Never Use CPAP When You Have APAP Capability (?)

goose · Post by **goose** » Thu Nov 22, 2007 7:49 pm

My DME has told me that soon they will not be distributing CPAP machines anymore...Since the APAP's can be run in CPAP mode they'll just set an APAP machine into CPAP mode with the prescription.
I didn't ask them about the difference in profit for their company....It may be that at volume sales the difference in actual cost is negligible.....

Mindy nailed my use. I use APAP to re-titrate on occasion. My present attempt may be somewhat pointless with a range of 9-11, but since 10 was working well and 11 didn't seem to.....I guess we'll see...

And Den makes an excellent point in that it's hard to hit a moving target.
If my machine is set at a specific pressure, the data that creates the trend is at least looking at a consistent target. When in APAP mode the numbers are based on a moving set of pressures.....

cheers
goose

billbolton · Post by **billbolton** » Thu Nov 22, 2007 10:25 pm

ted wrote:I would never consider running my APAP machine in CPAP mode—doing so defeats the primary purpose of APAP technology which is to provide responsive pressure, responsive to normal variances in pressure needs.

The "primary purpose" of APAP is to treat a class of users who had difficulty maintaining compliance with CPAP, for a variety of reasons.

If you don't happen to fall into that class of users then there may be no real benefit from auto pressure adjustment per se.

There may well be benefit from some of the non-auto flow control features that started out appearing only in what were then "high end" APAP flow generators, but now a days may be availble in non-auto flow generators..

It's your call what you personally chose to do, but APAP is not some sort of magic bullet that solves all OSA problems by any means.

Cheers,

Bill

RipVW · Post by **RipVW** » Fri Nov 23, 2007 9:01 am

That's a unique perspective, Bill, inconsistent with anything I've ever read or been told about APAP. Wondering about your source (?). I'd be interested in reading it--I continually search for reports, research and articles to increase my understanding of my apnea and how to best deal with it. While I have read that compliance is one of the advantages of APAP, I haven't heard it depicted as the "primary" purpose anywhere. Below is what I hear/read everywhere regarding the "primary purpose:"

"Different pressures are needed for different levels of sleep and positions. The purpose of APAP is to have the lowest possible pressure for each position or sleep level. [thinking this is the "primary" purpose--at least that's what I read everywhere]

At a given pressure, the machine adjusts the pressure higher until the occurrences are controlled, if a person starts to have an apnea or hypopnea. The pressure is decreased, if a person is in a sleep level or position that doesn’t need a higher pressure."

Here is the list of advantages noted in this article:
Advantages of APAP over fixed pressure CPAP:
• Detects adverse mask conditions.
• Ultra-sensitive snoring detection capabilities.
• Eliminates the necessity for CPAP calibration every night
• Improves CPAP compliance since the pressure rises and falls to deliver the minimum pressure required keeping the airway patent and hence there are lower mean pressures throughout the night.

So, I do see "compliance" referenced in the literature as among the "advantages" of APAP over CPAP, but not seeing it referenced as the "primary purpose" anywhere.

Respectfully,

Ted

Source: APAP - "Auto Adjusting Positive Airway Pressure" retrieved November 22, 2007, from http://www.sleepdisordersguide.com/topics/apap.html

_________________

CPAPopedia Keywords Contained In This Post (Click For Definition): CPAP, Hypopnea, APAP

mindy · Post by **mindy** » Fri Nov 23, 2007 9:19 am

ted wrote: Here is the list of advantages noted in this article:
Advantages of APAP over fixed pressure CPAP:
• Detects adverse mask conditions.
• Ultra-sensitive snoring detection capabilities.
• Eliminates the necessity for CPAP calibration every night
• Improves CPAP compliance since the pressure rises and falls to deliver the minimum pressure required keeping the airway patent and hence there are lower mean pressures throughout the night.

So, I do see "compliance" referenced in the literature as among the "advantages" of APAP over CPAP, but not seeing it referenced as the "primary purpose" anywhere.

Ted,

That article sounds to me a bit like a sales brochure than a research paper -- that doesn't mean it's not valid .... just that I'd personally take it with a grain of salt. What APAP is used for and what it is or isn't good for may change over time as more research is done.

It is certainly possible, since APAP includes the ability to use it as CPAP and the price difference between APAP and CPAP keeps decreasing, that straight CPAPs may disappear entirely. But we will still have a choice of therapies and therin lies the key ... patient choice!

Mindy

RipVW · Post by **RipVW** » Fri Nov 23, 2007 9:49 am

That article sounds to me a bit like a sales brochure than a research paper -- that doesn't mean it's not valid .... just that I'd personally take it with a grain of salt.

Good point, Mindy. Ultimately, though, all we read and hear is an attempt to "sell," whether selling a product, an idea, or a position. As one who spends much of my time dealing with research (primarily mentoring Ph.D. candidates through their dissertation research), I encourage all to seek "peer reviewed" sources upon which to base conclusions during one's literature review. But, we cannot ignore all of the other information out there, either, particularly if we see that it is consistently presented from multiple sources.

In regard to Bill's assertion regarding the primary purpose of APAP, consider the following from a peer reviewed medical journal:

There is conflicting evidence for and against the premise that treatment with APAP increases acceptance and adherence compared to fixed CPAP. In studies demonstrating an increase in adherence with APAP, there was similar improvement in measures of daytime sleepiness as with fixed CPAP treatment. Further studies are needed to determine if APAP can increase acceptance or adherence with positive pressure treatment in patients with OSA.

So, when one finds consistent evidence of a position from both peer reviewed and non-peer reviewed sources, one tends to accept the position as valid.

Berry, R.B., Parish, J.M., & Hartse, K.M. "The use of auto-titrating continuous positive airway pressure for treatment of adult obstructive sleep apnea: Auto-titrating CPAP" American Academy of Sleep Medicine Review. Retrieved November 23, 2007, from http://www.aasmnet.org/Resources/Practi ... rating.pdf

mindy · Post by **mindy** » Fri Nov 23, 2007 9:59 am

ted wrote:So, when one finds consistent evidence of a position from both peer reviewed and non-peer reviewed sources, one tends to accept the position as valid.

Ted,

I agree.

From a fairly cursory review, it seems to me that most of the medical literature on APAP Vs. CPAP is about compliance and is only beginning to move toward comparing the results of therapy. That may or may not change the picture!

Mindy

linuxgrl · Post by **linuxgrl** » Fri Nov 23, 2007 12:13 pm

As one of the people that prefers to run her APAP in CPAP mode, I'd just like to say that at least on my machine, CPAP is much quieter. I also sleep much more soundly in CPAP mode because all the changes in pressure would wake me up in the middle of the night. I also feel much more rested since I switched. AutoPAP is great for titration purposes but I was never able to find the proper range that worked for me.

Just my two cents.

Goofproof · Post by **Goofproof** » Fri Nov 23, 2007 4:30 pm

linuxgrl wrote:As one of the people that prefers to run her APAP in CPAP mode, I'd just like to say that at least on my machine, CPAP is much quieter. I also sleep much more soundly in CPAP mode because all the changes in pressure would wake me up in the middle of the night. I also feel much more rested since I switched. AutoPAP is great for titration purposes but I was never able to find the proper range that worked for me.

Just my two cents.

Usually a setting of 1 cm over your CPAP pressure and 2 or 3 CM under works the best. This only works after you have mouthleaking elimitated.

Your machine is probably as loud in CPAP, you won't notice it as much as the pitch remains the same, except for exhale.

Your Hh in your profile may be for the Classic. Jim

sleepycarol · Post by **sleepycarol** » Fri Nov 23, 2007 4:44 pm

Okay this may seem like a dumb question but I am going to ask anyway.

Why would a doctor prescribe an autopap set at a range of pressures if a plain cpap would be better? I had the titration study and so I wasn't prescribed an auto for that reason. My prescribed pressure is 8 to 12 -- I find most nights I stay between 9 and 11 but do go up to the 12 often enough that I feel more secure having it go up if necessary.

Why not just set it at 12 and be done with it? Just trying to figure it out.

DreamStalker · Post by **DreamStalker** » Fri Nov 23, 2007 4:52 pm

sleepycarol wrote:Okay this may seem like a dumb question but I am going to ask anyway.

Why would a doctor prescribe an autopap set at a range of pressures if a plain cpap would be better? I had the titration study and so I wasn't prescribed an auto for that reason. My prescribed pressure is 8 to 12 -- I find most nights I stay between 9 and 11 but do go up to the 12 often enough that I feel more secure having it go up if necessary.

Why not just set it at 12 and be done with it? Just trying to figure it out.

Comfort.

If you feel that variable pressure has no comfort benefits for you over the 12 cm straight CPAP ... 12 cm will work just fine.

The APAP becomes useful for other reasons too however. If your pressure needs increase for what ever reason (weight gain, medications, etc.), your APAP will be able to determine how much more pressure is needed easier and quicker than with a plain CPAP and cheaper than a titration study at the lab.

linuxgrl · Post by **linuxgrl** » Fri Nov 23, 2007 11:46 pm

Goofproof wrote:Usually a setting of 1 cm over your CPAP pressure and 2 or 3 CM under works the best.

Thanks, I'll try that! I think I was probably setting my range too big before.

WillCunningham · Post by **WillCunningham** » Sat Nov 24, 2007 1:24 am

I switched from a cpap to a bi-pap in auto mode. I eventually started to feel tired and spent some time trying to figure out what was going wrong for me. After switching from auto to set pressure, I noticed a large improvement in my energy and 'rested feeling'. The number of apnea's detected according to the resmed software was very low in either case, below 5 easily...but I still felt tired till I made the change away from auto. That setting was the only variable changed and I felt better afterwards and felt much better rested.

The theory that I have been going with is that the changes in pressure under auto mode, while enough to prevent apneas, must have also been enough to disturb my sleep. The end result being that I still ended up with a not so great nights sleep.

Now I use auto mode as a guide every once in a while to make sure weight gains or loss's have not affected the pressure that works best for me. I put it in auto mode for a few nights, go over the numbers and see if my set pressures should be updated. It has been working very well for me so I am glad to have the auto feature, just also glad that I am not forced to use it.

billbolton · Post by **billbolton** » Sat Nov 24, 2007 4:26 am

Randerath WJ wrote:APAP devices use different algorithms depending on the primary purpose of the application. Therefore, a clear distinction between automatic titration and treatment is of major relevance.While titration devices aim at the finding of one single pressure which is fixed to a constant CPAP device, automatic treatment means the chronic use of APAP at home for optimal adaptation of the treatment pressure to the actual requirements of the patient. A high constant CPAP level, huge pressure variability, insufficient compliance with constant CPAP may be indications for APAP treatment. The main reason for automatic titration is standardization of the initiation process.

Automatic Positive Airway Pressure Titration and Treatment

Randerath WJ, Sanner BM, Somers VK (eds): Sleep Apnea. Prog Respir Res. Basel, Karger, 2006, vol 35, pp 137-144 (DOI: 10.1159/000093156)

David W. Hudgel wrote:Abstract: This study is a 12-week randomized, cross-over, single-blind comparison of the tolerance, compliance, and symptomatic improvement obtained with standard nasal continuous positive airway pressure (CPAP) vs. an auto-titrating, self-adjusting device (APAP). Sixty newly diagnosed patients, 53 with obstructive sleep apnea (OSA) and seven with upper airway resistance syndrome were studied. Thirty-nine patients (65%) completed the 24-week protocol. Data were complete in 33. In these 33 patients CPAP and APAP reduced the Epworth Sleepiness score from 15±1 (±SEM) to 8±1 and 9±1 respectively (both <0.0001 from baseline but NS between modes). The APAP average pressure was lower than the CPAP pressure, 6.4±0.4 and 10.6±0.4 cm H2O, respectively. The average daily machine use was greater with APAP, 6.0±0.3 hrs. versus 5.5±0.3 hrs. with CPAP (P < 0.04). The number of days of machine use, and the pattern of use were not different between CPAP and APAP. A higher proportion of patients who did not complete the study was randomized to CPAP for their initial treatment period. This study showed that: 1) CPAP and APAP produced an equivalent improvement in daytime sleepiness, 2) APAP pressure was lower than CPAP pressure, 3) patients wore the APAP device longer during nights they used the pressure support system, and 4) patients who began the study with APAP were more prone to continue treatment. We conclude that APAP was better tolerated and used a greater number of hours than CPAP, but the extent of improvement in excessive daytime sleepiness was similar between the two modes of therapy

A Long-term Randomized, Cross-over Comparison of Auto-titrating and Standard Nasal Continuous Airway Pressure

David W. Hudgel MD and Caroline Fung BS, PA
Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH - SLEEP, Vol. 23, No. 5, 2000

UNICARE wrote:Failed CPAP is defined as any of the following criteria documented in the medical record:

* Claustrophobia; or
* Inability to breathe through the nose; or
* Pain or discomfort; or
* Patient intolerance; or
* Patients at high pressures of CPAP (>10 cm H20) complaining of pressure discomfort.

Auto-CPAP (APAP) is considered medically necessary as a second or third line alternative therapy for obstructive sleep apnea when documentation of the following is available:

1. The level of fixed CPAP required is at least 10cms H2O as evidenced by an in- laboratory, technician-attended CPAP titration during polysomnography; and
2. The patient is intolerant of high fixed CPAP pressures (>10cms. H2O) despite appropriate patient education and interventions to improve patient comfort and compliance. These interventions should include:
* The use of a topical nasal corticosteroid spray or anticholinergic spray if nasal complaints are significant; and
* Changes made by a nurse or technician, in consultation with the attending physician, to the CPAP circuit or mask, using different nose masks, face masks, nasal pillows or head harnesses as appropriate to achieve maximum patient comfort.

Subject: Treatment for Obstructive Sleep Apnea in Adults
Policy #: MED.00054 Current Effective Date: 02/05/2007

http://medpolicy.unicare.com/policies/MED/OSA.html

Cheers,

Bill

RipVW · Post by **RipVW** » Sat Nov 24, 2007 8:13 am

Thanks, Bill! I continue to learn SO much from this forum. Your knowledge/expertise is truly appreciated. I'm glad you're here!!

Ted

linuxgrl · Post by **linuxgrl** » Sat Nov 24, 2007 1:49 pm

WillCunningham wrote:After switching from auto to set pressure, I noticed a large improvement in my energy and 'rested feeling'.

Me too. I've only been on xPAP for a little over 2 months but I started on APAP (setting: 4-20) and initially I felt much better- but not completely rested. I was still having to take naps every day. Then at the advice of someone on this board, I switched to straight CPAP at my 90% pressure (9) and all of a sudden, no more afternoon naps. I did try a more narrow range last night (7-10) and my AHI was higher than usual (5.5) when it's usually under 1. I don't have my Encore Pro with me because I'm on vacation but I'm definitely curious to see what happened.

Never Use CPAP When You Have APAP Capability (?)

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Purpose Of APAP Usage

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