(01-30-2013 07:13 PM)yroseotex Wrote: Let me preface by saying I am a sleep professional as well as CPAP user. I have a PhD and I tend to analyze, well everything. When I see posts extolling the benefits of autoPAP and none of the caveats, I become concerned. All the auto machines rely on information they get from you through your mask. If you are not using one of the masks specifically recommended by your machine maker, your machine may be receiving false information that it then uses to determine the need for pressure changes. Most of the auto machines rely on an average or spot check of your breathing. That means you continue to have OSA to some extent, how much depends a lot on the variability of your breathing which in turn may vary due to position and/or sleep stage. If you do not have a sleep physician or respiratory therapist regularly review the data from your machine you may still be at an increased risk for heart attack, stroke, metabolic syndrome etc. Most of the "scientific" literature regarding the efficacy of autoPAP compared to CPAP rely on very low subject numbers, often less than 50. Do you really want to subject your health to information that is limited to what happens with a small number of people. Also, most research limits their study subjects to those that do not have many of the co-morbidities you see with sleep apnea. If you suffer from one of those then the machine you are using has not been verified to successfully treat your OSA.
Welcome to the board.
Unfortunately, your idea of what actually happens to the sleep apnea patient don't seem to agree with what happens to the patients we hear about. Both on this board, and in real life.
It's truly sad, but the real world standard of treatment seems to be:
- Stumble around in the dark, ignoring symptoms that scream sleep apnea. Run a lot of inconvenient and expensive tests for other conditions before finally stumbling on sleep apnea.
- Send the patient for an overnight in-lab PSG.
- Go to a lab with a lousy setup, poor room air conditioning, starting too early in the night vs. the patient's normal sleep schedule, noisy room, slap a full face mask on the patient, tighten it real tight and uncomfortable to prevent leaks, etc. Decide not to give the patient a sleeping pill to take in case she can't sleep in this uncomfortable environment.
After a terrible night in the lab where the patient sleeps little, if at all, because you didn't give her a sleeping pill, try to make a diagnosis on very poor data.
- Either try to do a split night titration, or see if you can get the patient to come back to your "torture chamber" for a second night for a titration.
- The titration is done by the sleep technician.
- Have an official "sleep doctor" review the results, but in practice, the pressure settings and treatment is usually whatever the tech said, and the doctor just rubber stamps it and rings the cash register.
- The pressure setting is done by a sleep tech, based on one night's data, in an uncomfortable night, stressed out patient, sleeping badly, not in her own bed.
- Send the patient to a local brick and mortar DME. The DME can increase his profit margin by giving the patient a brick CPAP machine without any apnea or leak detection. The doctor is usually too clueless to insist on a data capable machine. Many of them think they're all data capable when in fact, all they record is "compliance" data that tells whether the patient is using the machine. i.e. just what it takes to get insurance to pay.
- Every so often, the DME checks the data, and tells the doctor all is OK, i.e. the patient is using the machine 4 hours a night for 70% of the time.
- Even if the patient is lucky enough to get a good data capable machine, the doctor doesn't study the data, and may not get a full report with airflow waveforms. In a small percent of the cases, the doctor may look at AHI, but most of them leave that to the DME, who just gives it a cursory look, mostly checking for compliance.
- In general, if the patient is having problems, the doctor won't look at the data collected by the CPAP machine, every night, all night, in the patient's actual sleep environment. It's off to another expensive and inconvenient sleep study that the patient's insurance may not pay for again.
Never mind that there is a good chance that the doctor could figure out what's wrong, make adjustments, and verify that it worked by using the data the CPAP machine collected and by talking to the patient.
Maybe there are more good apnea doctors out there than we think, but the above scenario is what we hear about here on this board, and what seems to happen to people I know in the real world.
By the way, most of your objections about APAP machines may have had some merit about 10 years ago. You really need to acquaint yourself to the current crop of CPAP machines, such as an S9 AutoSet with ResScan to look at the data.
The modern machines do very well with a wide selection of masks, even if you don't set the correct mask type into the machine.
You also seem to be suffering from the idea that the only way to use an Auto CPAP machine is to leave it set on 4-20 cmH2O. I believe that it will almost always set the APAP to a narrower pressure range. The lower pressure range should be titrated to something that will take care of most of the patient's apneas. The doctor should also review the pressure the APAP machine chooses and evaluate how it's working and make adjustments as needed.
With a good doctor, you can always do a better job if you use an APAP machine, and take a proper look at the data. If necessary, you can set the APAP to manual CPAP mode if the APAP makes "wrong" decisions. Looking at the data is never a negative. Even if you don't believe it's accurate, if it indicates problems, you'd better check it. If it looks good, that gives you confidence in the existing treatment.
You should also be very careful about letting the DME or the DME's RT do your data checking. They have a financial incentive to not see problems.
Also don't forget that one of the common alternatives to CPAP is no treatment at all. If you make CPAP too inconvenient for the patient with extra tests, and not adjusting to her needs, she may very well just give up like a LOT of patients do. Or not get a sleep test at all because she's heard from her friends what a bad experience the whole process was.
Proper CPAP may be the best therapy that the patients who need it don't get because of the lousy system we have.
Stay around and listen to what happens to real patients. Maybe you can help improve the real world standard of care.