pressure without observation and education.

I use an APAP and I use adjustable pressures. It works very well for my needs. I start out with a minimum pressure of 10 cm and sometimes I see reports where I have hit 18 or 19 cm (and can't blame it on leaks). Pressure variations bother some people. High pressures bother some people. You need to know what to expect and how to deal with it.

Wonder if we can sneak some data off the loaner you are using to get an idea what is going on? That would be the smart thing to do.

[VVV]

Data and software should be your top priority. You want to be able to get up every morning and immediately see a chart showing events during the night, pressure, unintentional leak, etc.

Yes, you should also get an auto. It only costs a few bucks more (no more if your insurance pays) and offers flexibility and some advantage in therapy for some people.

Your doctor may be thinking, "He wants to get an auto and set it at 4 to 20 cm pressure range and let the machine determine the correct pressure."

That is not the proper way to do it. If you get an auto with software, you can learn here how to titrate properly and how to troubleshoot problems.

[VVV]

Let me add, after your therapy is stabilized, you will not be looking at a report each day.

[Alshain]

Wonder if we can sneak some data off the loaner you are using to get an idea what is going on? That would be the smart thing to do.

That machine doesn't have a friendly way to get the data. The unit's LCD is useless and you must have a card reader to get the recorded data. It's not something she is going to have available for a loaner machine, unless she can find a nearby friend with one.

[Pugsy]

That machine doesn't have a friendly way to get the data. The unit's LCD is useless and you must have a card reader to get the recorded data. It's not something she is going to have available.

No, no not the machine OP has showing in Profile (it is a brick). I was wondering what OP is using now for loaner. There is a 30 day trial going on with a full data machine of some sort to see why OP is not doing well. If doctor can get data so can we..... at least if it is a machine where we can use our software resources. It might be using a SD card....if so there is hope. That is why I asked what machine is being trialed.

[Alshain]

That machine doesn't have a friendly way to get the data. The unit's LCD is useless and you must have a card reader to get the recorded data. It's not something she is going to have available.

No, no not the machine OP has showing in Profile (it is a brick). I was wondering what OP is using now for loaner. There is a 30 day trial going on with a full data machine of some sort to see why OP is not doing well. If doctor can get data so can we..... at least if it is a machine where we can use our software resources. It might be using a SD card....if so there is hope. That is why I asked what machine is being trialed.

Ah, sorry. Missed that part. I agree then, lets hope it's an SD capable.

[HPM]

I may be repeating myself - not sure if I hit submit. Sorry if this is a repeat. The loaner is Respironics REMstar Pro M series. The card in it looks like a credit card

[Pugsy]

The loaner is Respironics REMstar Pro M series. The card in it looks like a credit card

Crap.. I got the software but the special card reader is needed. it costs $40. Sorry if you mentioned the Pro M somewhere..I didn't see it. Was hoping at least a PR S1 machine. Those SD cards make it easy..

[Otter]

If you can't stand to go from 10 to 11 cm...what would you do with an auto machine that thought you need 14 or more? That is what auto machines do. If you leak, they will increase the pressure just to try to fix the leak.

I don't believe my S9 does that. Friday night I had a 20 l/min leak that lasted about 10 min. That's about as high as it ever goes for me, but the machine did not increase pressure. Shortly after the leak sealed, the S9 bumped pressure up in response to a flow limitation. The timing of this makes me wonder if the leak was somehow masking the flow limitation, but the leak was definitely over before the pressure increase started.

Given that increasing pressure can cause CA for some people, it seems unlikely the machines would be designed to increase pressure on the off chance that would stop the leak instead of making it worse. I strongly suspect that none of the machines do this, and that it's the pressure causing the leaks, not the other way around. But I only have my own experience on one machine. Maybe this leak chasing thing really does happen.

It can't be set on 4 to 20 and expect the machine to miraculously zero in on the perfect pressure without observation and education.

Agreed. The key to good APAP is an appropriate range. Even for titration, leaving the machine at 4-20 cm isn't a good idea. Most people don't feel like they can breathe at 4 cm, so why not start at 6 and then lower the range if the machine hugs the minimum all night and your AHI is low?

I use an APAP and I use adjustable pressures. It works very well for my needs. I start out with a minimum pressure of 10 cm and sometimes I see reports where I have hit 18 or 19 cm (and can't blame it on leaks). Pressure variations bother some people. High pressures bother some people. You need to know what to expect and how to deal with it.

What Pugsy says is true. But there's no reason why you couldn't set up an APAP with a very narrow pressure range They'll even do straight CPAP.

[Pugsy]

I don't believe my S9 does that. Friday night I had a 20 l/min leak that lasted about 10 min. That's about as high as it ever goes for me, but the machine did not increase pressure.

Any APAP as the potential for runaway pressure increases in response to leaks. Depends on the leak. A 20 L/min leak is still within acceptable limits of where the machine can adequately compensate for minor leaks. I wouldn't expect the pressure to increase in this situation.

The pressure chasing leak thing does indeed exist. I have experienced it myself and seen it on the reports. Also seen it on a friend of mine's reports when she tried my APAP and had leaks at her already prescribed high pressure.

If the machine is running away with pressure increases..then the therapy pressure is unlikely to be where it needs to be and chances of centrals from pressure increases are remote because the therapy is exiting the body prior to entering the airway. Just because the machine blows at 20 cm during a large leak doesn't mean that the airway is getting 20 cm.
At least that is my take on it.

[Pugsy]

The key to good APAP is an appropriate range. Even for titration, leaving the machine at 4-20 cm isn't a good idea. Most people don't feel like they can breathe at 4 cm, so why not start at 6 and then lower the range if the machine hugs the minimum all night and your AHI is low?

I can't breathe comfortably at 4 cm either. I have used my APAP to self titrate (no sleep study at all) family members. They didn't like 4 cm either. I used 6 cm to 10 cm for screening purposes. I don't want a chance for runaway pressures on a screening study. Once I saw the need to use cpap because I saw pressure increases and a few events scored I then could make an educated estimate on appropriate range depending on where the machine wanted to go.

Minimum is critical.. Maximum not critical and really no reason to limit maximum pressures unless pressure changes bug someone or big leaks and big pressure circle shows up. The machine won't go there if it doesn't sense the need to for some reason. If a person is prone to large number of centrals that are strictly pressure induced..APAP is probably not the best choice of machines anyway.