Sleep Doc no longer a Fan of APAP

My Sleep Doc seems to be changing his mind about using an APAP machine.

I have had reason to see my sleep Doc again after 3 1/2 years and I mentioned the setting on an APAP machine.

He actually did prescribe me an APAP at my request, but never talked about a pressure range at the time and I guess he "assumed" i would use the machine more as a CPAP.

Anyway... he said he was no longer a fan of APAP becasue he thought the response time was not fast enough to stop an episode. He said he prefers only CPAP for that reason.

Well... my pressure is 10 and I set my APAP to 8-12 and never really had a problem. When i would D/L my info from my card, it almost always showed excellent numbers. But I noticed the upper pressure was being reached more and more often.

My sleep quality has gotten much worse in the last 6 months which is why I went back to the sleep Doc and just had another sleep titration study last Thursday.

The Doc said I have gained 8 1/2 pounds since he last saw me and as little as a pound increase could make a difference and hence the new study.

Anyway... has anyone else had their sleep Doc say anythig negative about APAP's and a sluggish pressure increase ?

Thanks

Many sleep docs are not fans of APAP, since they feel there isn't really any conclusive body of scientific evidence proving it solves the underlying condition of OSA any better than CPAP or that it makes more people compliant, on average. One reason for that may be because the minimum pressure wasn't "properly" adjusted for the patients studied--manufacturers still advertise their APAPs as machines to be run with the pressure range set wide open, with minimum at 4 cm, even though many patients find that pressure too low to tolerate, and many here have found that their numbers are better with the minimum up within a cm or two of what is needed for apnea prevention. In other words, your doc is probably right that response may be too slow IF an APAP is run with the minimum too low, as manufacturers continue to recommend.

Furthermore, some patients don't do well on APAP, since some never get used to the pressure moves that cause them arousals, and some end up with a machine with an algorithm that doesn't fit their particular breathing very well. And APAP manufacturers aren't especially eager to be forthcoming on the specifics of their algorithms and which patients may do best on which. No wonder many sleep docs aren't fans! They don't want to have to think that hard about variables, especially when prescribing a CPAP seems so easy and "safe" in comparison, to them anyway. One or two bad experiences with patients who have trouble with APAP, but do well with CPAP, and that doc may be lost as an APAP fan forever.

That is all beside the point for me as a patient, though.

APAPs ain't that much more expensive than CPAP these days, and APAP helps some people (and certainly helped me) with comfort, especially when starting out.

It is nice to be able to do some autotitration once in a while, even when mostly using the APAP in CPAP mode for nightly use.

For people who have widely varying pressure needs, APAP can be a deal saver. My allergies are bad some months of the year and not as bad other months. (I actually move my minimum depending on the time of year, but APAP helps me deal with those changing pressure needs night to night.) And if I land on my back on a particular night, my average pressure is higher to show the machine dealt with that.

Those reasons are enough for me.

If any of the above applies to you, or anything similar, mentioning the specifics of your particular situation may help you to keep the doc on board with your using an auto, if you want to keep him on board.

jnk,

Thanks for the reply. I agree with everything you said.

I don't feel real good about keeping some info from my sleep Doc. I DO like him, but I think I'll keep the fact that I am using my APAP machine AS an APAP machine.

I keep my pressure 2 above and 2 below my titrated pressure and it seems to work for me.... at least so far.

I do suspect that my "new" pressure after my study last week will be an increase based on the comments the study Tech made after the study.

The Tech did mention that the number of episodes was down from my study 3 1/2 years ago. At that time I was having 76 per hour. (Ya.. I know... WOW !)

My AHI at my diagnostic NPSG was 114.7. I am happy to be alive.

I personally see no reason to limit the UPPER (maximum) range of my APAP (actually, I use autobilevel, to be more specific) at all, since it never "runs away" to the maximum on the machine with me.

Personally, I would be afraid that limiting my upper pressure might prevent my machine from increasing pressure in a way that would keep my therapy on course if my pressure needs increased significantly, as yours apparently did. The way I see it, if I see how high my pressure goes, that gives me a valuable hint about where I should keep the minimum set.

jnk wrote:My AHI at my diagnostic NPSG was 114.7. I am happy to be alive.

I personally see no reason to limit the UPPER (maximum) range of my APAP (actually, I use autobilevel, to be more specific) at all, since it never "runs away" to the maximum on the machine with me.

Personally, I would be afraid that limiting my upper pressure might prevent my machine from increasing pressure in a way that would keep my therapy on course if my pressure needs increased significantly, as yours apparently did. The way I see it, if I see how high my pressure goes, that gives me a valuable hint about where I should keep the minimum set.

114.7 !!!! Holy Mackeral. I'd say you're lucky to be around. Glad you found some help with CPAP.

Until I talked to my Family Doc at my wife's insistance, I had never heard of Sleep Apnea.

I never gave a thought to the high end setting.... I guess it would be fine to set it even higher and check the reports to see if the machine ever feels it necessary to ramp it up to a high number.

I'll try it...... Thanks !

Any time.

Keep the board informed. A lot of helpful people here.

My husband was titrated at 12 cm water pressure. The DME was all set on selling us a S9 Escape; but hubby insisted on an Autoset,
because he had SO much trouble breathing during sleep study. The Dr's RX was to set it on CPAP mode at 12 with NO EPR.
Hubby set said machine for Auto 7-16 cm range RIGHT THERE! Guess what?--His 95th percentile pressure is consistently around 10--
and he wears it all night, every night--no complaints. Who knew that a sleep study could be so far off.
Makes you wanna go, "Hmmm."

chunkyfrog wrote:My husband was titrated at 12 cm water pressure. The DME was all set on selling us a S9 Escape; but hubby insisted on an Autoset,
because he had SO much trouble breathing during sleep study. The Dr's RX was to set it on CPAP mode at 12 with NO EPR.
Hubby set said machine for Auto 7-16 cm range RIGHT THERE! Guess what?--His 95th percentile pressure is consistently around 10--
and he wears it all night, every night--no complaints. Who knew that a sleep study could be so far off.
Makes you wanna go, "Hmmm."

I understand that some sleep docs tend to slap an extra 1 or 2 cm onto the Rx, just in case the titration happened on a particularly "good" night for the patient.

jnk wrote: I understand that some sleep docs tend to slap an extra 1 or 2 cm onto the Rx, just in case the titration happened on a particularly "good" night for the patient.

That's the problem - some people blow up like a balloon when the pressure is too high. Then they never end up using the machine. What's the extra 1 or 2 cm for - like topping up at the gas station?

I 'get' that, but this particular patient would have been 100% NON-compliant with the machine and setup prescribed.
--And I want to keep this guy around--he makes me laugh!
The Autoset gives him the leeway he might need without the misery he wouldn't have stood for.

chunkyfrog wrote:. . . this particular patient would have been 100% NON-compliant . . . misery he wouldn't have stood for.

Nah. You'd have got him to use it. You can be VERY convincing.

Nope, after 42 years, I know my limitations.

jnk wrote: -- many here have found that their numbers are better with the minimum up within a cm or two of what is needed for apnea prevention. In other words, your doc is probably right that response may be too slow IF an APAP is run with the minimum too low, as manufacturers continue to recommend.

Good points.

More about why I've long believed the minimum pressure is the really important one to "set right" when using an autopap in auto mode:

Results: 1st night with Auto A-Flex (topic started by TSSleepy)
Two nights graphs posted using pressure range 4 - 20 and 10 - 20
viewtopic.php?p=348963#p348963

November 2008 Just got an APAP (topic started by turbosnore)
viewtopic.php?p=319619#p319619

October 2008 Turning off Aflex and Cflex (topic started by DoriC)
viewtopic.php?p=307265#p307265

September 2008 New Guy - Need Help w/Settings (topic started by alanhj13)
viewtopic.php?p=294319#p294319

Wulfman, DreamStalker, and ozij explain why autopaps make changes slowly.
December 2008 Why adjust APAP. Isn't it auto? (topic started by oxygenium65)
viewtopic.php?p=323218#p323218

chunkyfrog wrote: Who knew that a sleep study could be so far off.

Me! lol. I was titrated at 6cm and miserable for the months it took me to be able to see another doc, get an auto, and learn (through the auto) that I need 11cm! No wonder I wasn't feeling any better for so long.

I was prescribed an APAP as my first machine when the doctor noticed that I was very difficult to titrate. (April 2009) Although there were a lot of centrals on the original split-night study, they were not showing up (or were being masked) by the DeVilbiss IntelliPAP machine I bought. However, pressure varied wildly from night to night for no apparent reason (FFM, leaks under control, etc.)

After much experimentation, and struggling with therapy, The doctor recommended I work towards a higher pressure range. I finally reached that range after a few months. But while on the way, I tried a few nights of straight CPAP at a fairly high pressure. BIG mistake. I felt TERRIBLE, and quickly stopped doing that.

The thinking here was that the IntelliPAP was not responding to pressure needs fast enough. (A study of various machines showed the IntelliPAP had the slowest responding algorithm.) In February of 2010, I started using a ResMed VPAP Auto 25, I obtained in a private sale. VERY comfortable machine to breathe against, and well engineered. So although this machine was supposed to have a fast responding algorithm, it was actually very slow responding for me. ('A10' algorithm) Few and far between were the nights when this machine adequately addressed my pressure needs. I was using this machine as a straight APAP, and not using bilevel functionality.

In May, my doctor looked at what I had been doing and the results I was getting, and immediately ordered a new sleep study. This was an 'anything goes' sleep study, and they tried several different things on me-- APAP, Bilevel and Adaptive servo ventilation.

In the end, the doctor ended up prescribing the ASV machine, based on the fact that it did make a measureable difference in therapy, and I noticed that difference as well. I do not have any of the problems that one would normally prescribe an ASV for (heart problems, or blood gas problems). Instead, I was very difficult to titrate, and apparently needed a machine with a very fast response to changes in my breathing. This has turned out to be a good choice. I have been using the machine for a bit over three months now. I can see the APAP algorithm this machine has dealing with slower changes, working with the ASV algorithm to deal with short-term stuff. The slower APAP and the faster ASV produce a better result together than either therapy would alone. The machine is also teaching me how to sleep better, so I am getting more restful sleep.

But when I had to go camping a couple months back, I chose to take the IntelliPAP out. Two reasons: Worked good on battery, and was a relatively inexpensive machine. I set a pressure range on it that approximated what the ASV machine can do and had acceptable results for the few nights of the trip. My pressure still varied wildly night-to-night.

So the bottom line is, that APAP is a lifesaver for some folks. If I had been stuck with a standard CPAP machine at the beginning, I probably would have given up by now. (I researched, chose and bought the first machine out of my pocket, and am so glad I did!)