Do I need a titration study?

[JeffV]

I've been on CPAP for two weeks now and I'm adjusting pretty well (11 out of 14 nights compliant, slept all the way through with it on the last 4 nights straight), and I'm wondering if I really need to go back for a titration study. I haven't really had a "Eureka!" moment or anything, but I've noticed that my tiredness seems more "normal", rather than just wanting to fall asleep in the middle of the afternoon at work or in the evening watching TV. No tremendous energy boost or anything, but then that's not a huge surprise since I'm still a fat out-of-shape lazy person. My AHI has been consistently between 1-2 each night. To my untrained eye the SH reports look pretty good, still with quite a bit of snore, though. (It's fairly creepy to look at the flow rate flatlining like that even a couple of times a night, but rationally I know that's to be expected.)

Rewinding a bit: I had a PSG a few months back, which was the worst night of my life. Couldn't sleep hardly at all. I barely got out of stage 1 sleep (not even close to REM), but based on the 2 hours of sleep they did see I came back with an AHI of 53 (almost all hypopneas). Doctor prescribed CPAP with a "starter" pressure of 7.0, and told me I'd do a titration study to dial in the pressure after I had some time to adjust to the machine. A couple of months of DME frustration later, here I am.

Two real questions - Do you think I need a titration study? And regardless of that answer, will my doctor and/or insurance require me to get one no matter what? I'd prefer to avoid another night of that particular horror if I can (not to mention the $$$$ out of pocket...)

[jnk...]

. . . Do you think I need a titration study? And regardless of that answer, will my doctor and/or insurance require me to get one no matter what? I'd prefer to avoid another night of that particular horror if I can (not to mention the $$$$ out of pocket...)

The money out of pocket has to be balanced against how useful the data from the titration will be for YOU. But sometimes insurance won't pay for a treatment machine without it. Sometimes getting your machine out of pocket is cheaper than a titration copay. It requires theoretical math to figure that stuff out.

That said, I feel that a titration study, done right at a reputable place that will give you a complete copy of the results, can be one of the most useful medical tests ever in anyone's life. You get to see how your body reacts to pressure, and you get to compare the results to the baseline of the diagnostic-study results.

It is true that in one sense the SH data over time is more valuable for dialing in a pressure. However, having the true lab results in front of you with sleep-position info and sleep-stage info can tell you things SH never will.

In some cases, I believe that insurance requires proof the PAP therapy is working before they will pay, and that could require a titration study. On the other hand, your doc may be able to prove it to them without it. Just depends. And it can be difficult sometimes to get that info out of either the insurance people or the doc.

Sorry that I don't have a more clear-cut opinion for you. I tend to revel in my wishy-washiness of straddling multiple opinions simultaneously.

[Sleeprider]

Have you had a look at the machine data you should be getting? FWIW I had a sleep study and slept so poorly I was prescribed an Auto CPAP (self-titrating) and never did have a titration study. I used my machine data in conjunction with the knowledge on this forum and I think I have pretty good results. My current insurance has high enough deductibles and copayments that if asked to do a sleep study, I would decline. My physician will write a machine prescription, and that is all I need. To me, the decision is mainly financial as I think I'm capable of using machine data and my own sense of well-being to determine the efficacy of OSA treatment. Sounds to me like you are of a similar mind.

If you do decide to do this on your own, I would recommend you put your machine in Auto mode, and allow the unit to self-titrate between your prescription of 7.0 and a max pressure of perhaps 12 or 13 cm. This will allow you to see a little better where the machine senses that you have an unobstructed airway and the kinds of events that lead to pressure increases.

[Pugsy]

I doubt your doctor or insurance company will "require" a formal in lab sleep titration study.
The insurance itself won't care about anything other than that you use the machine and you have a diagnosis to support using the machine. You already met the diagnosis part or you wouldn't have got the machine.
Some insurance companies or HMOs (like Kaiser) won't necessarily do a titration study if APAP use seems to be getting the job done. They save the in lab titration studies for the people who are having problems.

If you are seeing quite of bit of snoring with the low AHI...the snores mean that the pressure is not quite optimal (that would be the minimum pressure). The minimum pressure is sort of a baseline pressure from where the machine starts in response to apnea warning signs...and snores are one of those warning signs. Snores mean that the airway is trying to collapse but since you are having a nice low AHI that means that the snores aren't progressing to full grown obstructive apneas or hyponeas that the machine can't prevent. With the minimum pressure where it is right now it isn't preventing the minor collapse of the airway tissues that the snores are a product of. Hold the airway open a little better with a more optimal baseline pressure and the snores won't happen as often. In your case with the already low AHI..probably wouldn't need more than a 0.5 or 1.0 increase in that minimum pressure to deal with the snores. It all depends on just how much snoring you are seeing if the snores really need to be dealt with though.
If you are seeing large clustering of snores...then yes I would probably try to reduce their numbers.
Large numbers of snores could also possibly disturb a person's sleep...and that could impact how a person feels the next day..so even if they aren't full grown apneas...they can mess with sleep quality if nothing else.

I see no need for a formal in lab titration at this point based on what you have said.
Contrary to what some people might think...those in lab sleep titrations aren't magical. It's one night in a foreign sleep setting and not the best place to be trying to get a good night's sleep. I had a formal in lab sleep titration...out of 8 hours devoted to the titration I slept less than 3 hours and I only got 6 minutes of REM sleep where my OSA is worse and came out of that in lab study with a RX for 8 cm which does a great job in non REM sleep but totally sucks in REM sleep but I didn't get enough REM sleep to adequately figure out what pressure I need in REM sleep. I would have done better doing what you are doing but I didn't know any different back then..and I didn't know that I would get crappy sleep either.

For most people who have plain jane vanilla OSA with no complications....going the at home apap machine route for titration will get the job done quite well. Save the in lab titration for when there are problems and it doesn't sound like you are having any significant problems.
Your insurance will be glad to save the money...your doctor will probably only care about AHI and hours of use and if you tell him you don't want an in lab titration study I doubt he will have any need/want to force the issue.

[Pugsy]

The need for insurance to pay for a machine is normally based on the original diagnostic sleep study findings.
Not on titration results at all. That's why people have to wait to get the machine...not because of waiting on titration results.
All that is needed is to prove the need for the machine and your prior sleep study did that...how well the machine works for you isn't something insurance that most companies (you would need to check with your insurance company to know for sure) care about...all they care about is
1...your diagnosis supports the need and that's where the first sleep study comes in
2...that you use the machine so they aren't wasting their money paying for it...they normally never actually evaluate the results beyond hours of use. Even Medicare doesn't require anything but hours of use and a visit to the doctor before the 91st of therapy and you and your doctor saying "it works great".

[SGearhart]

My insurance company required a sleep study first to show I had sleep apnea, an AHI of 86.2. Then a titration study to prove that a CPAP would have an effect. The insurance company subsequently required the CPAP machine to be rented for a 30 day period to see if I would use it. The machine the tech used, during my titration study, can be remotely adjusted to see how the patient responds to different pressures and parameters. With each person being different, I find it somewhat strange that a pressure number can arbitrarily chosen without any test data to support it. Of course, my opinion and 2 bucks will get you a cup of coffee . . . if you don't go to Star Bucks.

[JeffV]

The money out of pocket has to be balanced against how useful the data from the titration will be for YOU.

I know full well that another formal study would get me data that I can't get at all out of SH (staging, position, RLS, etc). I'm all for managing my own care and making sure I'm using this therapy effectively, and I know that the more data I have the better I can manage, but there's a point of diminishing returns. If I could get a study scheduled before year-end (which I doubt), I'd be paying almost $500 out of pocket. If it comes after the first of the year, that number would be between $1500-$2000. I don't know that the data from the study would be useful enough to me to justify the expense. (Especially if I pay all that money and they just tell me that I'm already at the perfect pressure, or to bump it up from 7 to 8 or something. ) If I was still getting AHI of 20 or 50 or something on the pressure I have then my opinion would likely be quite different, but with an average nightly AHI in the 1.6 range so far...

It all depends on just how much snoring you are seeing if the snores really need to be dealt with though.
If you are seeing large clustering of snores...then yes I would probably try to reduce their numbers.

I'll post some graphs later tonight or tomorrow to get some more experienced opinions. I'm not really sure how much is too much, but the graphs are definitely showing more snores than apneas or hypopneas.

I had a formal in lab sleep titration...out of 8 hours devoted to the titration I slept less than 3 hours and I only got 6 minutes of REM sleep where my OSA is worse and came out of that in lab study with a RX for 8 cm which does a great job in non REM sleep but totally sucks in REM sleep but I didn't get enough REM sleep to adequately figure out what pressure I need in REM sleep.

Yep, that's exactly what I'm afraid of. Like I said, at my initial PSG I was hooked up to everything for over 6 hours, slept for just barely over 2 hours, and barely made it past stage 1 sleep (and never past stage 2), which of course meant I didn't feel like I had slept at all. Now that I know what to expect I feel like I could do it a bit better, but it's still something I'd rather avoid if I can.

[jnk...]

. . . Doctor prescribed CPAP with a "starter" pressure of 7.0, and told me I'd do a titration study to dial in the pressure after I had some time to adjust to the machine. . . .

If your insurance is good with it (and Pugsy, who has thousands of times more boots-on-the-ground experience than I do with this stuff seems to indicate that it is highly likely they will be, if I read her correctly), and your doc has already written you a non-temporary Rx and is good with your plans and preferences (and based on the reasonable approach of the doc in his going ahead with a pre-titration Rx, I doubt he would have an issue if he heard your financial situation), and you aren't itching to see titration data for yourself, I can think of no logical objection to what you suggest.

For me (and my financial circumstances and severity of condition are somewhat unique), the titration is what made the diagnostic worth the trouble--the two together became worth more to me than one alone. And in many ways I appreciated the data from the titration more than the diagnostic data. I got a titration quickly by volunteering to be on standby for any last-minute cancellations. But hey, that's just me. I value my titration, but certainly not $2000-dollars-out-of-pocket worth. So I hear ya. And my diagnostic study went smoothly with no trauma.

Most all medical-testing decisions are compromises. Seems to me you are thinking clearly and have the bases covered, which is more than most of us when we were starting out our therapy.

[chunkyfrog]

If your diagnosis had revealed significant centrals, I would vote yes on the titration study, even with the copay,
because it might mean a more advanced machine. I had both studies, because the cost to me was only about $175
for the titration study. In your situation, today, I would buy the full data APAP, even out of pocket. The software is free.

[JeffV]

This is a pretty typical night for me so far. On nights when I've used the machine all night, the VS summary number is always above 3. OA and H fluctuate below or occasionally slightly above 1, and this session was the first time I've seen CA pop up at all. (Image is probably too wide but should be clickable. If there's a way to resize for your viewing pleasure, please let me know.)

[Pugsy]

I can see the image just fine.
Your snores aren't horrible but there's a little more of them than I would want to see if it were my report.
I suspect increasing the pressure to 7.5 cm or 8.0 will clean them up nicely. A random snore here or there isn't a big deal but if seeing this many consistently then I would want to reduce them a little if it were me. It isn't something that is urgent though.

Your leak line is causing me to turn pea green with envy. Great job on the leak control.

I see you are using cpap mode with fixed 7.0 cm...I thought you were using APAP mode.
Doesn't really matter...looks like this is working well. If you wanted to do APAP mode then minimum of 7 or 7.5 and max of 9 or 10 would probably work also.

I see no need to do a titration study at this time from a OSA therapy perspective anyway. All it will do is likely tell you to use 7 or 8 cm pressure...and we already figured that out without spending the big bucks.

[JeffV]

I don't know that the leaks will stay quite that flat. I think right now it's more that any leaking air around my face is waking me up and I adjust the mask accordingly. I think maybe as I get more used to it, that may not look quite that pretty, but you never know.

Yes, I'm on CPAP and not APAP. That's what my initial prescription was for, and since I've got the modem for compliance, I figured I'd stay out of the provider side of things unless absolutely necessary. (I did briefly get in and play with the resistance settings but decided I liked it better with that turned off.) Once I'm rid of the modem I'll probably wing a few more dials, but for now I'll give the doctor's office a call in the next day or two and discuss some things.