Finally saw an actual sleep doctor

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jnk wrote:My understanding is that some labs allow the tech some leeway in exercising judgment to switch the titration to one for bilevel during the titration if 15 cm of pressure is reached and the patient seems to be having trouble dealing with the pressure. Other labs require the pressure to get up to 20 during titration before a tech can do that. That is during a sleep study.

In my case, the tech actually put me on bipap during the titration phase of my original sleep study, after only getting to a pressure of 11 on cpap. She set me at 14/11 on bipap, and that was the first real REM sleep that was recorded. That was also the final setting before she woke me up in the morning. I was not aware of all of this until I requested and received my sleep study. (It took more than a month for it to come in the mail.) I was sent home from my pcp shortly after my sleep study with a cpap at a pressure of 11, and then switched to auto with a wide open range. After 4 months, I am finally now going to get a bilevel to try at home.

Here are the 2008 AASM thoughts, which some techs and docs read for humor, if nothing else :

4.3.1.1 If the patient is uncomfortable or intolerant of high pressures on CPAP, the patient may be tried on BPAP. If there are continued obstructive respiratory events at 15 cm H2O of CPAP during the titration study, the patient may be switched to BPAP (Consensus). . . . this recommendation does not imply that BPAP is more effective than CPAP at maintaining upper airway patency. Additionally, efforts should be made to explore why the patient is uncomfortable or intolerant of high pressures on CPAP and to remedy the situation before trying the patient on BPAP.

4.3.1.6 The recommended minimum IPAP-EPAP differential is 4 cm H2O and the recommended maximum IPAP-EPAP differential is 10 cm H2O (Consensus).

http://www.aasmnet.org/Resources/Clinic ... 040210.pdf

JohnBFisher wrote:secret agent girl,*

John wrote:

When I later spoke with my sleep doctor at the time (a pulmonologist wise enough to listen to the input from others), he could show me a graph of my progression through the varous stages of sleep. You could SEE the fragmentation of my sleep due to the arousals. During CPAP the sleep architecture graph was all over the place. Lots of jagged lines showing transitions from deeper to lighter levels and then back again. But during the BiPAP part of the night, the graph showed a nice orderly progression from one stage to another.

In my opinion, "jbn3boys", is making mistakes by approaching the wrong medical specialists for advice. That lady sleep- doctor is the one to control the situation, assuming that she is a real qualified pneumologist, MD. The DME and all the others ore obliged to take the sleep doctor's ORDERS without questions, i.e.if you get an Rx from the sleep doctor for any machine, then if the DME carries it and gets paid for it then the patient should go for it. As to deciding on type of CPAPS and setting the pressures, on you own, read this from an article in NEJM, dated 2007:

There is no convincing body of data that any of these modified forms of pressure delivery (bileveld, auto-adjusted CPAP , and pressure relief CPAP) are better than fixed-pressure CPAP with regard to compliance and efficacy.


Sources:

http://www.ncbi.nlm.nih.gov/pubmed/17035433

http://www.ncbi.nlm.nih.gov/pubmed/15124718

jnk wrote:Here are the 2008 AASM thoughts, which some techs and docs read for humor, if nothing else :

4.3.1.1 If the patient is uncomfortable or intolerant of high pressures on CPAP, the patient may be tried on BPAP. If there are continued obstructive respiratory events at 15 cm H2O of CPAP during the titration study, the patient may be switched to BPAP (Consensus). . . . this recommendation does not imply that BPAP is more effective than CPAP at maintaining upper airway patency. Additionally, efforts should be made to explore why the patient is uncomfortable or intolerant of high pressures on CPAP and to remedy the situation before trying the patient on BPAP.

4.3.1.6 The recommended minimum IPAP-EPAP differential is 4 cm H2O and the recommended maximum IPAP-EPAP differential is 10 cm H2O (Consensus).

http://www.aasmnet.org/Resources/Clinic ... 040210.pdf

I was only giving my experience, not saying that it is the way it should be. That's why I started my post with "IN MY CASE". Just showing that people don't always follow the national standards, maybe. I don't know. All I know is my pressure was never above 11 before I was switched to 14/11 bipap during my sleep study.

avi123 wrote:In my opinion, "jbn3boys", is making mistakes by approaching the wrong medical specialists for advice. That lady sleep- doctor is the one to control the situation, assuming that she is a real qualified pneumologist, MD. The DME and all the others ore obliged to take the sleep doctor's ORDERS without questions, i.e.if you get an Rx from the sleep doctor for any machine, then if the DME carries it and gets paid for it then the patient should go for it.

Could you please clarify for me what mistakes I am making? I'm not sure I understand. My DME provides a machine that can be (AND IS) set to the exact pressures that the prescription is written for. However, they provide a machine that CAN, at a later date, IF NEEDED and IF prescribed, can be used in an auto mode for whatever reason the DOCTOR feels necessary. In my case, I was not allowed to see an actual sleep doctor until just this week, after having been on cpap/apap for four months and feeling miserable. I did play with my own pressure settings in auto, just as many people on these forums have done. But I'm still not sure what mistake I made. Had I actually SEEN a sleep doctor when I had my sleep study (which I had to beg for, by the way), I never would have messed with my own pressure. And, I have also said that I will "play by the rules" with this new machine, since I have the support of an actual medical doctor. She happens to be a neurologist, since that is the only sleep specialist that is available to me--the pulminologists in this area, at least the ones my insurance covers, do not see patients with sleep apnea.

(I'm sorry if I sound b****y...if I do, it is only due to lack of sleep....)

avi123 wrote:There is no convincing body of data that any of these modified forms of pressure delivery (bileveld, auto-adjusted CPAP , and pressure relief CPAP) are better than fixed-pressure CPAP with regard to compliance and efficacy.

Hi,

That may be the case for disorders that are treatable with CPAP. But when you have a disorder that is not treatable with CPAP, all the CPAP machines in the world are not going to help you. The key is to get a correct diagnosis, then get the right machine for that disorder, then get the machine set up correctly. In my case, that was a BiPAP machine.

-john-

jweeks wrote:

avi123 wrote:There is no convincing body of data that any of these modified forms of pressure delivery (bileveld, auto-adjusted CPAP , and pressure relief CPAP) are better than fixed-pressure CPAP with regard to compliance and efficacy.

Hi,

That may be the case for disorders that are treatable with CPAP. But when you have a disorder that is not treatable with CPAP, all the CPAP machines in the world are not going to help you. The key is to get a correct diagnosis, then get the right machine for that disorder, then get the machine set up correctly. In my case, that was a BiPAP machine.

-john-

Also, I have been 100% compliant, and have NOT achieved efficacy with a standard cpap. That is why I went to a sleep doctor. I did not go asking for a bilevel. I went asking if it was possible to get better treatment, however that may be. As a matter of fact, I was hoping to keep my same machine, but it was not to be.

avi123 wrote:...
There is no convincing body of data that any of these modified forms of pressure delivery (bileveld, auto-adjusted CPAP , and pressure relief CPAP) are better than fixed-pressure CPAP with regard to compliance and efficacy.
...

Oh boy! I fear I can drive holes through that logic.

I do not claim to be an expert. Just someone that has spent 20 long, hard years living with obstructive and central sleep apnea. I also recognize (and warn others) that my experience is unusual, since I suffer from a degenerative neurlogical disorder that impacts my brain stem and cerebellum.

The fact is that for me during my third titration study there was CLEAR evidence that bi-level therapy made a huge difference in my sleep. The arousals dropped to an acceptable level and my sleep architecture improved dramatically.

When I had to switch to ASV, there was again two titration studies that showed that ASV made a HUGE difference in my sleep. Without it, I have SERIOUS problems with sleep onset central sleep apneas. I stop breathing so long that my BiPAP machine's Auto Off feature would trigger. In otherwords, without ASV support, I stop breathing for more than one minute at a time.

Now, I don't know what sort of evidence you think is necessary, but there are many people who do require different therapies than CPAP.

jbn3boys wrote: . . . I was only giving my experience, not saying that it is the way it should be. That's why I started my post with "IN MY CASE". Just showing that people don't always follow the national standards, maybe. I don't know. All I know is my pressure was never above 11 before I was switched to 14/11 bipap during my sleep study.

I am glad you have shared, and hope you continue to share, your experience. I am not sure there is any "should be" yet, since even the AASM statements are less than "accepted practice" and are little more than a collection of common-sense thoughts based on limited studies. I am not sure that many labs follow those ideas from the AASM people. My personal opinion is that it should be easier to get bilevel. ResMed apparently thinks so too, since their CPAP machines' EPR is a lot like bilevel in many ways. Insurance seems to be the bully making the bilevel decisions more than docs or techs or RRTs. When you think about it, trying to find the best approach for a patient during one night of titration is a pretty silly idea from the get-go. Techs play around with the pressure while waiting for supine REM toward the end of the night and only get a few minutes to get it right with more than one patient at a time. It's the best idea there is for getting a good starting approach and starting pressure(s), so I am all for it and think it is the right thing to do, but it is all, still, in my opinion, a shot from the hip while riding a galloping pony through the dark in high wind, at best.