Are tritration studies accurate?

OK, I know all Drs are not equal and all sleep study labs are not equal. That being said...

Is it better to use a autoflex cpap or have the cpap set to a specific number based on a titration study?
We recently due to insurance requirements had to get a new cpap prescription (new DME because we moved to new state, yup doesn't make sense and turns out maybe not true, but told this by the DME and insurance).

New Dr said an autoflex cpap is ok, but it is better if it is set to one setting. So titration study done, new setting 7 (not autoflex 5-15).
But Hubby, immediately on new setting, was snoring - not as loud as without cpap, but audible and continual. And AIs went up to 9 (from 2.1 ish). At one month followup the Dr said didn't matter, his titration study showed 7 was where it should be. That cpap machines software are only for conformance and the other readings are worthless (e.g. not good enough software). And autoflex is ok, but a titration study is much better. He didn't care that mattresses might be different, sleeping might be different at home vs lab, etc.

5 months later I noticed problems were much worse. Hubby falling asleep just prior to bedtime unintentionally every night and very groggy arguing his cpap was one when I was saying no it isn't, put it on. We got an oximeter and luckily had a reading from the previous setting.
Autoflex 5-15: Above 90% = 99.2% of time, 85-90% (min 87%) = .8%
Setting 7:
1st night: Above 90% = 94.1% of time, 85-90% = 5.9% of time
2nd night: Above 90% = 47.9% of time, 85-90% = 61.4% of time, 80-85% = 1.6% of time, 75-80% = .1% of time
3rd night: Above 90% = 96.7% of time, 85-90% 13.3% of time.

I sent all data and symptoms to Dr, expecting a fight based on 30 day followup, luckily in 2 hours we had a prescription for flex 5-15.

But why is titration better than autoflex (and is that for most people or only some)? I understand an autoflex machine is more expensive. But won't sleep habits change over time (e.g. sleep different positions, sleep different on different mattresses/pillows, etc.).

FYI - Machine is Remstar Auto M series (about to be replaced).
Oximeter was cms50fw (bluetooth) bought thru http://myworld.ebay.com.au/contecmedica ... lgo=origal - we sent requests to this sender and got answers back quickly and they gave us the ebay link to use for US (they still had to do a tweak to it before we could pay for it to ok it, but it worked great, got it pretty quickly and love it).

IMO, the best scenario is a titration done in a lab to get an idea of the optimal setting, and then tweaking of the setting at home based on data. The titration is only one night, in a lab under unusual conditions, so it doesn't necessarily capture what goes on night after night (and there is night-to-night variability). On the other hand, in the lab they are able to know whether there are arousals because they are doing an EEG, whereas an Auto-Pap at home doesn't know whether the person is waking up or not. Personally, I think the best candidate for using only APAP at home to titrate themselves is someone who has flagrant apnea, perhaps with desaturations, and not a lot of daytime symptoms once the majority of the events are knocked out. Then you're titrating to an AHI or to an oxygen saturation, which is a lot easier than titrating to symptoms, IMO.

Some of us do not do well with a machine set to auto. Some of us, like me for example, have breathing patterns which confuse the algorithm that an auto machine uses to set pressure. For another thing, a machine set to auto chases leaks, creating more leaks with higher pressure, then raising the pressure again.

The frustrating part of a Titration study is that it starts with the pressure lower than what we need to keep the airway open, which means we spend quite a few minutes, if not hours, and we have a mask on, while not getting enough air to either sleep or sometimes to even feel comfortable.

A Titration depends on the quality of the lab, the knowledge and experience of the technician. Everything from whether their is noise or poor temperature control in the room, to whether the equipment is up to date. The skill of the technician should not be discounted either. What they do is not always as cut and dried as it might appear. Plus they might have a time consuming patient in the other room.

I put my money on a Titration with all kinds of equipment, and I hope, a knowledgeable tech, rather than the mindless algorithm of a machine at home, as I already know that an machine on Auto will not work for me.

However some Titrations do not always successfully determine the correct settings for an individual. Nor do some Sleep Docs realize that the Titration was not accurate even after the patient comes in with complaints.

I suspect your question is more related to, I really do not want to pay for the Titration, and/or go through that unpleasant experience again.

I can acknowledge, that at best, one will not get a full nights sleep during a Titration.

Thanks for the replies. Purple - makes sense everyone is different. So no auto for you but for hubby it seems better.

SleepingUgly - ok, I admit you talked above my head on some of that.
So how do you tweak the setting at home - the DME told us that we can't set it, only they can (for auto or for 7). We have the older machine but are shopping for a newer one as our machine "broke" when dropped off at the DME to change the setting. Suspicious but since it is 5 years old and I want better data capture I am not complaining too much.

I get no EEG at home.

Hubby has bad apnea - 91 hits an hour in his first study, "sleeps" thru most though the lab said he woke up 91 times an hour, he wakes up to go to the bathroom 2-4x a night and to turn over another 2-4 times.

Desaturations? Is this too low oxygen?

And before it was changed to a 7, no daytime symptoms, all was great. Afterwards just went downhill (AHIs trippled, oxygen saturation decreased significantly).

Yes, in the past we monitored AHI at home and it was good. Now we have an oximeter so can tritrate to oxygen saturation.

Did I miss something you were saying?

CpapWife wrote:Thanks for the replies. Purple - makes sense everyone is different. So no auto for you but for hubby it seems better.

SleepingUgly - ok, I admit you talked above my head on some of that.
So how do you tweak the setting at home - the DME told us that we can't set it, only they can (for auto or for 7). We have the older machine but are shopping for a newer one as our machine "broke" when dropped off at the DME to change the setting. Suspicious but since it is 5 years old and I want better data capture I am not complaining too much.

I get no EEG at home.

Hubby has bad apnea - 91 hits an hour in his first study, "sleeps" thru most though the lab said he woke up 91 times an hour, he wakes up to go to the bathroom 2-4x a night and to turn over another 2-4 times.

Desaturations? Is this too low oxygen?

And before it was changed to a 7, no daytime symptoms, all was great. Afterwards just went downhill (AHIs trippled, oxygen saturation decreased significantly).

Yes, in the past we monitored AHI at home and it was good. Now we have an oximeter so can tritrate to oxygen saturation.

Did I miss something you were saying?

Your DME is lying to you...we all adjust our settings occasionally. You want an Autoset machine that can be used both ways. Auto or fixed as needed.

CpapWife wrote:So how do you tweak the setting at home - the DME told us that we can't set it, only they can (for auto or for 7).

Absolute nonsense.

If you haven't seen this guide to data-capable machines, read up here before you get your new machine and make sure you get one that's fully data-capable. http://maskarrayed.wordpress.com/

DumbDoctor wrote:That cpap machines software are only for conformance and the other readings are worthless (e.g. not good enough software).

Also absolute nonsense. Look around for the free SleepyHead software to evaluate the data.

As has been noted, not everyone does well with varying pressures.

In an ideal world, you would get a pretty good setting on initial titration, and just use the APAP function to verify the titration setting. I've experimented (cautiously) with widening my range of pressures over the last couple of years, and I never seem to need much more than my original prescription. (I just lucked out.) I like the A-flex feeling better than the C-flex feeling, though, so I stick with A-Flex.

By the way, if "straight 7" was too low for your husband, I would have expected a range set for him to perhaps be 7-15 rather than 5-15.

CpapWife wrote:SleepingUgly - ok, I admit you talked above my head on some of that.

Sorry about that.

So how do you tweak the setting at home - the DME told us that we can't set it, only they can (for auto or for 7).

In theory, only by your doctor's prescription do the settings get changed. But in practice, you most certainly CAN change the settings. You just have to know how to get into the clinician's menu.

We have the older machine but are shopping for a newer one as our machine "broke" when dropped off at the DME to change the setting. Suspicious but since it is 5 years old and I want better data capture I am not complaining too much.

Consider the Resmed S9 Autoset or the Respironics System One REMStar 60.

Desaturations? Is this too low oxygen?

Yes.

Did I miss something you were saying?

I think all I was saying is that I think the best outcome is with an in-lab titration + an APAP at home.

Thanks for all the valuable info. I have time for a longer answer this time.

OK, I thought at first APAP was a typo, I figured it out Auto-cpap.
SleepingUgly, I am searching on the internet for all the terms I don't know now. Haven't been on this forum for almost 5 years, lots has changed. But thanks for the confirmation I understood you.

I did more cpaptalk reading and yup we have settled on the Resmed S9 Autoset or the Respironics System One REMStar 60 (seems pretty strong recomendations here for what we want) and I have been researching them.

Thanks Drowsey Dancer, I had found that link (so glad this forum is here!!) and also stumbled upon the sleepytime software in the forum. I had actually been lusting some after this and a new machine which is why even if the DME messed up our cpap on purpose I am not so upset, but our insurance would have replaced it anyway at year 3 (the DME just doesn't know this - e.g. not real competent, or is trying to soak us for 8 months of rental while our machine "gets checked out to see if it can be repaired" - yes don't get me started on that issue or their HIPPA violation and them claiming it was not until I told them I knew HIPPA, or them sending us masks automatically saying we said to when we said several times not to, or all the other black marks they have gotten in the last month, still not sure if they are incompetent and trying to cover that up or deliberately messing us over or both).

I just checked and the rental we were given is a Respironics System One Remstar 560 apap, with the humidifier (but last machine was apap with humidifier so they had to match that). So Maybe our DME got one gold star (to counter at least a little the 4-10 black marks they have gotten the last month). Nice we can test that one out (I was about to ask tomorrow if we can "rent" both over the month to compare them both, we might still want to rent the other one also to check both out).

Thanks for backing the Dr not having the straight story about software, yes I agree like most that they do the initial setup and it is hard to find someone to do more than that.

And for letting me know it is possible to change the setting at home (DME probably being territorial here, I am sure they don't want patients to not need them anymore). LSAT - our last one was Auto-Cpap that could be set either way, we just didn't know we could do that (now we do and I saw how she got into the clinical setting).

DrowsyDancer - makes sense to have 7-15 set. With new machine we will do more playing. He doesn't seem to have APIs up front, seems to have more towards end of sleeping per oximeter, but again new machine plus oximeter and sleepytime will help a lot. I finally have hubby on board with finetuning it better.

It is very hard to find Sleep Drs that also don't run a sleep center here in Phoenix. But it is nice to know we were not being taken advantage of that all of a sudden 5 years after the initial machine was set, a Dr wanted to do a titration study.

Big problem for me was that doing the tritration and setting our apap to that didn't help for us (made things worse, not better), so yes, since hubby does so well on APAP (AHI 2.1-2.3, saturation above 90% for 99.2% of time, and no leak problems), and did so poor after apap set to the 7 that the titration study said he should be at, I see no need to pay another $350 to get another one done. We could do another 10 of these just to confirm he needs an APAP, not worth the time or trouble if we can play at home with APAP settings and with better software (our old machine software quit running on the newer operating systems), we should be able to figure out better fine tuning titration. But good to know the potential problems with APAPs so we can keep an eye out.

SleepingUgly, I think my hubby might fit exactly your definition for being a good apap candidate, all of that seems true for him (severe sleep apnea, desaturates quickly even when he just really relaxes with no cpap on, and no daytime symptoms and very low nighttime symptoms with APAP.

I am suspicious that he needs very different pressure depending on his sleeping position (back, side), maybe other factors (had a beer that day which he has 1x week, muscles tense from workout, stressful day vs relaxing day, etc.), so he needs something that adjusts to where he is at each hour/minute. New software will help test out this theory.

OK, off to figure out differences between the two machines, if I remember right one of them adjusts breath to breath, the other resets it's base level every 30 days, but I will open a new topic to discuss this.

Your husband may indeed need different pressures for different sleeping positions and there's another factor in pressure needs that affect some people.....REM stage sleep. It's very common for either or both supine sleeping and REM stage sleep to cause more OSA events or the need for higher pressures.

I know about REM sleep events...that's where my OSA is worse and I also happen to sometimes need much, much higher pressures during REM. In non REM sleep my AHI isn't all that exciting at around 12 per hour but in REM sleep it's over 50 per hour.
Sleeping position doesn't seem to matter in my case.

My titration study didn't include much REM sleep (in fact only about 6 minutes) so my prescribed pressure of 8 cm didn't get much of a trial and it wasn't a big surprise to find out that it wasn't adequate for REM stage sleep....works great for everything but REM stage sleep. I have since learned that I need a substantial range of pressures for optimal prevention of the REM stage sleep events.
My minimum pressure needed to be 10 cm...not 8 cm. At 8 cm I was still having too many events and even in APAP mode the machine couldn't get to where it needed to be quickly enough to prevent the apneas from occurring. I found that 10 cm minimum did the best job for me and in APAP mode I sometimes would see pressures around 18 or 19 cm.
Usually in the wee hours of the morning where we have more REM sleep. If I were to use cpap mode I would have to use a much higher pressure all night to combat those few times where I need 18 or 19 cm....I don't really want to do that when 10 to 12 works great the other part of the night and that's why apap mode works best for me. I could do it but I don't really want to.
I am now on a bilevel pressure machine for other reasons but I used APAP for 2 1/2 years before I changed to Bilevel. Even on bilevel I need a wider range and auto adjusting pressures..same principles apply.

So in my case the sleep titration study didn't get me a good example of how I normally sleep. It was an all night study but my sleep was horribly fractured and I simply didn't get much REM to test. I did the pressure adjustments on my own with help from some forum members and the software reports. It wasn't difficult and just took a few nights to get dialed in. Just takes a bit of time to educate yourself. Once you understand what you are seeing mostly it is just common sense application of some basic cpap principles.

BTW...the PR S1 560 machine...has a full apap mode as well as the 30 day apap trial mode...so you aren't limited to just the 30 day thing where the machine finds optimal and changes back to that pressure full time.
So the 560 can be a full time apap machine if it needs to be just like the S9 Autoset. Both are great machines though and either one will do a great job. Some minor pros and cons with either but none are deal breakers. I have used both to compare.

Take a peek at the links in my signature and go to the 2 threads I have started about installing the software as well as the thread about understanding what you see. Lots of examples in them to help you understand what is seen and going on.

Accurate - yes. Precise - no!

BTW, welcome back to the board

Pugsy, Thanks for the info. Yup hubby showed REM problems on his original sleep study, and obstructional apnea. I am suspicious there is positional problems also. He gets most desaturation the first hour and the last few hours.

We have a loaner PR System One REMstar Auto with A-Flex 560 and I that looks like the one we will get.
I found a better DME - actually found one intelligent person there who said that the respiration seem to be better built (less things break, water tank removable for cleaning, etc.) and stellar support. They won't even do the S9s except by special order so we are ok to go with the System One.

First night on the loans, no SD card (I have some and am going down today to get a manual so I can figure out how to get data off it). But the oximeter showed an improvement over the cpap setting 7 on the AutoSeries M, but still a lot worse than the old apap setting on the AutoSeries M machine. I think he can't tolerate the flex? There was some snoring, much less, and typically after about 5-10 seconds the snore reduced but then came back in a minute or two. The System One trying to adjust to snores?
I am confirming settings and will get it set up to collect data and have turned the autoflex off(and we will see how tonight goes.

I am so glad there is better software out there these days.

CpapWife wrote:Pugsy, Thanks for the info. Yup hubby showed REM problems on his original sleep study, and obstructional apnea. I am suspicious there is positional problems also. He gets most desaturation the first hour and the last few hours.

We have a loaner PR System One REMstar Auto with A-Flex 560 and I that looks like the one we will get.
I found a better DME - actually found one intelligent person there who said that the respiration seem to be better built (less things break, water tank removable for cleaning, etc.) and stellar support. They won't even do the S9s except by special order so we are ok to go with the System One.

First night on the loans, no SD card (I have some and am going down today to get a manual so I can figure out how to get data off it).

[SNIP]

I am so glad there is better software out there these days.

No need for the manual 560 manual if you want to pull the data off the SD card. Just download Sleepyhead 0.9.3 (or Encore Basic) and point it at the root of your SD card.

My sleep study said 4-6, but added that 7 did not cause any problems so my prescription was written 4-7 ... However I still am getting obstructions at 10.5!

Maybe I just had a really good night at the sleep lab (I doubt it!) or they had a bad night, I'm going to a different place on Monday ... My O2 is fine ... Above 90 most of the time anyways ...

DiverCTHunter - I did put an SD in (I was hoping that was enough), so hopefully we will be all recorded tonight. I have software ready to read the SD in the morning.
I did find a manual online and the secret handshake to get into the other settings.

“Are titration studies accurate?”

Do you normally sleep in a lab?

Does the fact that this one night of sleep in the lab costs a lot of money and is likely to affect your health and life affect the way you sleep that night?

How much did you need to change your normal routine to attend this study?

Do you sleep the same every night? Every week? Every month? Every season? Every year?

If they do manage to get a pressure that works well and you get better is it likely that your titration needs will change?

Since our body has many cycles, does it make a difference which day of the week the study occurred? Which season?

What did you eat and drink that particular day?

Were you sick that particular day?

I think that sleep medicine has a long way to go.