(05-08-2012, 09:00 PM)SlightlySleepy Wrote: @mckevin32
What is a home titration? Does this satisfy your insurance company (I am being told I may need a new sleep study to get a new machine, presumably because they want more accurate titration, yet Dawei's post implies that the AutoSet is actually more accurate than a sleep study titration. I don't care so much about the cost of the study as the inconvenience, but my real goal is to always wake up, and always wake up alert and rested.
I did have the sleep studies, one for diagnosis and a second for titration. Some time later I felt that I wasn't getting "quality" sleep and my doctor ordered a home titration with my DME supplying an S9 Auto for 2 weeks, the doctor then used the data supplied by that to order an adjustment to the pressure setting on my Elite.
(05-08-2012, 09:26 PM)Dawei Wrote: SlightlySleepy-- One of my observations to the technician at the hook-up stage of this recent sleep study was just as you mentioned. I could not (do not) see how a brief, one-night snapshot of a person's sleeping in a strange environment all hooked up can produce results that are totally valid.
I agree with your assessment. When I finally got in for my titration lab, I'd already been on an Autoset machine for 2 months, with all that data collected, and on a CPAP for another 6 weeks at a pressure derived from the data collected on the APAP. In the first few weeks they determined that my pressure should be 18 cm H20, and set the CPAP at that. It was hard to sleep with, so rather then just give me the APAP back they dropped it to 16. At 16 my AHI went up, my compliance went down, and I started to feel like crap again. I went in for my titration, and it was teh single worst night of sleep I've had in 10 years. The tech actually came in 2 hours before they were supposed to, to send me home, because it was pretty obvious I was done sleeping - It took me 2 or more hours to finally sleep at all, and I *might* have managed 2 hours of fitful sleep.
My titration came back with a recommended pressure of 14.
I didn't even have to try it to know that just wasn't going to work. So I refused to accept a CPAP machine set at 14. Told my doctor that I didn't give a damn if they could justify it to OHIP, and that I wasn't about to contribute to the income of the DME I'm sure he owned a stake in... told him I'd buy it online for just a bit more then the 25% I was going to end up paying anyhow. He grudgingly gave me a prescription for it, told me to come back in 2 months. I did, armed with 60 days of solid date showing that the titration was wrong (95th percentile was over 17, high was 19.3, the *LOW* was 15) and I haven't seen him since. His office never bothered to call me back to remind me for a 1 year appointment - as they assured me when I made the appointment that they *always* do - and I didn't bother showing up given their disinterest.
The labs are good for diagnosing. They are useful for finding a *starting* pressure. I'll put a years worth of Autoset detailed data over 2 hours at a sleep lab any day.
05-08-2012, 11:51 PM
(This post was last modified: 05-08-2012, 11:58 PM by SlightlySleepy.)
Thanks for that detailed information about sleep studies, although I'm sure you know that I am well aware of what is involved in a PSG, being slightly more educated and experienced in them than a newbie (I've had at least three that I recall). I do agree with you 100% that a PSG is very important in the initial diagnostic phase to rule out non-obstructive apnea pathologies and probably at some (as yet unclear) interval thereafter if there are new symptoms or reason to suspect a change in underlying health or condition.
However, my concern is whether or not routine PSG's are the best way to fine tune the titration of an xPAP machine once the initial titration has been done. Titration is by definition mainly concerned with overcoming obstruction of the airway, not diagnosis of other pathologies (eg. RLS). Having all that extra data (e.g. sleep position) is somewhat irrelevant -- if the airway is obstructed, it's obstructed whether or not the user is on his back, side, or stomach (of course your questioning about whether the home machines actual detect obstruction accurately is perhaps valid, because I'm sure that most if not all home machines do not have a device that measures respiratory effort directly from the chest wall muscles). And perhaps there are situations where a progressive central apnea inducing neurological condition could creep up on a person, but probably no more likely than that in the general population, so unless you are advocating universal PSG's for everyone, I question whether serial PSG's are terribly important once a diagnosis has been made.
For example, I asked earlier if anyone on this forum had ever been 'cured' of sleep apnea without either weight loss or surgery, and the answer was 'no' (at least so far) so basically the only question at this point is "what pressure?", not "does she have x,y, or z diagnosis".
I tend to sympathize with CHanlon's implication that PSG's are seen as income generation sources. I was just commenting this evening at how closely medical practice recommendations correlate with compensation plans. Internal medicine trained Sleep Specialists recommend PSG's at labs in which they have financial ties in the same way that sinoplasty and UVP's are recommended by ENT surgeons, procedures for which they are highly compensated. Perhaps this is this an over generalization based on my small sample size. But my father's primary care doctor did not recommend a PSG of any kind for him, only a home study, with the comment "everyone over the age of 50 is slightly sleepy during the day anyway!". And in my the initial diagnostic phase of my own daytime fatigue no one even thought to do the sleep study until I myself raised the question of sleep apnea. I do not fit the normal body habitus of a sleep apnea patient, although I am told my nasal and oral structures are typical. (I am grateful to have medical training, at least for my own health benefit! I feel badly about people with less savvy.)
I mention this only to illustrate how to a hammer, everything looks like a nail, and we really don't have enough hard data to show that having a full blown PSG is the end all and be all of sleep xPAP titration, do we? Looking back at one of my PSG's, I see the technician wakened me at 5am! Of course that makes sense if they get off work in time to drive the little kiddies to school, but if that had been the night I did my first home oximetry while on CPAP for example, they would have missed my only two hypoxic apnea spells of the entire evening (these spells were within an hour of wakening, and definitely real because they correlated strongly with my feeling very fatigued the next day).
Can Patients with Obstructive Sleep Apnea Titrate Their Own Continuous Positive Airway Pressure?
Manual continuous positive airway pressure (CPAP) titration in a sleep laboratory is costly and limits access for diagnostic studies. Many factors affect CPAP compliance, but education and support, rather than in-laboratory CPAP titration, appear to be pivotal. Self-adjustment of CPAP at home will provide equal or superior efficacy in the treatment of obstructive sleep apnea (OSA) as compared with in-laboratory titration. A randomized, single-blind, two-period crossover trial of CPAP treatment at the in-laboratory–determined optimal pressure versus at-home self-adjustment of CPAP (starting pressure based on prediction equation).
Nonetheless, the findings from this study imply that routine overnight polysomnography is unnecessary for the purpose of CPAP titration in many patients with OSA, provided that the patient is given some basic education and support. Resources currently allocated to manual in-laboratory CPAP titration might be better spent on specific attention to patient education and support rather than pressure titration. A treatment algorithm that focuses on such ambulatory patient education and support rather than in-laboratory CPAP titration may realize significant efficiencies in the management of OSA without loss of treatment efficacy.
From the recent posts in this thread I see a general consensus. It's recognized that an autoset machine does not and cannot collect all the info that a sleep study can glean, and I can see that an initial sleep study is needed for verifying that OSA is present and whether or not special concerns, such as big centrals and others that have been mentioned, are also present. Following that, it seems that an Autoset has the capability of providing more accurate pressure response to a person's apnea because it can follow needs night to night, hour to hour, which the sleep study cannot.
In reply to McKevin--It appears to me that AutoSet IS more accurate than a sleep study in this context; others' comments do not appear to disagree with that view.
After my sleep study last September, my doctor prescribed a CPAP machine at a 10.0 pressure setting. The DME brought out a Respironics System One for me to try but based on some prior research, I asked her if I could try a Resmed S9. I thought I was getting a S9 Elite but it wasn't until I got home that I realized I'd received a S9 Autoset. My receipt said S9 CPAP so I think my DME may have given me the Autoset by accident.
I started out at the 10.0 CPAP setup and over the past several months have alternated between straight CPAP settings and an Autoset range of 9.0 to 12.0. While my AHI scores didn't change that much, I did notice that my average and 95% pressure using Autoset was over 11.0. Currently, I've gone back to a straight CPAP setup, but have increased my pressure setting to 10.8. I've only been at this level for a few days, but so far my average AHI has decreased from around an average of .5 to .3. Nothing significant, but still a slight improvement.
Maybe I'm a bit different from others, but I actually kind of prefer having the machine set on a constant CPAP setting throughout the night rather than having the pressure fluctuate in APAP mode. Also, I only used the ramp feature for one or two nights and have since turned that feature off. In my brief experience, I think I am able to get a consistently better mask seal and low leak rates with a constant CPAP setting.
However, I am glad that I got the Autoset because it has allowed me to experiment with small pressure setting changes so that I can determine which setting produces the lowest AHI scores. If you can get your doctor to prescribe an APAP and the out of pocket cost to you after insurance isn't much different, I'd definitely recommend going with the S9 Autoset. I've been very happy with mine.
We're all family here...you can call me B36 if you'd like!
(05-09-2012, 06:47 AM)Dawei Wrote: In reply to McKevin--It appears to me that AutoSet IS more accurate than a sleep study in this context; others' comments do not appear to disagree with that view.
I don't know even if I'd say that they are more accurate - they might not be. It could very well be that my Autoset tells me that 95% of the time I'm at 17 cm H20 to achieve a target AHI of < 5... yet, perhaps a sleep lab with all the wires, electrodes and a human monitoring it would come up with 16... or 18... as the specific, absolute precise value to achieve the same target.
Point is... who cares? That single data point of the sleep lab titration study is exactly that - a single data point. All it proves is that *that* night, under those condition, sleeping in that environment, the number was 16. Compare that to the 700+ data points collected by my autoset since I've had it. What would you consider to be the most accurate data? Can you plot the data from the titration on a graph and establish a trend? Nope... but *I* can with my Autoset data.
I guess what I mean is that perhaps under absolutely identical controlled conditions, if a sleep lab said "14" and an APAP said "17" one could judge that the lab is the single most accurate datum. But that's only a snapshot... and frankly, if they make the argument that the xPAP equipment isn't as accurate as the lab... isn't that saying "we've accurately determined that you need 14 cm h20... but that there CPAP is so darned inaccurate that when we set it at 14, well, its not really accurate enough to be sure that 14 is 14, maybe it should be 17..."
That's not really very reassuring - if the xPAP machines aren't "accurate" then setting an accurate number on them is really nothing more then a wild stab in the dark. :-) Another strong argument in favour of just *not* using fixed CPAP, and requiring autoset machines... because at least then you can bracket the target pressure of 14 by setting a range of +/- 2 (or 3, or 5, or whatever) and letting the machine do it's job.
(05-07-2012, 09:24 PM)mckevin32 Wrote: My machine is an S9 Elite @ 12.6. Not terribly long ago my Dr ordered a home titration using an S9 Auto, which I used for 2 weeks. Though my experience may or may not be typical, the 2 weeks with the auto were so much better than my current machine that I am on the fence about purchasing one as well (Insurance has declined the auto since my elite is still relatively new).
I did get the S9 autoset yesterday. From craigslist. Btw. Beware of people advertising a autoset and really having a (S9 escape auto ) these are two different machines. The first guy I went and bought the machine thinking it was a autoset. Which he advertised as having. My mistake, I didn't notice till I got home it was a escape auto. So I drove back and he gave me back the $725.
Some people have trouble adjusting to the pressure changes during the night, but for me the significantly lower pressure was much more comfortable and I didn't wake up when the machine had to respond to an event. With my Elite at 12.6 fixed I have to wear a chin strap to minimize mouth leaks, with the auto I didn't wear the chin strap and had very minimal issues with mouth leak.
The next girl had a brand new autoset. I got it the next morning. Pretty quick huh. See I don't have a prescription fir a autoset. That's how I get involved with craigslist. Besides the great deal. Retail stores do not give a warranty for the machine unless you pay fir it anyway.
Ok ok. Enough about craigslist please. ..
Last night was my first night. And it was way more comfortable.
7hrs with it on. AHI 1.0 central 0.5 leak 37ml
(05-09-2012, 06:28 PM)chaddy511 Wrote: Last night was my first night. And it was way more comfortable.
7hrs with it on. AHI 1.0 central 0.5 leak 37ml
Excellent and good on you spotting the the Escape Auto.
Just leak could be a bit lower but you seem to have a good handle on things
(05-09-2012, 06:28 PM)chaddy511 Wrote: ..See I don't have a prescription fir a autoset. That's how I get involved with craigslist. Besides the great deal. Retail stores do not give a warranty for the machine unless you pay fir it anyway. ...
I don't know about CPAP machines specifically, but usually if you request a specific piece of equipment, the DME provider will contact your doctor to OK it. It seems it is usually the insurance companies that care because it is their dime, although with contracted providers it becomes more the DME company you have to wheedle.
Did your doctor have some specific medical reason why he would not sign off on the S9 AutoSet?