Best approach to home titration?

sleepyWI · Post by **sleepyWI** » Wed Jan 10, 2007 11:44 am

I was diagnosed with mild to moderate sleep apnea in September last year. I had a split-night PSG. The first half of the study I ended up with an AHI 9.3 which were mostly hypopneas (desats in low 80's). My AHI jumped up to 17 during REM (although there was very little REM). After the titration (which was rough) my doctor prescribed me a constant pressure of 7 cm. I own a vanilla cpap with no data recording capability. I have used it for 3 months religiously and have had no relief...I'm still a zombie. The doctor says I just need more time to get used to it. I think he's wrong so I am going around him to figure things out for myself.

So, I was able to swing (free!) a 2-week loan of an Autoset Vantage from my RT to get some numbers. She set it up in cpap mode at my constant pressure of 7. After two nights my AHI was 9.3 with an HI or about 7 (compare to above!!!!). It is very clear that my titrated cpap pressure is doing absolutely nothing for me.

I would like to use this machine while I have it to titrate a new pressure and could use some advice from those of you who have done this. I know how to get around the clinical menu and make changes, change modes etc.

Thoughts?

DreamStalker · Post by **DreamStalker** » Wed Jan 10, 2007 12:02 pm

You need to know if your PSG showed any central apneas.

If yes, your best bet may be to try for another professional titration.

If no, the apap may very well be all you need.

I'm sure others will chime in and give their opinions.

Best of luck!

OwlCreekObserver · Post by **OwlCreekObserver** » Wed Jan 10, 2007 12:12 pm

sleepyWI wrote: I would like to use this machine while I have it to titrate a new pressure and could use some advice from those of you who have done this. I know how to get around the clinical menu and make changes, change modes etc.

Thoughts?

This is an ongoing process for me. My original pressure (straight CPAP) was just 7cm, which wasn't nearly enough to stop "cpap gasp." I got it raised to 8cm, but that wasn't much better. A month or so later, after I was finally able to see the real numbers with Encore, I could see that it just wasn't working.

Talking to my primary care guy one day, I asked if I could get another referral to the sleep doc so I could get his OK to gradually raise the pressure on my machine until I hit the right zone. His advice was, "Just call his office and tell them what you're doing." That's why I like my primary care doc.

Anyway, I gradually adjusted the pressure in half-point increments to 11cm where, MOST of the time, everything's pretty much where it should be. It depends a lot on which mask I'm using and how leak-prone it is. Higher pressures mean bigger leaks, for me anyway, and at some point increasing the pressure any further really doesn't make much difference, except to keep me awake half the night fiddling with the mask to stop the leaks.

OCO

Mile High Sleeper · Post by **Mile High Sleeper** » Wed Jan 10, 2007 12:55 pm

For a lot of basic tips on home titration, read the article on CPAP Pressures under the light bulb above/our collective wisdom, expand all. The tips are in the last half of the article.

sleepyWI · Post by **sleepyWI** » Wed Jan 10, 2007 1:28 pm

DreamStlker...I hid have a few centrals in my slep study. However, three days ago my Dr. said no to either a new sleep study or a supervised home titration ..... he clearly does not take my concerns seriously.

tomjax · Post by **tomjax** » Wed Jan 10, 2007 1:47 pm

Cases such at this makes me more convinced that APAP should be the standard for those who take the time to learn their condition.
If a titration study is utilized, and I dont think one is necessary,
A person should be sent home with an apap with 3 above and 3 below the titrated pressure and after about 10 days, take a look at the smart card and get the results.

If a dod, for whatever reason, wants to remain a Luddite, at least s/he can get an idea of the best pressure.
S/he should put everyone on an apap, imho.

But the prospects of another sleep and titration study is probably the reason for the plain jane cpap.
I could be wrong......
tomjax

dsm · Post by **dsm** » Wed Jan 10, 2007 2:08 pm

clinical menu is accessed by pressing the bottom & right buttons down at the same time for over 3 secs.

Exiting is by repeatedly pressing right button until back to normal.

Good luck

DSM

NightHawkeye · Post by **NightHawkeye** » Wed Jan 10, 2007 2:23 pm

sleepyWI wrote: The doctor says I just need more time to get used to it. I think he's wrong so I am going around him to figure things out for myself.

And that's why the compliance rate for xPAP usage in the U.S. is less than 50% (a well documented number, BTW).

If it turns out that you need a high pressure part of the night, you will almost certainly do better with a Respironics Remstar APAP with C-flex.

It's entirely possible that you have varying pressure needs like some of us here, and a single titration value won't work well for you. it sounds like that could be why your doc had trouble with the titration.

Keep doing what you're doing and see if you can reduce your AHI with gradual pressure increases. If that doesn't work then your best next bet is to get the software and record AHI and APAP pressures throughout the night to see how much variation there is and whether a specific APAP range setting will minimize this for you.

As for central apneas, it appears that most folks who come to this forum, do not have serious problems with central apneas. And for those who do, the sleep docs indicate that the central apneas usually diminish to insignificance after those individuals get used to xPAP therapy.

Hope this helps. Don't be surprised if there are issues along the way. Unfortunately, apnea is not easily resolved with a one-size-fits-all approach. Don't be overly concerned when you encounter stumbling blocks along the way. The folks here can usually help you resolve them.

Regards,
Bill

Snoredog · Post by **Snoredog** » Wed Jan 10, 2007 3:21 pm

Increase your pressure to 8cm for a few nights, if you don't feel better put it back at 7cm.

You should be fine at 8cm with the few centrals seen, 9cm seems to be the magic number you don't want to go over blindly if you have any CA noted on your study.

pedroski · Post by **pedroski** » Wed Jan 10, 2007 3:33 pm

sleepyWI wrote:I would like to use this machine while I have it to titrate a new pressure and could use some advice from those of you who have done this. I know how to get around the clinical menu and make changes, change modes etc.

Hi SleepyWI,

I also have a Vantage unit and used it for a home titration, but I didn't have any centrals in my study. That means you need to be more careful, but I think you could try a setting of 1 above and 1 below your titrated pressure on apap and see if that improves things. Check in the morning on the LCD screen as Snoredog & Doug (DCM) said to see what happened during the night. My titrated pressure was 14 but my average pressure on apap is 12.8. Not much difference but it made a big difference to my sleep.

Good luck

Peter

arthuranxious · Post by **arthuranxious** » Wed Jan 10, 2007 5:49 pm

My lab titration was for 7 cm. with the note added that "improvement of sleep apnea and desaturation with CPAP but residual events remain." AHI was 6 with CPAP and 13 in REM... untreated in first study, I had only 6 in REM!!!
Anyway, eventually I got my way and received a Resmed auto, now the pressure has been anywhere from 6.2 to 11.4 but averaging around 8.6--9.6 and the AHI averages around 2.5, with AI alone almost always zero. So, that sounds good and it probably is, but how do I know I won't have induced central apneas and not know about them? I do often go over 9, even though the sleep lab hit on 7 as the magic number.

Guest · Post by **Guest** » Wed Jan 10, 2007 8:52 pm

Don't know if this will be helpful regarding the possibility of aggravation of central apneas; the following is from the Autoset Spirit clinician's manual. (Assuming the same information pertains to the S8.)

"The pressure will not rise above 10 cm H2O when an apnea is detected, to prevent an inappropriate response to central apneas."

sleepyWI · Post by **sleepyWI** » Thu Jan 11, 2007 7:19 am

ok...so last night I set my machine for a min pressure of 6 (my cpap pressure is 7 and I didn't see any point to dropping it too low) and a max pressure of 10. Here are the numbers from the led readout

Pressure 10.0
AHI 15.5
AI 3.8
HI 11.7

THese are obviously worse than my numbers at a constatn pressure of 7 (AHI 9.3, AI 1.7, HI 7.6).

Can someone tell me what the pressure number means? Suggestions what to do next?

kteague · Post by **kteague** » Thu Jan 11, 2007 8:08 am

Generally if one's pressure reading stayed at the upper limit setting and you still had events, it would sound like your pressure is still not high enough to cover your events.

BUT, your titration history of centrals at even low pressures would make me very uneasy with just continuing to up the pressure. I personally would want another study and/or would want to know if you need a machine geared to handling centrals. IF you need higher pressure to handle your obstructions, what is happening with the centrals at these higher pressures? If your study didn't test you at these higher numbers, I would think these are questions for which I would want specific answers. Maybe the answer is that they are insignificant, but I think I'd want to know for sure before I caused something my machine was not equipped to fix.

Kathy

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CPAPopedia Keywords Contained In This Post (Click For Definition): Titration

JimW · Post by **JimW** » Thu Jan 11, 2007 7:58 pm

sleepyWI wrote:Can someone tell me what the pressure number means?

The pressure in the readout represents the 95th centile - your pressure was 10.0 or below 95% of the time.

As far as suggestions: You may want to track your results for straight CPAP over several nights, and see if you consistently get better numbers. Remember that your AHI now includes, in all likelihood, some REM time - perhaps significantly more than during your initial PSG. You could possibly slowly increase your APAP minimum to see if that changed anything; I believe you can increase it by 1/10 cm at a time, increasing perhaps to as much as your originally titrated pressure of 7.

I've not much experience with making these adjustments; if there is a significant flaw or potential hazard in any of this, I'd appreciate it if those more experienced than I would hasten to contradict me.

Best approach to home titration?

Best approach to home titration?

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home titration

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Pressure of 10