Titration or straight to auto-adjusting CPAP?

[schneider4]

Hi -

It looks like my wife may be joining me on CPAP (I'm a veteran of over 4 weeks on the hose!)

She just had a sleep study, with the following diagnostic numbers:

AHI: 19 (pretty much all hypopneas)
Sleep efficiency: 55%
Lowest O2 saturation: 94%
Apnea index: 0%

Here's our dilemma: they tried to titrate her for part of the night, but she was unable to get back to sleep for more than a few minutes (her nose was clogged from allergies, and for some reason they used a nasal pillow). They've recommended that we come in for a titration study so that they can try to find the optimal pressure setting. However, that's likely to be out-of-pocket since I don't think our insurance will cover a second study so quickly. Plus, since she's likely going to need a CPAP machine anyway, wouldn't it make sense to get one (such as a Respironics REMStar Pro) that has an auto setting, since (as I understand, anyway) that machine will find the best pressure setting on its own.

We're seeing her doctor in a couple of weeks to go over the results, but I wanted to get the community's thoughts first.

Thanks in advance for any suggestions!

[jnk]

. . . they tried to titrate her for part of the night, but she was unable to get back to sleep for more than a few minutes. . . . They've recommended that we come in for a titration study so that they can try to find the optimal pressure setting. However, that's likely to be out-of-pocket since I don't think our insurance will cover a second study so quickly. Plus, since she's likely going to need a CPAP machine anyway, wouldn't it make sense to get one (such as a Respironics REMStar Pro) that has an auto setting, since (as I understand, anyway) that machine will find the best pressure setting on its own.

We're seeing her doctor in a couple of weeks to go over the results, but I wanted to get the community's thoughts first.

Thanks in advance for any suggestions!

In my opinion, the titration is the most valuable service provided in all of sleep medicine. Documenting reaction to pressures and verifying that the pressure does not unmask other sleep conditions is a very valuable thing.

That said, if the lab/center is unable to find a way to get your insurance to pay for a real titration, a full-data machine, preferably an Auto, can be used to home titrate easily enough (for most) if the diagnosis involved strictly obstructive events with no indications of other problems, as I understand it.

I would not pay for a titration out of pocket without a VERY good reason, myself, even though, as I said, I think a titration study is VERY valuable to have on record in one's files.

[DougVK]

Hi -

It looks like my wife may be joining me on CPAP (I'm a veteran of over 4 weeks on the hose!)

She just had a sleep study, with the following diagnostic numbers:

AHI: 19 (pretty much all hypopneas)
Sleep efficiency: 55%
Lowest O2 saturation: 94%
Apnea index: 0%

Here's our dilemma: they tried to titrate her for part of the night, but she was unable to get back to sleep for more than a few minutes (her nose was clogged from allergies, and for some reason they used a nasal pillow). They've recommended that we come in for a titration study so that they can try to find the optimal pressure setting. However, that's likely to be out-of-pocket since I don't think our insurance will cover a second study so quickly. Plus, since she's likely going to need a CPAP machine anyway, wouldn't it make sense to get one (such as a Respironics REMStar Pro) that has an auto setting, since (as I understand, anyway) that machine will find the best pressure setting on its own.

We're seeing her doctor in a couple of weeks to go over the results, but I wanted to get the community's thoughts first.

Thanks in advance for any suggestions!

IMO if you can pay for it or the insurance covers it you should do a in lab titration.

Do you know why they didn't try a full face mask if she had problems breathing through her nose that night?

[Pugsy]

since she's likely going to need a CPAP machine anyway, wouldn't it make sense to get one (such as a Respironics REMStar Pro) that has an auto setting, since (as I understand, anyway) that machine will find the best pressure setting on its own.

The Pro will not automatically adjust the pressure. It is straight CPAP only. One pressure setting at a time.
To do the auto adjusting pressures you would need the machine that I have showing in my profile at the bottom of this post if you are sticking with Respironics machines. The PR System One Remstart auto CPAP with Aflex. It will work in auto mode and also straight cpap mode.

A person can self titrate with the PRo and using the software but it is easier using the APAP to self titrate with the software. If insurance will pay for the second titration study let them if your co pay doesn't take food off your table.
If the won't, you can self titrate with the APAP at home. It's done often in other countries and even here.
I wouldn't pay out of pocket for it though. Steep learning curved involved but it can be don't.

I used one of my M series APAP machines to test my sister and her husband. I got enough informtion to see best setting to use. Sister had no events but tons of symptoms. Her husband snores and that was pretty much it. and he had treateable events. He blew it off though. Tried 2 nights and gave up.

Yes Ideally the sleep study wish devoted to just tiration is the optimal way to go but even then it is in a weird environment and no way does it replicates a home situation which is what we sleep in every nihght. So not the best of circumstances. Not perfect setting.
\Your choice, your money. It can be done but it is a bit of work.

[schneider4]

Thanks Pugsy - I should've been clearer: if we do decide to go straight to CPAP (actually APAP, I guess) at home and skip the titration we would of course buy an auto-adjusting machine. She was very uncomfortable in the lab, so I think it might be better to just have the machine pick the right settings (and we could then review the data to see if things are improving).

[Guest]

Plenty of people have titrated their own pressures. In my opinion an auto can be helpful in that regard.

However, if she ends up needing a more complicated machine, like a bilevel, you might have screwed yourself on buying a machine you can't use.

Best course of action--find a good used auto for not a lot of money, or call you insurance to see if they will pay for another study.

[AMUW]

She just had a sleep study, with the following diagnostic numbers:
AHI: 19 (pretty much all hypopneas)
Sleep efficiency: 55%
Lowest O2 saturation: 94%
Apnea index: 0%

Hi Schneiders: My comments are meant to be constructive:
I am not very knowledgeable with the various strategies and protocols sleep doctors use in accordance with each insurance coverage, but I try to be well informed, and I don't see sufficient information provided in this split-night PSG study to take a wise next step:
- in my case a first full night PSG study was requested, based on the initial examination of factors
- my numbers were considerably worse than your wife's: severe OSA dxed, and lower O2 saturation; my "first night lab effects" were considerable, still there were sufficient reasons to go to the PSG CPAP titration night, and to eliminate other causes
- if your wife's experience was significantly worse during this night than usual, then was there enough evidence of a sufficient degree of SA? has anybody looked at the full PSG report yet?
- was there sufficient data derived from the short titration PSG to justify any CPAP model to the insurance? in other words can it be shown that on-CPAP results were significantly better than off-CPAP? I'd venture to guess more data would be required, hence the insurance would find it more cost effective to pay for the full night titration (if justified by the doctor)
- given the nasal congestion, which I also have been struggling with, are she and her sleep doctor sure that home auto-titration will be successful? if too many parameters need to be controlled, then it could become an agonizing search for a needle in a haystack. And the rules of the "compliance game" are pretty stringent on where the patient should be after one month, then after three months. Instead a full night titration PSG could provide some shortcuts.

P.S. did the sleep doctor discuss with your wife options to first fix the problem without CPAP: trying another sleep position, solving the nasal resistance problem, loosing weight, a home sleep session with just nasal cannulae and pulse oximetry to get a sanity check on the AHI=19. I don't mean to be controversial, but in my case addressing those contributing factors was beneficial.

[Pugsy]

Thanks Pugsy - I should've been clearer: if we do decide to go straight to CPAP (actually APAP, I guess) at home and skip the titration we would of course buy an auto-adjusting machine. She was very uncomfortable in the lab, so I think it might be better to just have the machine pick the right settings (and we could then review the data to see if things are improving).

Gottcha, then yes, you could do what you are asking with a minimum of work.
You will need the software to make it easier which is easy to obtain.
If your wife has plain jane run of the mill OSA without any of the complicating factors like centrals then you could at least try home titration and leave the option to do the formal titration on the back burner.

[torontoCPAPguy]

You have a lot of good information and suggestions on here and doing some searching will certainly come up with more than you want....

My only piece of additional advice is that you MUST NOT expect your APAP to select the pressure for you. You still need to titrate to a 'range' of pressure that will deal with your issues.

But noting your SpO2 staying above 94% if that is what I am reading, I have cause to question the entire sleep study as one of the byproducts of hypopneas, depending on length, will be sudden and steep drops in blood oxygen and THAT is your warning bell to be honest. It is the sudden and steep drop in SpO2 that leads to spikes (BIG SPIKES) in blood pressure followed by resumption of normal SpO2 and sudden drops in blood pressure and it is THIS that is probably the single most significant factor in body health maintenance. Messing up your steady BP is a major causitive for atrial fibrillation amongst other things; and I can with some degree of confidence say that OSA in general can be linked to all sorts of maladies including Type 2 Diabetes and symptoms that will lead your GP to put you on meds that you have no business being on.

You want to do some research on 'statin' drugs to control cholestorol. They are poison to your body and there are numerous studies by the Mayo Clinic, Johns Hopkins, the Cleveland Clinic and so on about statin drugs (such as Lipitor or Atorvistatin). They destroy heart function amongst other repercussions and the destruction is very difficult to impossible to reverse. I have discontinued all statin medications, my cholestorol shot up, I changed my diet to a more Paleo diet (South Beach, etc.) and my cholestorol ratios are back in the almost normal range, my diabetes (did I ever have it?) is disappearing, etc. I supplement daily with magnesium, potassium, Taurine and CoEnzyme Q10 (ubiquinol) amongst others such as Vitamin E, Vitamin C, B12, etc. and have not had a cold although all around me have.

Your body is a complex and self-healing machine for the most part (there are obvious exceptions) - do NOT screw with it, nourish it properly and that includes taking care of your OSA, and you will be forever grateful for finding this forum.

If you are afflicted with other 'diseases' as your GP might call them, find the forums and get educated. I have surprised the heck out of my GP and specialists in showing them the path that I am taking and having sorta found the path, despite the difficulty, I am healing. Now to deal with the Atrial Fibrillation.

Again, do not for one moment think that an APAP machine is going to be magical. You will still use the data from it, along with perhaps the data from a Contec CMS50EW pulse oximeter and a BP cuff to help in healing yourself. Understand the data and work with it. Your goal is AHI=0.00 every morning and SpO2 over 90% all night and every night without exception. I have found the path to keep mine at a steady 95-98% all night every night and my body is starting to thank me for it.

One last thing. Asides from being shy of Magnesium, Potassium, Taurine, CO Q10, chances are you are also dehydrated. To heal yourself you need to be very well hydrated as well. And if you want a clue as to supplementation with vitamins, etc., try http://www.aFibbers.org where you will find information that makes the information associated with OSA seem like reading the comic books.

My end goal is to have all minor afflictions that are or may be associated with OSA GONE forever perhaps even including the OSA. And getting the atrial fibrillation fixed forever once and for all.

Your chances of AFib are HUGELY higher if you suffer from OSA as you grow older (I am 58).

If I was going to choose a blower? There is not a smidgen of doubt in my mind that it would be an APAP machine that collects data and I recommend to your consideration, although I dislike the company politics, the Respironics S9 Auto system and a Resmed Quattro FULL FACE MASK for night time.

You need to get aggressive about this. As much as it may be poo-poo'd by your GP, family and friends, I am here to tell you that it is LIFE THREATENING at best. Be educated, be aggressive and be your own advocate and do it asap.

Oh. And the Paleo diet if you are overweight. It is easy as pie (no pie) and the weight will come falling off you rapidly.... do not let any dietician tell you that you need carbs, that you need this, that you need that. What you need to save your life if you are overweight and growing older is to get that weight off and you need it off NOW. My experience with dieticians has been wonderful. They are great to chat with - but tell them you are going with a Paleo type diet and they will have a coronary. Yet some of the most successful weight loss doctors around here ALL, WITHOUT EXCEPTION, use a form of Paleo type eating. The shopping list is short and the food can be concocted so that even teenagers will drool over it. We had pot roast and TONS of veggies last night (we just buy the bagged frozen veggies and dump them in). No blatant carbs. No chemicals. No processed foods whatsoever. You will feel better the second day after starting and the weight will fall off and your OSA may improve to boot.

Watch your data. Work with your doctors and get copies of your blood test results (and demand them at least once a month to make sure that you are 'in the zone' as far as serum levels of magnesium, potassium, etc., are concerned. Drink only distilled water (no sugary drinks and no drinks with chemicals in them). Exception? Low sodium V8 for its mineral content expecially potassium.

And take every bit of salt that is in view and put it in the closet. Salt is bad news. More than enough in the foods we eat.

Good luck.

[mt mama]

test

[purple]

Actually, the OP may find out that the insurance company will not pay for a machine unless the doc writes a script for a specific pressure setting. If the doc wants you to do a Titration, I would be pretty sure the insurance company will cough up the money for the insurance company portion of that.

Of course, I know nothing of your co-pay or your personal financial situation. (For the record, I receive Social Security Disability and am underwater on all my medical bills, and I can not pay for the pleasurable things I personally want. Translate that, to I know where a lot of -We need to get out of paying for as much as possible" comes from).

I am not aware of an insurance company refusing to pay for the second night Titration. Can some of you others chime in if you have?

If your doc is a qualified sleep doc, and is OK with writing you an initial pressure setting, perhaps with an Auto machine. Then of course, he is a better judge of your medical needs than I am.

That being said, a lot of folks on this board seem to say one can titrate one's self by using an auto machine. I do not agree with that. Some can develop a problem exhaling against pressure (one example of a central) and perhaps kill themselves by playing this auto titration at home. That is a pretty rare circumstance. and truly your doc may already be sure you do not have that problem or one of several others that might rule against using an auto machine to to a home titration.

I am OK with some people doing things to tweak their therapy by changing pressures themselves. I do.

I would also say that some do better on a straight pressure than an auto setting of pressures. Sometimes a machine on auto can chase things other than apneas, which leaves the patient with an uncomfortable set of circumstances, running a far higher pressure than they actually need.

I also feel that starting Sleep Apnea Therapy can be very frustrating, and trying to self titrate at home with a machine on Auto multiplies the frustrations. Why anyone would try to make starting xPAP therapy harder by trying to self-titrate at home is beyond me.

If have not seen it: To lift it entirely out of someone else's post:
"Read and re-read JanKnitz's Mask Arrayed blog before you meet or talk with the DME and your insurance company. Her [url=http://maskarrayed.wordpress.com/what-y ... me-part-i/]What you need to know before you meet your DME is chock-full of important info. "

Myself I have found DME's to be kind, caring people. At some points I was frustrated in that every time I spoke with my DME they could not tell me how much I owed them, or how much something would cost. They said they were the part of the DME that provided service, and did not have access to Billing information. What I have come to realize is, that after it was on my record that I had Medicare, meaning the company would get paid something for everything they provided, the person I spoke with was never concerned with whether their company made or lost money on me, whether I owed them money or not. They just sent me whatever I needed. They do keep records of like on mask every three months, but they those who provide me service do not know whether my bill is up or not.

On the other hand, I do get bills from the DME billing arm every month. If never paid anything, that might be a problem. And I guess what I owe them is less than a hundred dollars. What I am trying to say, DME employees are not always evil trolls trying to cheat us. But do follow Janknitz's advice and keep your guard up.

If you do go to an overnight sleep titration, try not to be like me. I am such a smart mouth I can fail to create the space for the tech to tell me things about doing the treatment when I get home. All kinds of little things they know, but are not going to occur to us when starting treatment at home in a sleep deprived state. Every thing arranging the mask, pillows, or sometimes, the tech or sleep doc can look at our face and suggest the right mask, then coach us in using in. Instead of us, or me that is, trying to do it my way and suffering for it. I would observe that sometimes, the late night sleep techs do that part of the work because they prefer not to talk to people very much. All the ones, I actually I shut up long enough to listen to, knew an incredible amount how to do the treatment the easy way.

You can ask the sleep clinic for a payment plan of say, ten dollars a month for your co-pay.

[chunkyfrog]

Two (of many) reasons to do a titration in the lab:
1: (nearly all hypopneas)--shows some complexity in her condition--better not to do this at home.
2: insurance is likely to cover the second study; it's considered necessary.
One more thing; do not wait until the beginning of a new plan year--your deductible could reset--very bad!