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Self Titration - Scientific Study Confirms Apnea Board Approach
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Post: #11
RE: Self Titration - Scientific Study Confirms Apnea Board Approach
HeadGear Wrote:
Steven,(time=1301582397) Wrote:Here is another link to more information on the topic of Self Titration AND even on the subject whether a Sleep Study is actually needed. It is a bit older (2004), but I think the theory is sound.

http://www.tnlc.com/Lara/laura/osa/Barba...t_0830.pdf
Interesting lecture slides and references! The presenter makes a little too much of BMI (obesity) as diagnostic criteria. All the people that I know to have gone on PAP in the past two years were not obese, in fact below average BMI - as was I, when first diagnosed. Other than that I have very little to quibble about. For me a sleep study involved a six month wait list, although I was bumped to 3 months by a vacancy. In the meantime, an APAP titration put me at 8 cm H2O. Guess what, three months later, the sleep lab titration put me at 8 cm H2O. Of course, over time, the titration needed to be revised, which would imply that good practice would be a sleep study at least every year. But, at what public expense! Where I live, wait lists are already 6 months to a year!

As the author points out, sleep disordered breathing is on a broad continuum, imprecisely definable, and the associated issues are quite variable. Perhaps it is accurate to say sleep disordered breathing treatment is a target in continuous movement! What better way to track then with data capable machines, in the comfort of your own bed! Furthermore, I'm convinced what happens during a nights sleep at home is not at all like what happens in the lab. The current models are a bit on the pretentious side. The science of sleep apnea is really not at all that precise - as pointed out by the author!
02-28-2012 06:31 PM
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Post: #12
RE: Self Titration - Scientific Study Confirms Apnea Board Approach
Steven,(time=1301582397) Wrote:Here is another link to more information on the topic of Self Titration AND even on the subject whether a Sleep Study is actually needed. It is a bit older (2004), but I think the theory is sound.

http://www.tnlc.com/Lara/laura/osa/Barba...t_0830.pdf
Thanks Steven... interesting, definitely!!

I copied and uploaded the PDF presentation to our web server, just in case this link disappears.

The link to get this study is at:

http://www.apneaboard.com/sleep-study-not-always-necessary.pdf

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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.

02-28-2012 06:32 PM
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Post: #13
RE: Self Titration - Scientific Study Confirms Apnea Board Approach
zonk Wrote:Another article from "American Journal of Respiratory Critical Care Medicine ".

Accuracy of an Unattended Home CPAP Titration in the Treatment of OSA
http://ajrccm.atsjournals.org/cgi/content/full/162/1/94
02-28-2012 06:32 PM
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Post: #14
RE: Self Titration - Scientific Study Confirms Apnea Board Approach
Thanks for this article, Zonk... good finds...

I'm reposting the entire article here:
(fair use applies)


Quote:Accuracy of an Unattended Home CPAP Titration in the Treatment of Obstructive Sleep Apnea

ABSTRACT

Treatment of sleep apnea-hypopnea syndrome (SAHS) by fixed continuous positive airway pressure (CPAP) requires an in-laboratory titration procedure to determine the effective pressure level (Peff ). We recently reported that one auto-CPAP machine can be used without titration study allowing Peff determination. The aim of this study was to evaluate the accuracy of an auto CPAP trial at home. A 1- or 2-wk automatic CPAP trial was done at home in 40 patients by estimating the reference pressure (Pref ) to be set and a Pref + 3 cm H2O/-4 cm H2O pressure interval. Peff was then determined according to the percentage of CPAP time that was spent =< Pref. This Peff value was set on a fixed CPAP machine for two additional weeks and a control sleep study was done.

The pressure setting on fixed CPAP had to be increased by 1 ± 1 cm H2O (mean ± SD) above estimated Pref. Sleep improved with fixed CPAP, with a normalization of the apnea + hypopnea index (AHI) in 38 of 40 and resumption of diurnal hypersomnolence. CPAP compliance remained excellent (CPAP use: 6.1 ± 1.7 h/ night) after 6.5 ± 2.8 mo of CPAP treatment. These results indicate that auto-CPAP therapy represents a new useful and accurate way to identify conventional CPAP setting outside hospital and sleep laboratories

INTRODUCTION

Obstructive sleep apnea-hypopnea syndrome (SAHS) is highly prevalent in the middle-aged active population (1). It significantly interferes with quality of life (2) and is associated with an increase in morbidity and mortality (3). It is currently admitted that nasal continuous positive airway pressure (nCPAP) represents one of the most effective treatments for SAHS. The determination of the effective pressure level (Peff) is realized during a titration sleep study that is routinely achieved during in-laboratory sleep studies and consists of the continuous acquisition of electrophysiologic, ventilatory, and respiratory efforts and transcutaneous SaO2 characteristics. Peff corresponds to the pressure level that abolishes obstructive apnea and hypopnea and sleep fragmentation related to flow-limited breaths in every sleep stage and body position. In expert hands, this procedure can also be realized automatically outside sleep laboratories during in-hospital recordings using auto-titrating continuous positive airway pressure (CPAP) machines that allow a continuous self-adjustment of the positive pressure level to the required needs (4).

Even if obstructive breathing disorders are theoretically abolished at the end of the CPAP titration night, this procedure only provides useful information on the Peff level during one single night in a dedicated environment. However, other factors such as body and neck or mandibular position, weight changes, and nasal obstruction may further contribute to modify Peff (5). One way to bypass these intra-night and night-to-night changes in Peff is to use automatic CPAP machines at home (8, 9).

However, up to now the identification of patients who will benefit from these new devices compared with conventional CPAP remains unknown, making constant CPAP the standard treatment mode in the majority of patients with SAHS. However, considering that sleep conditions during the titration sleep study may significantly differ from those encountered at home and do not take into account the night-to night variability in the Peff level, an ideal CPAP titration procedure should be based on a CPAP titration trial conducted at home during several nights.

We have recently reported that one of the first-generation auto-CPAP machines (Morphée Plus/Cloudnine, Pierre Médical/Nelcor Puritan Bennett, Minneapolis, MN) can be used without titration sleep study by estimating the pressure around which the machine is constantly tuning to identify the minimal effective pressure level (reference pressure: [Pref]) (10). In these circumstances, the ability of the device to decrease the positive pressure level below Pref decreases with increasing Pref underestimation, with a negative relationship between the percentage of CPAP time =< Pref and the difference between Peff and Pref. According to this relationship, one could determine Peff by measuring the percentage of CPAP time spent below Pref for a given estimated Pref value.

We reasoned that the aforementioned relationship could be used to determine the adequate setting for fixed CPAP therapy after an automatic CPAP trial at home for several days without need of an in-hospital titration sleep study. We therefore designed a study to evaluate the accuracy of such a procedure to determine the positive pressure level setting for fixed CPAP therapy using the Morphée Plus/Cloudnine machine at home during 1 or 2 wk in newly diagnosed, untreated patients with SAHS.

METHODS

Subjects


Forty-two untreated consecutive patients with SAHS (age range, 37 to 66 yr) who were willing to undergo CPAP therapy as a treatment for their sleep disorder were included in the study. The only inclusion criterion was that they were living within 100 km from the hospital. Each patient had a baseline polysomnographic study to confirm clinical diagnosis (see DATA AND STATISTICAL ANALYSIS for details). The review board of our institution accepted the protocol and an informed consent form was obtained from each participating subject.

Protocol

A subjective assessment of diurnal hypersomnolence was done using the Epworth sleepiness score (11). Figure 1 illustrates our study design. After the baseline polysomnographic study, Pref was estimated according to the formula: Pref = 0.193 * body mass index (BMI) + 0.077 * neck circumference + 0.020 * apnea + hypopnea index (AHI) - 0.611. This formula differs slightly from that we previously used (9) but was prospectively validated in 50 consecutive patients previously investigated in our laboratory using our standard recording and interpretation methods. To evaluate the effect of the home titration duration on the accuracy of this titration procedure, patients were randomly allocated to a 1- or 2-wk home automatic CPAP trial, the two groups being paired (± 1 cm H2O) for the estimated value of Pref. The automatic CPAP setting was then fixed to +3 cm H2O above and -4 cm H2O below the estimated Pref. CPAP installation, determination of the adequate size of nasal mask, and demonstration of the procedures to operate the machine and install the mask were made by a home care company (Vital Aire, Québec, Canada). In 17 patients, a heated humidifier was prescribed within the first days of treatment owing to nasal congestion and stuffiness secondary to CPAP use. In these patients, the pressure setting was adjusted so that the mask pressure corresponded to the prescribed pressure value when using the humidifier circuit.

[Image: figure1.jpg]
[small]Figure 1. Schematic representation of our study design. [/small]

At the end of the automatic CPAP trial, patients brought their machine back to the home care company, and a print-out of the night-by-night characteristics of positive pressure delivery was obtained. This chart provides the time during which a positive pressure was applied and the percentage of this time spent at the different pressure levels. According to these data, the investigator (F.S.) determined the percentage of CPAP time that was spent at or below Pref.

Using the previously validated relationship that exists between the time spent at or below Pref and the difference between Pref and estimated Peff, it is possible to determine Peff according to the formula Peff = Pref - 0.056 * % CPAP time =< Pref + 4.479) (Figure 2). This formula was validated in 21 subjects, nine being added to our previously published results (9). This new pressure level was set on a conventional fixed CPAP machine for two additional weeks and a control sleep study was done while using their CPAP machine at the end of the study period. A new assessment of diurnal sleepiness with the Epworth sleepiness score was obtained.


[Image: figure2.gif][small]
Figure 2. Correlation between the percentage of positive pressure time that is spent at or below the Pref and the difference between the measured Peff and Pref. There is a significant negative relationship between these variables. [/small]

A follow-up visit was obtained after 3 to 12 mo of CPAP therapy to determine the number of patients who were still using the machine and to estimate CPAP observance by measuring the difference in time counter hours from the beginning of treatment.

Data and Statistical Analysis

Sleep (electroencephalogram [EEG], electro-oculogram [EOG], submental electromyogram [EMG], anterior tibialis EMG) and respiratory variables (nasal flow, thoracoabdominal movements, transcutaneous SaO2, breathing noise) obtained during the baseline and control CPAP polysomnographic studies were analyzed manually according to standard criteria (12). For the CPAP sleep study, breathing disorders were scored on the instantaneous flow tracing provided by a pneumotachograph (Hamilton Medical flow sensor, Via Nova, Switzerland) connected to the nasal mask. Comparison of the two groups' characteristics at baseline values were compared by an unpaired t test. To compare the changes obtained in the 1- and 2-wk auto-CPAP groups, a repeated analysis of covariance with baseline data as covariate was performed. The alpha level was set at 0.05. Data were analyzed by using the SAS statistical package (SAS Institute, Inc., Cary, NC).

RESULTS

The CPAP trial was interrupted during the home auto-CPAP trial in two subjects owing to incapacity to wear the mask (claustrophobia) in one, and to the wife's complaints concerning CPAP treatment requirements in the other. We will therefore present the data obtained in 40 subjects. Characteristics of the patients are reported in Table 1. No difference was found in any of these variables between the two groups. No subject experienced any difficulty in initiating CPAP treatment.

Treatment compliance was high during the home titration phase as assessed by the number of hours the machine was used (6.6 ± 1.5 h/night) and the number of hours a positive pressure was applied (5.9 ± 1.4 h/night) during this study period. No significant difference in these parameters was found between the 1- and 2-wk auto-CPAP titration groups. The percentage of CPAP time that was spent below estimated Pref measured at the end of this home titration phase was 63.8 ± 13.0%.

The number of patients corresponding to each amount of pressure change calculated according to the previously described relationship between the percentage of CPAP time and the difference between estimated Pref and the constant pressure level to be set is represented in Figure 3. For the whole group, the mean calculated pressure setting was 1 ± 1 cm H2O higher than estimated Pref. This new pressure level was set on a fixed CPAP machine for two additional weeks. There was no dropout during this second part of the study.

[Image: table1.jpg][small]
TABLE 1 - CHARACTERISTICS OF THE STUDY POPULATION*[/small]

[Image: figure3.gif]
[small]Figure 3. Repartition of the patients according to the difference between estimated Pref and calculated Peff measured at the end of auto-CPAP trial. [/small]


The changes in sleep and respiratory variables and in subjective daytime sleepiness are described in Table 2. A significant improvement was observed in each of these parameters (sleep architecture, sleep fragmentation, AHI, nocturnal desaturation). The AHI normalized (< 10/h) in all but two subjects. In the first one, the calculated pressure setting was 10 cm H2O. His AHI was 15.2/h, apneic and hypopneic events being essentially central in nature. We asked this patient to interrupt CPAP therapy for 1 wk to realize a conventional sleep study. Peff level measured during this titration night was 9 cm H2O but central events were even observed at this pressure level, which was the optimal one to abolish sleep-induced obstructive breathing disorders.

In the other subject, the AHI was 35/h (obstructive events). It was retrospectively found that his auto- CPAP machine was unfortunately damaged during the first home CPAP trial, and that this interfered with the ability of the compressor to adequately adapt the positive pressure level. The arousal index with CPAP was 15.9 ± 6.7/h and the frequency of respiratory-related arousals was normal (< 15/h) in all patients but the two subjects whose AHI remained abnormal (9.4 ± 9.4 n/h). The Epworth sleepiness score significantly improved (Table 2), the score going down to normal values (< 10) in 33 subjects. In the seven others, three had sleep fragmentation because of periodic leg movements, two because of persisting sleep apneas, the sleep study being normal in the other two.



[Image: table2.jpg]
[small]TABLE 2 - MEAN ± SD VALUES OF BASELINE AND CONTROL CPAP SLEEP STUDIES AND MEAN DIFFERENCE BETWEEN THE TWO STUDIES*[/small]

Patients were seen at follow-up after 6.5 ± 2.8 mo of CPAP treatment using the pressure setting determined during the auto-CPAP trial. Thirty-six of them were still on CPAP (two stopped CPAP therapy because the machine was too cumbersome, one because of pressure discomfort, and one owing to financial considerations). Symptom relief was still present in each of them. The number of hours the machine was turned on from the beginning of fixed CPAP therapy was 6.1 ± 1.7 h/ night.

DISCUSSION

Recent data from the literature demonstrate that auto-CPAP therapy is as effective as conventional CPAP (8, 9, 15). However, the benefits of this new mode of CPAP therapy are not clearly defined because no comparison of medium- or long-term efficacy of fixed and auto-CPAP on sleep and respiratory variables, treatment compliance, improvement in objective daytime sleepiness, and risk factors has been done so far. Therefore, today fixed CPAP still remains the reference for home treatment for obstructive sleep apnea. Auto-CPAP machines may have another application, that is, to automatically determine the Peff level outside sleep laboratories. The accuracy and efficacy of this strategy depend on the machine that is used but have been shown to be generally good in experts' hands (18, 19). However, auto-CPAP titration requires review of recording to verify the adequacy of automatic pressure changes, to delete the undesirable recording periods (e.g., with mask leaks or mouth breathing), and to analyze the positive pressure trend to determine the effective pressure level. Such expertise is not required in the algorithm of effective pressure determination that is described in the present study. In fact, determining Peff only requires (1) estimating the reference pressure to be set on the Morphée Plus/Cloudnine machine (using the formula with BMI, neck circumference, and AHI values); (2) measuring the percentage of CPAP time that was spent below Pref during the home CPAP titration period; and (3) correcting for Pref estimate according to the percent CPAP time =< Pref / Peff-Pref relationship. These different steps could be done automatically by the auto-CPAP machine with a dedicated program.

Besides the efficacy of this titration procedure after 2 wk of fixed CPAP therapy, the present results provide very important information on the feasibility of CPAP treatment without in-hospital recording in patients whose first experience with this treatment was done at home without any on-line recording or attending by specialized personnel. Furthermore, our results demonstrate that this strategy does not alter treatment compliance during the initial titration period, neither during conventional CPAP therapy for both short- and long-term treatment periods, because CPAP therapy was accepted by 86% of patients at the control visit. The proposed home titration procedure is simple, requiring only good training of patients by the home care company; according to this strategy, a simple computer analysis of positive pressure changes during the trial allows a determination of the fixed pressure level to be set at home. From our data, a 1-wk trial is as efficient as a 2-wk period to determine Peff.

As previously mentioned, Peff corresponds to the pressure level that abolishes obstructive respiratory events and sleep fragmentation related to flow-limited breaths. It could be argued that the home titration procedure that we propose could be imperfect because the apparatus that we used only detects and corrects apneic and hypopneic events but does not identify flow-limited breaths. This potential drawback is compensated by the relationship that is used to calculate Peff according to the percentage of positive pressure time spent =< Pref because in the patients in whom the formula was validated, Peff was determined during a conventional titration sleep study and therefore met the ideal Peff measurements criteria.

It can be asked if our procedure to determine Peff could be improved by further tuning of our formula to estimate Pref (i.e., increase Pref by 1 cm H2O, which is the average difference between Peff and Pref in our study population). We believe that this will not bypass the need for an auto-CPAP trial because improving Pref accuracy (i.e., mean pressure change equal to zero in a given patient population) would mean that an equal number of subjects need an increase or a decrease in their pressure setting. Therefore, Peff determination will still have to be checked by the home auto-CPAP trial.

The results of this study should have important practical repercussions on the way CPAP treatment is initiated in obstructive sleep apnea patients. A short auto-CPAP trial at home for 1 or 2 wk could be proposed by home care services before setting fixed CPAP therapy. However, it is particularly important to be aware that the algorithm of Peff determination that we have validated cannot be applied to other auto-CPAP devices that have different pressure limits and pressure responses criteria that should obviously modify the relationship that is used to determine Peff. Another important clinical issue arising from our results is that auto-CPAP titration at home must be accompanied by a strict follow-up of these patients. In those whose clinical response is not optimal, a control polysomnographic study with the determined pressure setting should be done to distinguish between inadequate pressure setting and other causes of persisting hypersomnolence (periodic leg movements, idiopathic).

We conclude that auto-CPAP therapy represents a new useful and accurate way to identify conventional CPAP setting outside hospital and sleep laboratories, and that CPAP titration procedures should be realized in patients in whom this strategy had failed.



Footnotes

Supported by Medical Research Council of Canada Grant MT12151.

Correspondence and requests for reprints should be addressed to F. Sériès, M.D., Centre de Pneumologie, Hôpital Laval, 2725 Chemin Sainte Foy, Sainte Foy, PQ, G1V 4G5 Canada. E-mail: Frederic.Series@med.ulaval.ca

(Received in original form August 5, 1999 and in revised form October 22, 1999).

References
[small]
1. Young, T., M. Palta, J. Dempsey, J. Skatrud, S. Weber, and S. Badr. 1993. The occurrence of sleep-disordered breathing among middle-aged adults. N. Engl. J. Med. 328: 1230-1235 [Medline].

2. Toussignat, P., M. Cosio, R. D. Levy, and P. A. Groome. 1994. Quality of life years added by treatnent of obstructive sleep apnea. Sleep 17: 52-60 [Medline].

3. He, J., M. H. Kryger, F. J. Zorick, W. Conway, and T. Roth. 1988. Mortality and apnea index in obstructive sleep apnea: experience in 385 male patients. Chest 94: 9-14 [Abstract/Free Full Text].

4. Stradling, J. R., C. Barbour, and R. J. O. Davies. 1997. Automatic nasal continuous positive airway pressure titration in the laboratory: patient outcomes. Thorax 52: 72-75 [Abstract/Free Full Text].

5. Sériès, F., I. Marc, Y. Cormier, and J. La Forge. 1994. Changes in the required levels of nasal continuous positive airway pressure in the course of treatment of obstructive sleep apnea. Eur. Respir. J. 7: 1776-1781 [Abstract].

6. Meurice, J. C., I. Marc, G. Carrier, and F. Sériès. 1996. Effects of mouth opening on upper airway collapsibility in normal sleeping subjects. Am. J. Respir. Crit. Care Med. 153: 255-259 [Abstract].

7. Lafond, C., and F. Sériès. 1998. Influence of nasal obstruction on auto-CPAP behaviour during sleep in sleep apnoea/hypopnoea syndrome. Thorax 53: 780-783 [Abstract/Free Full Text].

8. Teschler, H., and M. Berthon-Jones. 1998. Intelligent CPAP systems: clinical experience. Thorax 53: S49-S54 [Free Full Text].

9. Meurice, J. C., I. Marc, and F. Sériès. 1996. Efficiency of auto-CPAP in the treatment of obstructive sleep apnea/hypopnea syndrome. Am. J. Respir. Crit. Care Med. 153: 794-798 [Abstract].

10. Sériès, F, and I. Marc. 1997. Efficacy of automatic continuous positive airway pressure that uses an estimated required pressure level in the treatment of obstructive sleep apnea syndrome. Ann. Intern. Med. 8: 588-595 .

11. Johns, M. W.. 1993. Daytime sleepiness, snoring, and obstructive sleep apnea. The Epworth sleepiness scale. Chest 103: 30-36 [Abstract/Free Full Text].

12. Rechtschaffen, A., and A. Kales, editors. 1968. A Manual of Standardized Terminology and Scoring System for Sleep Stages of Human Subjects. Brain Information Service/Brain Research Institute, University of California at Los Angeles.

13. American Sleep Disorders Association. 1992. EEG arousals: scoring rules and examples. Sleep 15: 174-183 .

14. Sériès, F., and I. Marc. 1999. Nasal pressure recording in the diagnosis of sleep apnea hypopnea syndrome. Thorax 54: 506-510 [Abstract/Free Full Text].

15. Boudewyns, A., V. Grillier-Lanoir, M. J. Willemen, W. A. De c**k, P. H. Van de Heyning, and W. A. De Backer. 1999. Two months follow up of auto-CPAP treatment in patients with obstructive sleep apnoea. Thorax 54: 147-149 [Abstract/Free Full Text].

16. Ficker, J. H., G. H. Wiest, G. Lehnert, and E. G. Hahn. 1998. Evaluation of an auto-CPAP device for treatment of obstructive sleep apnoea. Thorax 53: 643-648 [Abstract/Free Full Text].

17. Behdehani, K., F. Yen, E. Lucas, and J. Burk. 1998. A sleep laboratory evaluation of an automatic positive airway pressure system for treatment of obstructive sleep apnea. Sleep 21: 485-491 [Medline].

18. Lloberes, P., E. Ballester, J. M. Montserrat, E. Botifoll, A. Ramirez, A. Reolid, C. Gistau, and R. Rodriguez-Roisin. 1996. Comparison of manual and automatic CPAP titration in patients with sleep apnea/ hypopnea syndrome. Am. J. Respir. Crit. Care Med. 154: 1755-1758 [Abstract].

19. Teschler, E., M Berthon-Jones, A. B. Thompson, A. Henkel, J. Henry, and N. Konietzko. 1996. Automated continuous positive airway pressure titration for obstructive sleep apnea syndrome. Am. J. Respir. Crit. Care Med. 154: 734-740 [Abstract]. [/small]

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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.

02-28-2012 06:33 PM
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Post: #15
RE: Self Titration - Scientific Study Confirms Apnea Board Approach
archangle Wrote:I think there are two possibilities here.

1) Doctor/DME in control but the sleep study is done in the home with an auto CPAP machine. Still the mushroom theory, but sleep study done in the environment where the machine is going to be used.

2) Patient in control with an auto CPAP machine with assistance/advice from the doctor/DME.

Option 1 is probably better than the current "in lab" sleep study in a lot of ways. My first sleep study was pretty worthless because I usually sleep in a recliner or on my side in a bed. I didn't sleep the first time, and had to take ambien for the second test, and didn't sleep well anyway. I suspect a lot of people don't sleep well in the traditional sleep lab either and the results are different from sleeping at home.

There is, of course, a range of patient/doctor/DME control/involvement between the two options above.
02-28-2012 06:34 PM
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Post: #16
RE: Self Titration - Scientific Study Confirms Apnea Board Approach
HeadGear Wrote:
archangle,(time=1302039802) Wrote:1) Doctor/DME in control but the sleep study is done in the home with an auto CPAP machine. Still the mushroom theory, but sleep study done in the environment where the machine is going to be used.
I was told that most measures, except EEG can be done on a machine you take home! Sleep and Lab are oxymoron!
02-28-2012 06:34 PM
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CPAP Software: SleepyHead

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Post: #17
RE: Self Titration - Scientific Study Confirms Apnea Board Approach
Ltmedic66 Wrote:
HeadGear,(time=1302047352) Wrote:
archangle,(time=1302039802) Wrote:1) Doctor/DME in control but the sleep study is done in the home with an auto CPAP machine. Still the mushroom theory, but sleep study done in the environment where the machine is going to be used.
I was told that most measures, except EEG can be done on a machine you take home! Sleep and Lab are oxymoron!
I know I am an exception, but I had a CPAP success experience in the sleep lab. I felt like it was the first restful sleep I had in years. I am sure there are a few things that helped with that- I'm used to sleeping in a fire station with lots of disturbances, so a lot of the "noise" of the lab didn't really bother me. Also, I've used a respirator for over 2 decades, so I really had not issues with a mask on my face. Third, I'm around medical stuff every day, and I really have no issued with being hoocked up to medical gear. Finally, I think I was in such a state of chronic exhaustion that the opportunity to get a real night of sleep was too good to pass up.

I know that sleep labs can be a rotten place to try to sleep, but I think a lot of it is "state of mind". I think it is natural to be apprehensive about the experience. Quite frankly, I think if the medical team invested a little time in psychologically preparing the patient, we would see much better success. Afterall, studies have proven that CPAP users are more successful when their treatment is complimented by congitive therapy- seems the same would hold true for the lab.
02-28-2012 06:35 PM
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Mask Type: Nasal pillows
Mask Make & Model: ResMed Mirage Swift II
Humidifier: none
CPAP Pressure: 12.5 - 18.5 cmH20 (auto range)
CPAP Software: SleepyHead

Other Comments: Have diabetes Type II

Sex: Male
Location: Illinois, USA

Post: #18
RE: Self Titration - Scientific Study Confirms Apnea Board Approach
HeadGear Wrote:
Ltmedic66,(time=1303433157) Wrote:I know that sleep labs can be a rotten place to try to sleep, but I think a lot of it is "state of mind". I think it is natural to be apprehensive about the experience. Quite frankly, I think if the medical team invested a little time in psychologically preparing the patient, we would see much better success. Afterall, studies have proven that CPAP users are more successful when their treatment is complimented by congitive therapy- seems the same would hold true for the lab.
I think you are right about the psychological component, but it is a very real impact and fully outside patient control. For example, at one of my sleep studies, I forgot my chin strap. Oh oh, I though I was in trouble! On the contrary, I had no mouth leaks all night. I could not do that at home!!! My theory about that was that my sleep was lighter, more attentive than it would have been in the comfort of my own home and bed. That could also explain slightly lower pressure requirements in the lab. Greater relaxation at home would imply deeper sleep, greater muscle paralysis and perhaps greater obstruction requiring more pressure to clear. That said, I slept fine at all my sleep studies in terms of rapid sleep onset and hours of sleep.

No amount of preparation could create the same level of sleep comfort in the lab as at home. However, your point about cognitive therapy is well taken with regard to anxiety, poor sleep hygiene and similar factors.

As you got a good sleep at the lab, I presume it was your first in a long time without so many apneas! That must have been a great experience!
02-28-2012 06:35 PM
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SuperSleeper Offline

Administrators

Posts: 9,976
Joined: Feb 2012

Machine: PR System One REMstar Auto (DS560)
Mask Type: Nasal pillows
Mask Make & Model: ResMed Mirage Swift II
Humidifier: none
CPAP Pressure: 12.5 - 18.5 cmH20 (auto range)
CPAP Software: SleepyHead

Other Comments: Have diabetes Type II

Sex: Male
Location: Illinois, USA

Post: #19
RE: Self Titration - Scientific Study Confirms Apnea Board Approach
am0665 Wrote:
archangle,(time=1302039802) Wrote:1) Doctor/DME in control but the sleep study is done in the home with an auto CPAP machine. Still the mushroom theory, but sleep study done in the environment where the machine is going to be used.
2) Patient in control with an auto CPAP machine with assistance/advice from the doctor/DME.
I agree with Archangle's comment, but prefer to go a step further.
Generally, I see the issue not being "which weapon to choose" to first diagnose, then to treat OSA. Rather to recognize that it is a multi-disciplinary issue, that the situation varies from patient to patient
... hence [big]how to best combine all possible and available weapons at the start and during therapy[/big].
In fact I've been in mode
3) after the basic and titration PSGs didn't do a complete job, and after the sleep doctor wouldn't pick up the ball afterwards, I switched teams and immersed myself into Assisted home CPAP... trying to use as much infromation as possible from all the tests and advice sources.

In other words, no matter how one starts, in the long run the patient can become responsible for his own chronic therapy protocol.
02-28-2012 06:36 PM
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SuperSleeper Offline

Administrators

Posts: 9,976
Joined: Feb 2012

Machine: PR System One REMstar Auto (DS560)
Mask Type: Nasal pillows
Mask Make & Model: ResMed Mirage Swift II
Humidifier: none
CPAP Pressure: 12.5 - 18.5 cmH20 (auto range)
CPAP Software: SleepyHead

Other Comments: Have diabetes Type II

Sex: Male
Location: Illinois, USA

Post: #20
RE: Self Titration - Scientific Study Confirms Apnea Board Approach
archangle Wrote:The grumpy old man in me says, "It will never happen. Sleep studies are no longer about serving the patient, they're about bilking the maximum amount of money out of the insurance company and patient."
02-28-2012 06:36 PM
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