CPAP Basics - 2 - Dial Wingin'

http://www.aasmnet.org/Resources/clinic ... 040210.pdf

http://www.sleepapnea.com/downloads/100 ... fGuide.pdf

I had the impression you take a dim view of dial wingin'. Is this offering in the nature of "harm reduction"?

I have a copy of the first document, but have never seen the second one before. PR doesn't make their stuff very googleable.

"Wait - Watch - Observe - Think. Patience is the key to successful titration."

Words of gold, really.

Drowsy Dancer wrote: I had the impression you take a dim view of dial wingin'. Is this offering in the nature of "harm reduction"?

Hey, all this stuff is out there, I'm just doing an "RG Links To" type of thing. Much to all of this material is already here on the forum, it's just a little difficult for one to search through 0.8 million posts (seriously, that's what it's up to) to find what one is looking for, especially if one is not familiar with using Search Tools and Tricks.

More important, they may not know what they want. They really want to find what they need.

However, in response to your question, I do not take a dim view of DWing, I'm saying I don't participate in it, for a variety of reasons:

• Chances are you've (generic) are paying or already paid somebody a lot of money to do the DWing for you. They need to provide that product.
• The above noted HCP is ultimately culpable for DWing results.
• Unadulterated DWing could fracture the relationship between you and your HCP.
• If anything goes wrong, they can turn around and say "See? You chose to self-treat, so it ain't my fault you smashed up your car when you fell asleep at the wheel!"
• A lot of DWing instruction is wrong and/or stupid. Somebody finds something that's sounds impressive and hands out that advice to everybody because they think it makes them look smart (like ASV or CO2 control of ventilation).
• People who arbitrarily hand out stupid advice think there's a safety net here to correct them if they're wrong. There isn't.
• Posters seldom reveal all of they necessary information to make DWing successful ("Oh yeah, did I forget to tell you I'm a meth head?")
• When pushed for more information that may be pertinent to their case, they get all crazy and turn all their posts into dots.
• DWing cannot be a successful approach to the overall care of the SDB population. Success rate of xPAP therapy drops off dramatically if patients are not acclimatized within a few days to a week. There's a ton of lost souls out there who never get to a Self-Help Forum (you may think there's a lot of people here. There aren't.)
• Some DWing advice can cost a ton of money that the advisee doesn't have ("Sure an ASV will help! Who cares if you have to pay for it out of pocket!")

mollete wrote:Chances are you've (generic) are paying or already paid somebody a lot of money to do the DWing for you. They need to provide that product.

That raises a question about titration-as-product that may be totally unanswerable: is the time allotted for titration in a split-night study really adequate to identify the best pressure for a patient? The titration "product" appears to be defined by my insurance company as the process of titration, and not a successful titration.

Surely there must be a level of skill involved in a manual titration process that results in a benefit to the patient being diagnosed, Otherwise our insurance companies would stop paying at all for sleep studies and would put us all on APAPs set @ 4 to 20. But there seems to be a lot of watching and letting time pass during a titration , and can that really be done in six hours or less? There are so many variables to isolate, even a full night doesn't really seem to be enough time.

I developed a sense that my pressure of 8 was somewhat arbitrary when my doc raised my pressure from 8 to 9.5 at one of my earliest appointments so I could sleep on my back, which was more comfortable for me and my CPAP-emergent stiff neck. No further titration, nothing, just a twitch of a dial. Which frankly seems like DW, MD. In retrospect, I don't know why he didn't change my machine to APAP with a range of 8.0 to 9.5 rather than yanking up my CPAP pressure.

My OSA appears to be pretty plain vanilla, and I think the titration got my number pretty close, because I didn't need any tricky stuff. I've always felt a certain amount of liberty, however, to play around in my doctor-approved 8 to 9.5 range by making small changes (none of these ballsy 1.5 jumps--I guess that's the confidence that an MD provides). I don't think I could justify the cost of a second PSG out=of=pocket.

Drowsy Dancer wrote:

mollete wrote:Chances are you've (generic) are paying or already paid somebody a lot of money to do the DWing for you. They need to provide that product.

That raises a question about titration-as-product that may be totally unanswerable: is the time allotted for titration in a split-night study really adequate to identify the best pressure for a patient? The titration "product" appears to be defined by my insurance company as the process of titration, and not a successful titration.

Surely there must be a level of skill involved in a manual titration process that results in a benefit to the patient being diagnosed, Otherwise our insurance companies would stop paying at all for sleep studies and would put us all on APAPs set @ 4 to 20. But there seems to be a lot of watching and letting time pass during a titration , and can that really be done in six hours or less? There are so many variables to isolate, even a full night doesn't really seem to be enough time.

I think it works well for some, and depends on the skills of the sleep tech in addition to how well the patient sleeps. For example, in my case, I did the split night study, and my titration was dead on. In actually, the titration is not fully complete as I only slept on my back for two short times during the titration phase. So, they did not successfully prevent the apneas during my supine sleeping. Since I stayed on my side once the pressure was up to 11, which was handling my side sleeping okay, they had no reason to go any higher and had no more attempts to titrate my back sleeping. BUT! Clearly the sleep tech was experienced enough to give a good estimate of the needed range. The report recommends 11-17. Most of my night is spent at 11-12 something. Some nights, I will have 2-4 spikes up to 15, and on rare occasions, up to 16.9. So, the 11-17 covers it quite well. My machine doesn't waste time getting up to 11 and doesn't have to go up much at all to take care of most of my night.

I have also seen a lot of stories here where people were told they must sleep on their back for the study or most of the study. I understand the theory that it presents the worse possible scenario to determine if the person has sleep apnea. But it can also make it very difficult if it causes the person not to sleep well. My sleep tech told me to sleep any way I want. I was never told to sleep on my back, side, etc. I think that helped to get a better idea of how I sleep as well as a better quality of sleep. In stead of being uncomfortable and awake, I was able to sleep and give them data.

Personally, I think a lot of the Dial Wingin' is caused by patients with CPAP and not APAP.

My last sleep test was in 2001. For years I had a Resmed S6 that had no data, not even compliance data. Over the past couple of years with a S9 Elite I have come to appreciate the ability to tweak or DW. At one point I slowly raised my pressure over a couple months from 12 to 17. It was pretty eye opening that, for me at least, more isn't better. Now I am usually around 12.4-12.6 and I may go a few more up or down from there depending on a number of factors, but it is educated guess work at best.

But I have discovered is that a lot of this DW "may" have been avoided if I had an APAP. Not with the generic 4-20 setting, but with a reasonably close range. I do say may because it is still possible that straight CPAP would provide the best results.

John

Or someone could be like me...I didn't meet criteria for split study during diagnostic part of the sleep study until right before it was time to get up. Criteria was 15 events per hour to earn a split study...and I only managed 12 per hour in Non REM sleep but in REM I kick butt with 53 per hour but couldn't stay in REM long enough to "officially" get enough events to extrapolate to meet the basic criteria.
Desats weren't part of the criteria so it didn't matter that I dropped to 73%.

So then I had a second sleep study just for titration and out of the whole night I got 156 minutes of sleep..with 6 minutes in REM sleep...which is where I have those super human OAs requiring more pressure than those in Non REM sleep. It's no wonder they didn't quite get the pressure needs to what I need. They did get close and if I didn't have those weird REM events requiring a lot more pressure sometimes (not all the time) then the RX from the sleep study would have done a good job.

I did some dial a wingin early on in my therapy but it was carefully controlled and I started out with pretty much RX that came from sleep lab and I made my changes slowly and carefully and very small.
I did inform my doctor at the 90 day visit of what I had done and why and had documentation of my before and after results.
Got the blessing to "keep it up" "go ahead and use 20 max on the apap because sometimes you need it and sometimes you don't and it won't go up there if it doesn't think there is a good reason".."let us know if you run into trouble".

Hi there, complete noob here who has not had his second study yet but anticipates a machine in the future ...

I feel like I just stepped into a conversation that was well underway before this thread started. Can someone tell me what "Dial Wingin'" is? And why I should be concerned about it.

pootsie wrote: Can someone tell me what "Dial Wingin'" is? And why I should be concerned about it.

Dial Wingin...fiddling with settings on the cpap machine normally left to the professionals. Usually referring to pressure settings....changing pressures yourself.

Some things are considered comfort settings and those settings are normally considered settings that are okay for the patient to change based on comfort. Exhale relief..humidity setting...temperature setting....mask preference or choice. Things like that are normally considered to be okay left in the hands of the patient to determine comfort needs.
Though some DMEs act like all of those we shouldn't mess with either.

Why be concerned about changing pressures? If you don't know what you are doing or why...then you shouldn't do it.
If you aren't totally comfortable with it..then you shouldn't do it. If you think that so and so pressure works for so and so then elect to try it for yourself without any understanding of why....you shouldn't do it.

Ideally people come away from a titration study with a good idea what pressure to use...sometimes we don't get ideal. Sometimes we don't have insurance to pay for things.
So sometimes we dial a wing our own pressures. It's not ideal...but if we don't have access to "ideal" sometimes we do the best we can but it takes a lot of understanding and education to do it optimally and if we are going to do something...optimally is the goal IMHO.

Thanks for the info, Pugsy.

It reminds me of that time I tried to remove my own appendix ...

I never had an attended sleep study -- no baseline study, no titration study. I'm not boasting about this, I think it's shameful given that I'm with one of the largest medical groups in the country. My own educated D Wingin' was a more carefully controlled and monitored process than the sleep medicine department's approach which is to send patients home with wristwatch-type devices to diagnose, and then send them home with APAPs for a week to titrate.

Respironics Mask Resistance Settings



Which, in turn, will give you the correct pressure:

pootsie wrote:Can someone tell me what "Dial Wingin'" is? And why I should be concerned about it.

It may not be a reliable methodology of determining Ideal Pressure Settings if your algorithm is:

And of course, anybody can DWing:

mollete wrote:And of course, anybody can DWing:

No offense but actually, he might know just as much as some of the sleep professionals. Pandatx's case comes to mind.

49er

PS - Just remembered the RT at Kenwood's DME who said he didn't have any leaks.