APAP Discussion

sleepinginseattle wrote:I think there ought to be general agreement to either discuss APAP therapy in the absence of a sleep doctor's guidance (self-titration) or with it.

I'm going to say it one more time. Self titration does not mean absence of a sleep doctor's guidance and it never should.

snoredog wrote:Fact is there are NO guidelines for autopaps setting them 2 above or 2 below. 2 above or 2 below what?

That's actually what she's trying to say. There are NO guidelines for setting autopaps 2 above and 2 below your titrated pressure, yet that has come up quite a few times recently. Even our lightbulb has this to say:

The lightbulb wrote:Continuing with APAP, some people use their central number and add three points above and below it for a range. For example, if the titrated pressure is 10 cm/H2O, the range is 7 to 13 cm/H2O. Some people start with their titrated setting and go 3 cm/H2O under and 2 cm/H2O above the titrated pressure; for example, 7 to 12 cm/H2O. Some people benefit from an even narrower range, since that helps the machine to respond faster to events; for example, 9 to 11 cm/H2O.

Some people use their titrated pressure as their lowest setting and go up 2 or 3 cm/H2O to catch events. For example, if the titrated pressure is 10 cm/H2O, the range is 10 to 12 or 13 cm/H2O.

I see some assumptions in your post that bear correcting.

Snoredog wrote:Fact is the PSG lab will find your ideal pressure...

They're not always right. Take CollegeGirl's for example.

Snoredog wrote:Why is this bad? Allowing the autopap machine to run up from there is dangerous, just like an obstructive apnena, a pressure induced central apnea can put undue stress on the heart.

So, I'm confused. If a patient was mistitrated, like CollegeGirl was, she should keep running at that low pressure which causes OSA events because she's stupid if she wants to get rid of them without causing CSA events? She shouldn't try a higher pressure for a few days to find out? It's that much worse to her health to have a single pressure induced central while she's finding out, as compared with the piles of hypopneas that she gets at lower pressures due to the mistitration?

You seem to assume that titrations are always right. That's not the case.

Snoredog wrote:Autopap runaways do occur and they happen more often than you think they do. Some machines are better than others, some people should not be on them at all.

I'm curious about this. How often do they happen? Do you have any info that I can look at to get a handle on specific numbers? You seem to be looking at data that I haven't seen...

Snoredog wrote:When I give suggestions about a machine, I ignore the other posts in the thread, because they are usually from some cpap newbie who has been reading way too much of the wrong information, has never owned that particular machine and doesn't have the condition.

I'm confused when you say "doesn't have the condition." Which condition, CSA or? It sounds like you're saying the newbies don't have OSA here...

My biggest problem with your post is that you didn't need to go on a personal attack. I would love to hear your views, as I respect them highly, but it's hard to parse your views out of sentences like, "You are a train wreck waiting to happen." especially when you're saying that to her because of a view that she even states she disagrees with in her post.

Snoredog wrote:It is not that hard to figure out, if you don't improve with higher pressure you have gone the wrong direction. It is all quite simple when you think about it and apply a bit of common sense.

I don't see where she suggested otherwise...?

blarg wrote:

sleepinginseattle wrote:I think there ought to be general agreement to either discuss APAP therapy in the absence of a sleep doctor's guidance (self-titration) or with it.

I'm going to say it one more time. Self titration does not mean absence of a sleep doctor's guidance and it never should.

snoredog wrote:Fact is there are NO guidelines for autopaps setting them 2 above or 2 below. 2 above or 2 below what?

That's actually what she's trying to say. There are NO guidelines for setting autopaps 2 above and 2 below your titrated pressure, yet that has come up quite a few times recently. Even our lightbulb has this to say:

The lightbulb wrote:Continuing with APAP, some people use their central number and add three points above and below it for a range. For example, if the titrated pressure is 10 cm/H2O, the range is 7 to 13 cm/H2O. Some people start with their titrated setting and go 3 cm/H2O under and 2 cm/H2O above the titrated pressure; for example, 7 to 12 cm/H2O. Some people benefit from an even narrower range, since that helps the machine to respond faster to events; for example, 9 to 11 cm/H2O.

Some people use their titrated pressure as their lowest setting and go up 2 or 3 cm/H2O to catch events. For example, if the titrated pressure is 10 cm/H2O, the range is 10 to 12 or 13 cm/H2O.

I see some assumptions in your post that bear correcting.

Snoredog wrote:Fact is the PSG lab will find your ideal pressure...

They're not always right. Take CollegeGirl's for example.

Snoredog wrote:Why is this bad? Allowing the autopap machine to run up from there is dangerous, just like an obstructive apnena, a pressure induced central apnea can put undue stress on the heart.

So, I'm confused. If a patient was mistitrated, like CollegeGirl was, she should keep running at that low pressure which causes OSA events because she's stupid if she wants to get rid of them without causing CSA events? She shouldn't try a higher pressure for a few days to find out? It's that much worse to her health to have a single pressure induced central while she's finding out, as compared with the piles of hypopneas that she gets at lower pressures due to the mistitration?

You seem to assume that titrations are always right. That's not the case.

Snoredog wrote:Autopap runaways do occur and they happen more often than you think they do. Some machines are better than others, some people should not be on them at all.

I'm curious about this. How often do they happen? Do you have any info that I can look at to get a handle on specific numbers? You seem to be looking at data that I haven't seen...

Snoredog wrote:When I give suggestions about a machine, I ignore the other posts in the thread, because they are usually from some cpap newbie who has been reading way too much of the wrong information, has never owned that particular machine and doesn't have the condition.

I'm confused when you say "doesn't have the condition." Which condition, CSA or? It sounds like you're saying the newbies don't have OSA here...

My biggest problem with your post is that you didn't need to go on a personal attack. I would love to hear your views, as I respect them highly, but it's hard to parse your views out of sentences like, "You are a train wreck waiting to happen." especially when you're saying that to her because of a view that she even states she disagrees with in her post.

Snoredog wrote:It is not that hard to figure out, if you don't improve with higher pressure you have gone the wrong direction. It is all quite simple when you think about it and apply a bit of common sense.

I don't see where she suggested otherwise...?

You haven't been on the hose not even a year, and you think you know what you are talking about. You have a lot to learn kid.

CollegeGirl wrote:Please, let's be civil about this. No personal attacks, no flaming, no "camoflauged" personal attacks

Well......so much for that

Sleep lab finding the correct pressure?? Please. A fair part of my job is spent cleaning up that botched mess of pseduo-medical trickery that the sleep lab calls a 'titration study'. And what suggestion do they send when they can't get the job done?? "Place patient on auto-titrating CPAP for 3-4 weeks and download for optimal pressure" WTF?!?!? Gimme a break!! If you can't properly titrate someone that night, HAVE THEM COME BACK FREE OF CHARGE. After all, your job wasn't done and they shouldn't have to pay until it is. Does this EVER happen???.....Noooooo .

BrianRT wrote:Gimme a break!! If you can't properly titrate someone that night, HAVE THEM COME BACK FREE OF CHARGE. After all, your job wasn't done and they shouldn't have to pay until it is. Does this EVER happen?

It happens a great deal more than you think.
SAG

BrianRT wrote:And what suggestion do they send when they can't get the job done?? "Place patient on auto-titrating CPAP for 3-4 weeks and download for optimal pressure" WTF?!?!? Gimme a break!!

RTFLOL!!! Thanks for bringing this back to reality BrianRT. . .

And thanks for reinforcing what many of us here already knew all along.

Regards,
Bill

Snoredog wrote:You haven't been on the hose not even a year, and you think you know what you are talking about. You have a lot to learn kid.

You're right. I do. Could you please answer the questions I asked so I can start learning?

StillAnotherGuest wrote: It happens a great deal more than you think.
SAG

ummmm......I 'THINK' it nevers happens in my dealings with sleep labs. IF it does, then GREAT, it SHOULD be the default, instead of the exception. My point is, a number of sleep labs use auto's as their 'go-to' device when they can't properly titrate (*gasp* dirty insider secret just leaked folks...no pun intended). Problem is, the patient has to pay for that 2nd night titration study when NOTHING WAS ACCOMPLISHED.

But, if it happens 'a great deal more than I think', then let me ask the opinions of the residents of this fine forum. Has anyone ever been told to come back for another titration study because the lab couldn't quite get it right the first time??

blarg wrote:

Snoredog wrote:Autopap runaways do occur and they happen more often than you think they do. Some machines are better than others, some people should not be on them at all.

I'm curious about this. How often do they happen? Do you have any info that I can look at to get a handle on specific numbers? You seem to be looking at data that I haven't seen...

That's hard to quantify because of all the variables involved, including having a patient with that susceptibility and then doing the follow-up to know that that had actually occurred. However, here's one, anyway, from the thread

viewtopic.php?t=14225



SAG

StillAnotherGuest wrote:That's hard to quantify because of all the variables involved, including having a patient with that susceptibility and then doing the follow-up to know that that had actually occurred. However, here's one, anyway, from the thread

viewtopic.php?t=14225

SAG

Yeah, it's obviously hard to quantify, which is why I'm interested in seeing the numbers that Snoredog has access to. It would shed a great deal of light on the situation. It's obvious it happens to some people, I'm just wondering how many.

blarg wrote:

StillAnotherGuest wrote:That's hard to quantify because of all the variables involved, including having a patient with that susceptibility and then doing the follow-up to know that that had actually occurred. However, here's one, anyway, from the thread

viewtopic.php?t=14225

Yeah, it's obviously hard to quantify, which is why I'm interested in seeing the numbers that Snoredog has access to. It would shed a great deal of light on the situation. It's obvious it happens to some people, I'm just wondering how many.

Morgenthaler et al at Mayo in Complex Sleep Apnea Syndrome: Is It a Unique Clinical Syndrome? in SLEEP 2006:9 showed that the incidence of CompSAS (which would pretty much be the thing that would get you into trouble with pressure-induced events) was about 15%, so that might be a good number to start with.
SAG

That's a great number to start with. Thank you.

I did not receive a print out of my sleep test, but with Encore Pro and testing different pressures, I found out for me pressures above 15.5 Cm caused a increase in centrals. Having had major heart surgery, I thought it might be better to not exceed 15.5 cm, (My sweet spot) on CPAP.

So when I went APAP, I set my limit at 15.5 cm. and found when my leak rate went up to 40 to 45 cm, I snored and it drove the APAP to the top setting, in fact it was marked as 16 CM quite a few times???

Now I'm at 11 to 15 cm, and alls right with the APAP World. AHI 0.68 and under. Jim

During my sleep test the set my AHI at 150. 450 for 3 hours of sleep.

CPAPopedia Keywords Contained In This Post (Click For Definition): Encore Pro, CPAP, AHI, APAP

Snoredog wrote: You haven't been on the hose not even a year, and you think you know what you are talking about. You have a lot to learn kid.

CollegeGirl, Blarg: You both have done a fantastic job at expressing your points of view. Both of you are concise and clear with the information you are presenting. I am always impressed with posts that are written by one or both of you. But as gifted as the two of you are when it comes to technical communication you need to be prepared when you bash wits with somebody like "Snoredog".

"Snoredog" managed to cram two logical fallacies and one double negative In the short posting I've quoted above. That is a feat that not many people can accomplish, even while writing with a sunburned neck.


Levi

_________________

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

Snoredog, you've done a lot of experimenting with a lot of machines while working on your own treatment. The type of sleep disordered breathing that showed up on your PSG happened to involve a lot of centrals for you. Your lab titration and your own use of autopaps found what's right for you. I don't know this for a fact, but my guess is that your case is rather unusual compared to the type of sleep disordered breathing most people have.

StillAnotherGuest wrote:Morgenthaler et al at Mayo in Complex Sleep Apnea Syndrome: Is It a Unique Clinical Syndrome? in SLEEP 2006:9 showed that the incidence of CompSAS (which would pretty much be the thing that would get you into trouble with pressure-induced events) was about 15%, so that might be a good number to start with.
SAG

If that Mayo study is right, approximately 85% don't have the kind of SDB problem that may be what was revealed in your PSG sleep study, Snoredog...i.e. the numerous centrals you had along with your other OSA events. The experience you have when you increase pressure is not likely to happen to most people with plain OSA who choose to use an autopap, imho. I think your own experience very much colors your advice about autopap settings. But then, that's probably so to one extent or another for all of us.

I do think that your insistence on the danger of raising pressure and risking "pressure induced centrals" is overstating the possibility because you've seen that happen to you. I don't think that would happen to most people using autopap. Just my opinion, and I'm not a doctor.

viewtopic.php?t=14225
Page 2:

StillAnotherGuest wrote:The phenomena of pressure-induced central apneas is tossed around far too freely. The vast majority of people do not get centrals because of ultra-therapeutic CPAP levels. BiLevel, Pressure Support (PSV) and Proportional Assist (PAV) Ventilation are another matter. You need some mechanism to drive the pCO2 below the sleeping apneic threshold, and plain old CPAP rarely is able to do that. OK, if you wanna argue that CPAP increases base lung volume (Functional Residual Capacity)(FRC), and since that increases gas exchange, some people can generate centrals that way, fine. But it's not as many as you might think.
SAG

(bold emphasis mine)

True, SAG was referring to "plain old CPAP", not autopaps. However, I think autopaps are delivering one straight cpap pressure, too...varying that pressure, yes. But I think autopaps are more in the category of "CPAP" than being the type of machines that would deliver the kind of treatment (BiLevel, PSV, PAV) he goes on to speak of as being "another matter."

about auto bipap. I am in the process of writing a letter to my doctor who first recommended I switch from cpap to bipap due to retaining carbon doxide in my lungs but then switched to remstar auto with c flex due to my sharing several people on here said they had similar problems (high pressures, little help from treatment, mouth breathing) by autopap.

But I have wondered if that is good due to not wanting to retain co2. I then found out that auto bipap existed which some people thought would be best of both for me. I do not know which machine is good to ask him to prescribe. I heard they is an old one and a new one and they run differently.

Please help me before I finish this letter to find which is best. I need some info on it.

PLEASE HELP...I need answer now as I am mailing letter tonight or early tomorrow