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Are auto titrating bipap devices as effective as in lab manual titration?
#1
Are auto titrating bipap devices as effective as in lab manual titration?
Just wanted you guys thoughts on this topic.

I was just wondering is something like the vauto auto titrating BiPAP as effective as in lab manual titration performed by sleep specilist to figure out the most effective bipap pressures?
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#2
RE: Are auto titrating bipap devices as effective as in lab manual titration?
Bilevel titration is not a passive process and requires more than just setting default values on a machine then letting it do the work. An auto bllevel is not difficult to optimize, you just need to understand a few basic principles and know how to read and react to the data. The basic bilevel titration flowchart is easy to follow and is the best way to titrate your machine, whether it is performed by the user based on the machine's data, or a technician based on data from a titration machine.

The titration results will be similar but a titration test in a clinical lab must be completed in a short time which means a self titration will have the advantage of recording a wider variety of sleeping conditions, and can continue to be optimized for years after the initial titration. Keep in mind that most clinial labs will attempt to identify optimium fixed pressures for bilevel, not a range. The auto bilevel can be set to lower initial pressures and achieve good results for obstructive apnea, hypopnea and even flow limitation and respiratory event related arousals (RERA). The lab is likely to look at a much more limited scope for titration of only apnea and hypopnea events.

The answer to your question is, "it depends". Self titration is better if you are willing and able to look at the machine data and know how to follow the schematic titration protocol to respond to OA, H and FL. If you cannot do this or don't understand it, then a clinical titration is the best option.

[Image: attachment.php?aid=4118]
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#3
RE: Are auto titrating bipap devices as effective as in lab manual titration?
Here are the Philips Respironics Titration Protocol recommendations for BiPAP S and BiPAP Auto (Click to enlarge).

   

   
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#4
RE: Are auto titrating bipap devices as effective as in lab manual titration?
IMHO self-titration by a knowledgeable user is the best method of finding the best settings for either CPAP or Auto CPAP or bi-level such as ResMed's Vauto.
A sleep lab is looking at only one night and is very good at determining starting pressures, for that one night, in a bed that you are not used to sleeping in and wired up to who knows how many wires. That's just like home right????

Because of all the different data a sleep lab collects it can certainly offer good insight to what is happening.  Provide good insight into the apneas that are happening and even trial (1-night trial) of different classes of machines when so directed by a doctor.  The basic classes of CPAP machines are CPAP/AutoCPAP, Bi-Level/Auto Bilevel, Bi-Level with a backup rate, and bi-level with ASV.  It would be expensive for you to buy all these machines to try.

Fortunately, when you self-titrate with a full data capable machine you can tweak in settings to suit your home environment. Also we will see what kinds of apnea we are seeing and formulate treatment plans accordingly and if necessary determine which of the advanced machines would best suit you and your flavor of apneas. 

One thing a sleep lab can do that we cannot do is determine that you do not need a CPAP.  We can only determine that you are ell treated at the machines minimum pressure.

Most titrations we see from a sleep lab need to be tweaked.  And over time your needs will change and those titration values from the sleep lab from years ago will be off enen if they were originally dead on.


Fred
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
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#5
RE: Are auto titrating bipap devices as effective as in lab manual titration?
Regardless of whether you do a self-titration or a titration in a sleep centre, it is necessary to monitor your results over the long term and make changes if necessary.

I personally question the value of a sleep-lab titration for the majority of patients. You're in a strange bed, in a strange room, with 19 probes and electrodes attached to your body, a plastic alien strapped to your face and pressures varying all night long. Just relax and sleep normally - who are they kidding? A further issue which can be overlooked by the normal protocols is that apneas often come is clusters - you might sleep fine for four or five hours then experience a cluster of apneas lasting half an hour. The protocol seems to assume that your apnea experience is uniform through the night, giving potentially misleading recommendations.

My personal view is that most people are better off self-titrating over a period of time and monitoring their own progress thereafter. It's not really that hard.
DeepBreathing
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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#6
RE: Are auto titrating bipap devices as effective as in lab manual titration?
Thank you all for your response I greatly appreciate it!

I feel more confident In my decision not to seek a sleep lab titration now.

So for the aircurve Vauto titration, is it best to set the initial settings as the following :

EPAP min: 6
PS: 4
IPAP MAX:25

And then observe the data for a bout a week or so and then adjust the EPAP min close to the 90tb percentile and after that increase pressure support for any left over hypopneas, snoring, and flow limitations?

Does that sound about the right way to do a self titration with the VAuto?

Unfortunately VAuto only has a fixed pressure support unlike the Phillips machine where it had psmin and psmax so is it best to find the most effective EPAP min pressure first (for obstructive apnea) before increasing the pressure support for hypopneas, flow limitation and snoring or is another method/order a better way of tackling the settings?

Thanks again guys!
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#7
RE: Are auto titrating bipap devices as effective as in lab manual titration?
You have been using an Autoset at pressures of 11-14 with EPR 3. This can be replicated on the Vauto with EPAP min 8.0, IPAP max 14, PS 3.0. If the objective is to increase PS you can make some adjustment upward with the max IPAP, but you will never need 25 cm. The machine will only go as high as needed to elevate EPAP to resolve non-responsive obstructive apnea. If you want to open things up a bit and fully re-titrate, then starting at EPAP 6, IPAP 18, PS 4, I suspect that should work okay. Increase EPAP if OA is not stopped, and PS for hypopnea; decrease PS for CA.

In my experience the auto PS on the Philips is not a huge advantage. The machine allows hypopnea to occur before elevating PS and does not respond well to flow limitation, so you're better off manually titrating for PS.
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#8
RE: Are auto titrating bipap devices as effective as in lab manual titration?
(01-08-2019, 09:42 AM)Sleeprider Wrote: You have been using an Autoset at pressures of 11-14 with EPR 3. This can be replicated on the Vauto with EPAP min 8.0, IPAP max 14, PS 3.0. If the objective is to increase PS you can make some adjustment upward with the max IPAP, but you will never need 25 cm. The machine will only go as high as needed to elevate EPAP to resolve non-responsive obstructive apnea.  If you want to open things up a bit and fully re-titrate, then starting at EPAP 6, IPAP 18, PS 4, I suspect that should work okay. Increase EPAP if OA is not stopped, and PS for hypopnea; decrease PS for CA.

In my experience the auto PS on the Philips is not a huge advantage.  The machine allows hypopnea to occur before elevating PS and does not respond well to flow limitation, so you're better off manually titrating for PS.

Yea sleeprider I was trying to restart my re titration from scratch with the vauto. I did my first night yesterday and will post my results when I get home.

The settings that time used were 6 Epap min, 25 IPAP Max, and 4 pressure support. 

I also have my trigger set to very high because I found that this helps with central apneas and also helps the machine to recognize when I don't fully inhale all the way if that makes sense. Cycle was left on the default medium. I will lower ipap to 18 since 25 is not realistic of ever reaching that number.

Thanks
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#9
RE: Are auto titrating bipap devices as effective as in lab manual titration?
Here are screenshots for my first night. I woke up a few times during the night and I provided zoomed in screenshots of my breathing right before I woke up. I was still awake during the first and second break of therapy in the beggining and that was because I stopped the machine in order to switch the trigger setting to very high and reduce the cycle setting from very high back to medium. It's crazy because EPAP min a 6 handled my obstructions very decently but on the autoset, the pressure always goes way above 6 to handle obstruction apneas. It looks like I'm having multiple arousals with all of that random spike like breathing when breathing is normal and then all of a sudden turns into spike breathing. Why is that? Any thoughts on what you see with these screenshots?


Attached Files Thumbnail(s)
                   
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#10
RE: Are auto titrating bipap devices as effective as in lab manual titration?
Here is the second part of the screenshots


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