Thought this was some intresting information to think about

Thought it was intresting on why they don't like us to change the pressure our selves. Refering to If you lower it too much, you're not providing enough pressure to fix apneic episodes. If you raise it too high, you run a risk of having pressure-induced central apneas PLUS having an adverse effect on intrathoracic pressure and venous blood return. It's not that the information is a secret protected by an esoteric society, it's that willfully providing this info can easily be made a legal issue as far as liability of the DME for example

CPAP/Bipap Provider Manuals--THE TRUTH
by: azuresky73( 185)
73 out of 88 people found this guide helpful.
Guide viewed: 4899 times Tags: cpap | bipap | respironics | resmed | sleep apnea


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I've noticed that several enterprising individuals have taken it upon themselves to sell the Provider Manauls that come with CPAP and Bipap machines. This is different from the User Manuals that ARE given to the patient. The Provider Manuals give information about how to access the Clinical Menu and change pressure settings and other parameters.

These manufacturer states that the Provider's Manual is NOT to be given to patients. This is because some people may attempt to change their settings away from the setting that was determined at a titration study at a sleep lab. The reasons are varied. Perhaps some people want to lower the pressure to make it more comfortable, others may want to raise it. I think that it is fair to inform people that lowering or raising the pressure on your own can have detrimental effects to your health. If you lower it too much, you're not providing enough pressure to fix apneic episodes. If you raise it too high, you run a risk of having pressure-induced central apneas PLUS having an adverse effect on intrathoracic pressure and venous blood return. It's not that the information is a secret protected by an esoteric society, it's that willfully providing this info can easily be made a legal issue as far as liability of the DME for example.

I feel that people have the free will to do whatever they please, but I feel an obligation to educate so that their choices can be informed decisions and what risks CAN be associated. I am a Respiratory Therapist who specializes in Sleep Medicine and PAP applications so hopefully you can feel confident about what I'm saying.

However, the main things that really aggravate me about the Provider Manual sellers is that they play off of peoples' fear and ignorance. They try to convince you that you can save $$$ by making changes yourself with the help of their manual. Let me state once and for all that, DMEs DO NOT CHARGE FOR THIS SERVICE. Changing settings on a CPAP or BIPAP machine is part of being the customer of their machine. Service like this is included. There isn't even a billable code to submit to insurance for this service!?! IF your DME tries to charge you for this service, simply inform them that they are being unethical, immoral, and that if they don't follow the order and adjust the setting, then you will promptly inform your Doctor about their non-compliance. The simple fear of losing a referral source should change their mind quickly.

If you are looking for an answer to your CPAP woes, please let me say that adjusting your pressure setting probably isn't the best way to start about it. I will be soon completing an ebook which I feel will be of tremendous value to CPAP users and people with other forms of sleep apnea. Written from my perspective as an RT, I hope to clear up several myths (like the one above) and point out other little ways that people like to prey on the uniformed.

I hope you have found something of value in my guide. If you have, please vote!

Thank you!



Guide ID: 10000000003664204Guide created: 06/01/07 (updated 07/04/08)


Introduction & Importance

The blood coming from the tissues are transported by the venous system which is composed grossly by the venules, the small and the great veins. The pulmonary artery contains mixed venous blood, which is actually the sum of the superior vena cava and inferior one venous blood. Venous congestion is seen in some diseases and is consequence to abnormal high venous pressure.
Venous Return

The venous return (VR) can be defined as the volume of blood reaching the right heart. If one defines the term central venous pool - roughly the blood contained in the great thoracic veins and in the right atrium - then venous return will be the volume of blood entering this compartment, coming from the periphery. According to the Ohm’s law, there must be a pressure gradient between these two compartments. Keeping others variables constant, the venous return is inversely proportional to the central venous pressure. These two parameters can be plotted in a diagram, yielding the venous return family curves. In hemodinamically stable conditions the VR must be virtually equal to the CO - changes from one heartbeat to another do exist - otherwise blood would be damped back. CVP is always inherently driven to the equilibrium value that makes CO and VR equal. At CVP of 2 mmHg, CO is about 5 l/min.
Major factors influencing venous return

1) Respiratory cycle - Central venous pressure (CVP) decreases with inspiration thereby increasing venous return. This is explained by the negative intrathoracic pressure originated at inspiration, which is transmitted to the great veins of the thorax; moreover, the downward diaphragm movement during this phase helps the pulling of blood toward the heart by increasing the intrabdominal pressure. At expiration, the mechanisms reverse. 2) Venous tone - is governed by autonomous system. 3) Right heart function - The blood reaching the right ventricle is pumped to the pulmonary circulation and therefore will not be damped backward in the venous system. 4) Gravity - discussed below 5) Muscle pump - discussed below


http://www.medstudents.com.br/basic/cardfs/cardfs4.htm

It's fair to say that you have a right to understand your equipment and treatment, and make changes if you want to. It's easy enough to search the net or buy the book to learn how. Also fair to expect the mfg to protect their butts in court.

People have a tendency to self medicate. We also have a history of trying to avoid responsibility, which is why we have so many warning labels and lawsuits. Safety regulations aren't just to protect suppliers, they're supposed to help protect us from our own stupidity. When pharmacies were required to keep better track of sales, fewer people died.

In my view it's a good thing that it's inconvenient for us to play around with our prescriptions.

http://ajrccm.atsjournals.org/cgi/conte ... /167/5/716

American Journal of Respiratory and Critical Care Medicine Vol 167. pp. 716-722, (2003)

Can Patients with Obstructive Sleep Apnea Titrate Their Own Continuous Positive Airway Pressure?
Michael F. Fitzpatrick, Christi E. D. Alloway, Tracy M. Wakeford, Alistair W. MacLean, Peter W. Munt and Andrew G. Day
Departments of Medicine and Psychology, Queen's University, Kingston, Ontario, Canada

In summary, this study demonstrates that self-titration of CPAP in patients with OSA is as efficacious as manual titration in a sleep laboratory, with similar subjective and objective outcomes, and CPAP compliance. Clearly, for this strategy to be successful, the patient must understand when and how to change the CPAP. Although the patient population studied did include a wide age range, this strategy would not be feasible for intellectually disadvantaged patients and those with physical handicaps that would severely limit vision and/or manual dexterity. Nonetheless, the findings from this study imply that routine overnight polysomnography is unnecessary for the purpose of CPAP titration in many patients with OSA, provided that the patient is given some basic education and support. Resources currently allocated to manual in-laboratory CPAP titration might be better spent on specific attention to patient education and support rather than pressure titration. A treatment algorithm that focuses on such ambulatory patient education and support rather than in-laboratory CPAP titration may realize significant efficiencies in the management of OSA without loss of treatment efficacy.

http://ajrccm.atsjournals.org/cgi/conte ... /167/5/674
American Journal of Respiratory and Critical Care Medicine Vol 167. pp. 674-675, (2003)

Editorial

Can Continuous Positive Airway Pressure Be Self-Titrated?
Samuel T. Kuna, M.D.
<snip>
In general, attempts to titrate CPAP out-of-laboratory, either by the patient's self-adjustments or by autoCPAP machines, are made easier by the wide therapeutic window of CPAP treatment. Over the normally applied pressure range of 4–20 cm H2O, CPAP is usually safe and efficacious as long as it exceeds the patient's "optimal" pressure. The level of CPAP has not been reported to affect patient adherence to treatment (14). AutoCPAP titration, however, is currently not recommended for patients with underlying cardiopulmonary or neuromuscular diseases who may suffer from central sleep apnea. One wonders whether or not patients with these disorders should also be excluded from self-titration (4). Most autoCPAP algorithms take into account that central apneas may persist or appear as pressure is increased, and the machines are programmed not to increase pressure above a predetermined level, despite the persistence of apneas. The untrained bed partner assisting in a self-titration would not be able to distinguish central apneas and might mistakenly advocate unwarranted increases in pressure.

wlo2008 wrote:...............If you lower it too much, you're not providing enough pressure to fix apneic episodes. If you raise it too high, you run a risk of having pressure-induced central apneas PLUS having an adverse effect on intrathoracic pressure and venous blood return............

If the data were available I am sure we would see that sleep labs prescribe a suboptimal pressure more than 50% of the time. So one of the two results in your quote are exactly what more than 50% of sleep labs patients are getting.

Case in point, I was titrated at 10 cm. Continuing to feel horrible for two years I kept complaining to the sleep doc and he eventually lowered the pressure to 7 cm. He also insisted at one visit, "I know the lab got the pressure right!".

I finally obtained a data capable machine and software for my personal use. At 10 cm my AHI was 32. No wonder I felt horrible!

I changed doctors and had another titration study. They found a pressure of 19 cm was needed to keep my airway open. The doc prescribed apap set to 18 - 24 cm. Since my machine would only go to max 20 cm she wanted me to buy another machine. I refused.

Using my machine at home over the next several months I eventually found out that if I sleep on my side a pressure of 8.5 cm consistently yields AHI of under 1.0. So now I use this setting and wear a backpack to force side sleeping.

Thank God I was able to titrate at home and not have to rely on the results of two accredited sleep labs! The results from the sleep labs were allowing me to continue a rapid downward health spiral!

You have a lot to learn wlo2008.

This subject has been discussed (debated) a lot on this forum. There will never be a consensus of opinion. And that's quite alright. We each have to do what we feel is best for our own well being.

The info you quoted is interesting, wlo2008. I had not taken time to try to understand the intricacies and impact of the blood flow. What I would like to better understand is exactly how cpap affects the blood flow, especially in relation to those having neuromuscular and cardiopulmonary conditions. Problem is, my brain is still not recovered enough from years of sleep apnea to process a lot at once. Sure would appreciate a "dummied down" explanation.

I am one who has benefitted from having access to my data and being able to understand my settings (thanks to members here). I was dying at the hands of my well intended but oblivious sleep doctor at that time. By the way, I've had so many sleep studies I've lost count - maybe 5 or 6 over 10 years. So I'm one who will fend for myself if I see a doctor isn't hearing me.

I do want to qualify that though. I have long been aware that "knowing just enough to know nothing" can be dangerous. For instance, a young man in chat a couple years ago who just wanted to crank his machine up to the max to help with his shortness of breath during anxiety attacks. Or the one who was obviously stuck in the throes of a manic episode and making health decisions they were not equipped to make at that time.

For the garden variety OSA, unless I was given a better understanding on that blood flow subject, I doubt there's a lot of danger for the average person. But again, on the flip side of that, how many of us don't have underlying conditions? Maybe it only matters to the exceptions, but if I'm one of those exceptions, it sure does matter to me. I think we can get cavalier about our cpap treatment. After all, it can be do or die. Just wouldn't want to hasten that end with misguided self treatment.

Thanks for the info. Knowledge is good.

kteague wrote:........ Sure would appreciate a "dummied down" explanation.

.......

There is more to it that what is posted here, but the "dummied down" interpretation of wlo2008's post is simply if the pressure is set above the optimal level there is a risk of inducing central apneas which can do damage to your health. This is no new info to most regulars here.

There will never be a consensus of opinion.

Kathy,

I know what you mean with this statement. But I would like to propose that a ground swell of people finding their optimal pressure at home is a growing reality.

Who can say what the future holds? Surely better than production-style sleep labs taking stabs one night at titration and sending you home with a prescription?

Regards,

Rooster

[quote="rooster"]

You have a lot to learn wlo2008.

_________________

Number one I never said that I did not agree that one should not educate them selves on what pressures are good for them. I have been dealing with People with SA for a long time. I was a care giver to my Uncle with SA who died from heart failure do to complications. That was over 10 years ago.

All I said it just gave us something to think about.

And I am living proff that Cpap can cause Centrals or complex SA

I already had Centrals pre treatment. But strait Cpap made them worse. That is why I had to be put on a Vpap. All I am saying if you just try to treat your self on knowledge that you think you have. Then sometimes NOT all times can you make it worse.

Some like me have more complex SA. And people have to realize that there is more then just the run of the mill SA. ANd to encourage others to mess with there treatment when you are not sure there full history is not wise at all. That in turn is why the DME's and Doc's do not just give out the info. They make sure they are covered.

It is funny we say we want to be in charge of our treatment and make adjustments when we see fit. But the one time something goes wrong who do we blame. Oh the doc should have told me I should have not been messing with my prescribed pressure and so on.

I was just trying to bring out some risk facts. And how anyone chooses to deal with their own health is their deal not mine. I just hate seeing people encouraging others and just saying oh yeah here is how you change your settings. When they are not sure of what that person really has. SA can be more complicated then just OSA.

We all still have a lot to learn. And just with any Sceince there is new information that comes out and they fix what they did wrong and add to it. If you choose not to listion to new information and just think that it is hogg wash then that is when you get into trouble. Everyone should know the pros and cons to messing with an RX.

That is why I posted it. Not to cause trouble and for you to think I have no clue. Because I do. And Centrals from strait Cpap for me are not fun at all. And I know others who had there pressure to high that caused Centrals as well. Happened with my Aunt. She took it apond her self as well. And ended up with Centrals. She had no clue. Went back down to her normal pressure and they went away. And her AHI was below 5 and fine.

ozij wrote:http://ajrccm.atsjournals.org/cgi/conte ... /167/5/716

American Journal of Respiratory and Critical Care Medicine Vol 167. pp. 716-722, (2003)

Can Patients with Obstructive Sleep Apnea Titrate Their Own Continuous Positive Airway Pressure?
Michael F. Fitzpatrick, Christi E. D. Alloway, Tracy M. Wakeford, Alistair W. MacLean, Peter W. Munt and Andrew G. Day
Departments of Medicine and Psychology, Queen's University, Kingston, Ontario, Canada

In summary, this study demonstrates that self-titration of CPAP in patients with OSA is as efficacious as manual titration in a sleep laboratory, with similar subjective and objective outcomes, and CPAP compliance. Clearly, for this strategy to be successful, the patient must understand when and how to change the CPAP. Although the patient population studied did include a wide age range, this strategy would not be feasible for intellectually disadvantaged patients and those with physical handicaps that would severely limit vision and/or manual dexterity. Nonetheless, the findings from this study imply that routine overnight polysomnography is unnecessary for the purpose of CPAP titration in many patients with OSA, provided that the patient is given some basic education and support. Resources currently allocated to manual in-laboratory CPAP titration might be better spent on specific attention to patient education and support rather than pressure titration. A treatment algorithm that focuses on such ambulatory patient education and support rather than in-laboratory CPAP titration may realize significant efficiencies in the management of OSA without loss of treatment efficacy.

http://ajrccm.atsjournals.org/cgi/conte ... /167/5/674
American Journal of Respiratory and Critical Care Medicine Vol 167. pp. 674-675, (2003)

Editorial

Can Continuous Positive Airway Pressure Be Self-Titrated?
Samuel T. Kuna, M.D.
<snip>
In general, attempts to titrate CPAP out-of-laboratory, either by the patient's self-adjustments or by autoCPAP machines, are made easier by the wide therapeutic window of CPAP treatment. Over the normally applied pressure range of 4–20 cm H2O, CPAP is usually safe and efficacious as long as it exceeds the patient's "optimal" pressure. The level of CPAP has not been reported to affect patient adherence to treatment (14). AutoCPAP titration, however, is currently not recommended for patients with underlying cardiopulmonary or neuromuscular diseases who may suffer from central sleep apnea. One wonders whether or not patients with these disorders should also be excluded from self-titration (4). Most autoCPAP algorithms take into account that central apneas may persist or appear as pressure is increased, and the machines are programmed not to increase pressure above a predetermined level, despite the persistence of apneas. The untrained bed partner assisting in a self-titration would not be able to distinguish central apneas and might mistakenly advocate unwarranted increases in pressure.

Hello wlo2008,

I will agree that a great majority of people should not be changing their prescribed pressures (I would not even trust many of them to put air in my automobile tires).

Would you agree that other well informed people with data capable equipment and software would do better to start with the lab prescription and 'tweak' it at home to find an optimal pressure?

[quote="wlo2008

]........ Oh the doc should have told me I should have not been messing with my prescribed pressure and so on.

...........

.

I have read maybe tens of thousands of posts on this forum and don't remember ever seeing this complaint on cpaptalk.com.

Best regards,

Rooster

rooster wrote:Hello wlo2008,

I will agree that a great majority of people should not be changing their prescribed pressures (I would not even trust many of them to put air in my automobile tires).

Would you agree that other well informed people with data capable equipment and software would do better to start with the lab prescription and 'tweak' it at home to find an optimal pressure?

[quote="wlo2008

]........ Oh the doc should have told me I should have not been messing with my prescribed pressure and so on.

...........

.

I have read maybe tens of thousands of posts on this forum and don't remember ever seeing this complaint on cpaptalk.com.

Best regards,

Rooster

I appreciate your efforts to provide information, wlo2008. I agree that pressure changes could have unintended bad consequences; under-treated sleep apnea can also have nasty consequences. A sleep study is only a small snapshot in time and some of us don't sleep well in the sleep lab.

I've worked with my sleep doc in making changes ... and it was my sleep doc who, based on JSkinner's EncorePro Analyzer graphs, suggested increasing my pressure. When I tried her suggested pressure, I saw very unstable breathing patterns and then lowered the pressure until it stabilized nicely.

I think that pressure changes should be carefully considered and we need to be aware of the consequences.

Understand, too, that anyone can post on this forum and we don't really have much to go on as far as qualifications (other than what sometime tells us they are -- and how accurate are they?)

Over time I've read enough on this forum to have a general idea of whose suggestions I would listen to and whose I wouldn't.

Mindy (not logged in today)

Post written in error - Deleted

Edited.......to protect the innocent.


Den

Post written in error - Deleted