An interesting one for those of you who are technically minded.

Might be useful as a 'Sticky' ? Mods ???

Daniel.


Clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea.
KUSHIDA CA, CHEDIAK A, BERRY RB, BROWN LK, GOZAL D, IBER C, PARTHASARATHY S, QUAN SF, ROWLEY JA.
J Clin Sleep Med 2008;4(2):157-71.
Stanford University Center of Excellence for Sleep Disorders, 401 Quarry Road, Suite 3301, Stanford, CA 94305-5730, USA
Abstract:
  
Positive airway pressure (PAP) devices are used to treat patients with sleep related breathing disorders (SRBDs), including obstructive sleep apnea (OSA). After a patient is diagnosed with OSA, the current standard of practice involves performing attended polysomnography (PSG), during which positive airway pressure is adjusted throughout the recording period to determine the optimal pressure for maintaining upper airway patency. Continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BPAP) represent the two forms of PAP that are manually titrated during PSG to determine the single fixed pressure of CPAP or the fixed inspiratory and expiratory positive airway pressures (IPAP and EPAP, respectively) of BPAP for subsequent nightly usage. A PAP Titration Task Force of the American Academy of Sleep Medicine reviewed the available literature. Based on this review, the Task Force developed these recommendations for conducting CPAP and BPAP titrations. Major recommendations are as follows:
(1) All potential PAP titration candidates should receive adequate PAP education, hands-on demonstration, careful mask fitting, and acclimatization prior to titration.
(2) CPAP (IPAP and/or EPAP for patients on BPAP) should be increased until the following obstructive respiratory events are eliminated (no specific order) or the recommended maximum CPAP (IPAP for patients on BPAP) is reached: apneas, hypopneas, respiratory effort-related arousals (RERAs), and snoring.
(3) The recommended minimum starting CPAP should be 4 cm H2O for pediatric and adult patients, and the recommended minimum starting IPAP and EPAP should be 8 cm H2O and 4 cm H2O, respectively, for pediatric and adult patients on BPAP.
(4) The recommended maximum CPAP should be 15 cm H2O (or recommended maximum IPAP of 20 cm H2O if on BPAP) for patients < 12 years, and 20 cm H2O (or recommended maximum IPAP of 30 cm H2O if on BPAP) for patients > or = 12 years.
(5) The recommended minimum IPAP-EPAP differential is 4 cm H2O and the recommended maximum IPAP-EPAP differential is 10 cm H2O
(6) CPAP (IPAP and/or EPAP for patients on BPAP depending on the type of event) should be increased by at least 1 cm H2O with an interval no shorter than 5 min, with the goal of eliminating obstructive respiratory events.
(7) CPAP (IPAP and EPAP for patients on BPAP) should be increased from any CPAP (or IPAP) level if at least 1 obstructive apnea is observed for patients < 12 years, or if at least 2 obstructive apneas are observed for patients > or = 12 years. (8) CPAP (IPAP for patients on BPAP) should be increased from any CPAP (or IPAP) level if at least 1 hypopnea is observed for patients < 12 years, or if at least 3 hypopneas are observed for patients > or = 12 years.
(9) CPAP (IPAP for patients on BPAP) should be increased from any CPAP (or IPAP) level if at least 3 RERAs are observed for patients < 12 years, or if at least 5 RERAs are observed for patients > or = 12 years.
(10) CPAP (IPAP for patients on BPAP) may be increased from any CPAP (or IPAP) level if at least 1 min of loud or unambiguous snoring is observed for patients < 12 years, or if at least 3 min of loud or unambiguous snoring are observed for patients > or = 12 years.
(11) The titration algorithm for split-night CPAP or BPAP titration studies should be identical to that of full-night CPAP or BPAP titration studies, respectively.
(12) If the patient is uncomfortable or intolerant of high pressures on CPAP, the patient may be tried on BPAP. If there are continued obstructive respiratory events at 15 cm H2O of CPAP during the titration study, the patient may be switched to BPAP.
(13) The pressure of CPAP or BPAP selected for patient use following the titration study should reflect control of the patient's obstructive respiration by a low (preferably < 5 per hour) respiratory disturbance index (RDI) at the selected pressure, a minimum sea level SpO2 above 90% at the pressure, and with a leak within acceptable parameters at the pressure.)
(14) An optimal titration reduces RDI < 5 for at least a 15-min duration and should include supine REM sleep at the selected pressure that is not continually interrupted by spontaneous arousals or awakenings.
(15) A good titration reduces RDI < or = 10 or by 50% if the baseline RDI < 15 and should include supine REM sleep that is not continually interrupted by spontaneous arousals or awakenings at the selected pressure.
(16) An adequate titration does not reduce the RDI < or = 10 but reduces the RDI by 75% from baseline (especially in severe OSA patients), or one in which the titration grading criteria for optimal or good are met with the exception that supine REM sleep did not occur at the selected pressure.
(17) An unacceptable titration is one that does not meet any one of the above grades.
(18) A repeat PAP titration study should be considered if the initial titration does not achieve a grade of optimal or good and, if it is a split-night PSG study, it fails to meet AASM criteria (i.e., titration duration should be > 3 hr).


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The untreated Sleep Apnoea sufferer died quietly in his sleep.......
Unlike his three passengers who died screaming !!!!!!

(Anon)

Good Info Daniel...Thanks for posting it.....I agree...should be a sticky.

 Due to my fog I had difficulty focusing on it...only thinking others may benefit from each of the 18 lines having a break between them.


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I am A ZOMBIE! 20 years+ undx'd. BiPAP Auto M 14/9. Nasal Swift&F&P Flex Fit 431 Full Face. RLS/PLMD, Primary CNS Hypersomnia, Sleep Paralysis, Parasomnia, Degenerative Disc Disease, Clinical MS, Fibromyalgia, COPD plus other past dx's..what's next?

Quote:

(1) All potential PAP titration candidates should receive adequate PAP education, hands-on demonstration, careful mask fitting, and acclimatization prior to titration.

Ooops! The American sleep profession is falling on its face already!

Quote:

(13) The pressure of CPAP or BPAP selected for patient use following the titration study should reflect control of the patient's obstructive respiration by a low (preferably < 5 per hour) respiratory disturbance index (RDI) at the selected pressure, a minimum sea level SpO2 above 90% at the pressure, and with a leak within acceptable parameters at the pressure.)

And what, pray tell, is a leak w/in acceptable parameters? What are the acceptale parameters?


_________________
Some people are like Slinkies... Not really good for anything, but they still bring a smile to your face when you push them down a flight of stairs.
Resmed VPAP Auto. Humidaire 3i, Simplicity mask, ResScan 3.7, S8 ResLink, Embla oximeter.

Unfortunately they are only guidelines.  Doc's, sleep centers, and dme's can ignore them because they are JUST guidelines :-/

Yeah, I sounded a bit sarcastic when I didn't mean to w/my last remark. (I DID mean to w/the first remark). Really, tho what is considered an acceptable leak rate during a titration?

If we dig thru our xPAP's literature we can usually find an approximate upper limit of leak the device can compensate for. BUT, what are the parameters for an acceptable leak rate during a titration - or at least the GUIDELINES or SUGGESTED leak rate parameter?

I mean, assuming we use the same mask during our titration as the mask we use at home. It would seem that the leak rates should be fairly close.

Yet how many of us encounter a totally unacceptable leak rate at home w/our mask used during titration? And how many of us encounter an unacceptable leak rate as far as our xPAP's compensation abilities yet that is never addressed by our sleep doctors when they "supposedly" go over our downloaded data on follow up?

One would assume that if the titration allows for an unacceptable leak rate one could be titrated at a higher pressure than is really necessary IF the leak rate is brought under control at home?

Can I assume most of today's CPAPs' compensatory abilities are pretty much the same across brands and models and that it is the leak rate limit that is considered acceptable during a titration study?


_________________
Some people are like Slinkies... Not really good for anything, but they still bring a smile to your face when you push them down a flight of stairs.
Resmed VPAP Auto. Humidaire 3i, Simplicity mask, ResScan 3.7, S8 ResLink, Embla oximeter.

Mrs Rip Van Winkle wrote:

Good Info Daniel...Thanks for posting it.....I agree...should be a sticky.

 Due to my fog I had difficulty focusing on it...only thinking others may benefit from each of the 18 lines having a break between them.

yes i also have trouble reading this.  i am not i'm afraid very "technically minded".  tee hee ;)

i read somewhere here that AutoPap can be dangerous?  why?
that is what i am on, since they were not able to get a "tiration" (see i'm learning - haaha! ;) ) on me at my at home sleep study.

I just wanted to say thanks for having all the definitions to the shortcut letters so I can understand the meanings. Really good info should be promonent somewhere.
Deb

I agree with them  falling on their face. I have been on Bipap for a few days short of a couple months. I took my card in and the numbers were horrible which I already knew because I checked the readout on my machine and have a card reader.  The technician didn't say a work, I had to ask what can be done to improve my numbers, something if going on I am not sleeping well  and waking up several times a night. She said she would talk to my doctor to see what he says maybe increase the pressure.

I didn't hear from her for a week and also noticed my machine was shutting down and starting up in the middle of the night. Again I called them and they said well stop by. They didn't believe what I said and checked the maching and quickly said oh here is your machine we don't have a loadner Bipap so use this till the new one comes in. The new one didn't come in as promised because she was too busy to order it so I had to use a defective maching for another night for a total of four nights after they said it was a bad machine.

New maching comes in and they say if my numbers don't impove doc said we can increase pressure one or two numbers. Or use a pulse ox at home to see how I am with that. I didn't sleep through the first night because I was at the firehouse but last night is the first night I have slept through without waking up since my titration. My titration on bipap was the first night in years I slept all night.

I have found if you aren't active in your own therapy and follow up and bug the !@#! out of them you won't get anywhere.

Gerry


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Respironics M series BiPap auto set to 16/20
Resmed Mirage Quattro FF
Diagnosed in 04 unsuccessful titration
retested and retitrated to new machine in 11 of 08

Color me red-faced! I didn't thank you, Daniel, for posting this article w/the titration guidelines. Moi bad!

Gerry, you are oh so right. No one has a more vested interest in your health care than you do so you DO have to be proactive about your own health care!


_________________
Some people are like Slinkies... Not really good for anything, but they still bring a smile to your face when you push them down a flight of stairs.
Resmed VPAP Auto. Humidaire 3i, Simplicity mask, ResScan 3.7, S8 ResLink, Embla oximeter.

Daniel thanks for your time & effort in submitting the article on Titration - I am a newbie & didn't understand all of it - but I was fitted December 31, 2008, and I quickly realized I was shortchanged in my entire session with the technician.  He told me my doc had order a mask, Res Med Swift LT nasal pillows, because I am claustrophobic, & Res Med S8 Elite ll.  He handed me the mask- the smallest size pillows were too large, the mask leaked.  He told me to tighten both straps and it would fit.  He ran through the specifics of the machine.  I asked if I had an option to learn about other equipment.  I was told thats what the Dr ordered, and that's what I was getting, and if I objected, I was doomed to failure with apnea because I was uncooperative.  The merchandise was piled up.  He spent more time compiling the bill than explaining - all in all, I was out of his office in 20 minutes with a bag of unfamiliar stuff.  After the third night of trying to get the machine to ramp, I called at 9 am,  12:30, and at 4.45.  The same clerk had taken my 2 messages, at the last call, he said wait and I will do to his office and he will take your call.  I asked what I had done wrong to my machine to have it blow off my face after the 45 minutes of ramping.  He said just keep doing it. it will get better.  I asked why am I being startled awake with a water running up my nose.  He assured me it was normal.  From posts here I learned to put the hose under the covers.  Viola! No more waking feeling I am being waterboarded.  I have learned here I am probably stuck with the mask because Medicare is my prime ins.  But I will tell my doc I want to go to a place with better service than I have received.  After the "Rude Awakening" to the world of sleep apnea the technician gave me - I have received support from Daniel, Vicki, Chronnie too, White Beard and others.  I want to be successful with my treatment, so far my best hope for information is from this forum. Thanks from JRJR

Maybe your doctor or sleep lab will put some behind the scenes pressure on this DME to get you a better fitting mask. Or maybe they have one they could give you. IF you want to switch DME suppliers that is your perogrative, your doctor has nothing to do w/it. BUT you need to do so w/in the first 30 days and make sure the new DME will "take" you as a client before dumping this one. And will the new DME give you as good a CPAP as you've got w/that Elite? Once you've been w/a DME 30 days you are pretty much stuck w/them for the full 13 months Medicare capped rental. There is a Resmed Swift LT for Her and Petite nasal pillows for it that will also fit the regualr Swift LT. You can buy "just" the nasal pillows - AND Medicare will buy one pair w/in 30 days if you request them from your DME. You SHOULD have gotten 3-4 sizes of nasal pillows w/that Swift LT. If you didn't get them your DME supplier was holding back, CHEATING. Your insurance paid for the ENTIRE mask including 3-4 sizes of nasal pillows (I forget whether it was 3 or 4, 3 for sure, maybe 4, check at cpap.com). When I got original Swift it came w/3 sizes of nasal pillows, when I got the Swift LT from the DME supplier it came w/at least 3 sizes, maybe 4. I don't remember.


_________________
Some people are like Slinkies... Not really good for anything, but they still bring a smile to your face when you push them down a flight of stairs.
Resmed VPAP Auto. Humidaire 3i, Simplicity mask, ResScan 3.7, S8 ResLink, Embla oximeter.

To: ChronieToo
Thanks so much for your reply, I've read it over & over.  I needed some friendly, informative guidiance, & you were kind enough to give it. I've never felt this helpless with anything.  I have Diabetes, High BP & a very cranky back.  Like most everyone you learn to live with those things and go on with your life.  Sticking to a diet & taking my BG 3 X daily helps me keep my Diabetes reasonable, BUT . . .

 Apnea is so complex, that I found just getting the equipment was like going into a mine-field blindfolded. Wasn't there an old movie or book called "Innocents Abroad"  (aka newbies) I followed your suggestion & called my doc, she said she sent a pres. for a face mask of my choice & for some reason she said give the dealer a 2nd chance.  I called but asked for a different technician - I was fortunate, there was no response. Monday, I"ll give that message to her nurse and ask for the pres. to be sent to the new dealer - Proxair.  I just had an awful thought, will I have to give the Elite ll back to the original dealer????

I have been following every post I can find on Masks.  ResMed had a web site where you take facial measurements & submit them - they give suggestions for masks.  The first few suggestions were Puritan Breeze nasal with dreamseal, Resperion Comfort Classis nasal w/ headgear. ResMed Mirage Activa nasal, or Mirage Micro Nasal - anyone have experience with any of these?

The Sleep Apnea Support Forum, & the Members are a "Godsend" to newbies like me.   JRJR - = Junior

Yep, switch local DME suppliers and you would most likely have to return that Resmed S8 Elite II - unless your insurance paid for it in total up front. Most insurances require at least 30 days of compliance and most require 3 or more months of "rent to own" before paying off the CPAP and it becomes your property.

You might want to go in and talk to Praxair first and know EXACTLY what you would be getting and how lenient their mask exchange policy is going to be.

I never had much luck w/any of the mask fitting guides. And masks are such an individual thing - my perfect mask might be the absolute worst mask you ever tried and vice versa. I tried the Breeze during my first titration and didn't care for it. I tried the original Swift as my first mask from the local DME supplier. I hated that hose attachment to the side. I just recently tried the new Swift LT w/the hose attachment in the center and liked it quite well altho I am not particularly a nasal pillows fan. I also recently tried the OptiLife w/the cradle cushion rather than the nasal pillows and could like that as well except I need a chin strap to prevent excessive leaks and the OptiLife chin support is not meant as a chin strap but rather as a headgear stabilizer. My personal favorite is one of Respironics' oldest masks, the Simplicity simple nasal cushion. Its uber light weight. Probably my second favorite is the Resmed Mirage Micro nasal cushion but it is so much heaver than the Simplicty and despite the forehead angle adjustment is much more difficult to get comfortable at the bridge of the nose.


_________________
Some people are like Slinkies... Not really good for anything, but they still bring a smile to your face when you push them down a flight of stairs.
Resmed VPAP Auto. Humidaire 3i, Simplicity mask, ResScan 3.7, S8 ResLink, Embla oximeter.

What is the desired relationship between the 90% pressure and the max pressure?  I have the max at 10 cm H20 and the 90% is running 9.8 cm H20.  My gut feeling is that the max pressure should be increased so 90% pressure is not running so close to the max.  Right?

What is the desired AHI under cpap?  

How do you decide the right min pressure?  Mine is 4 cm H20, but I feel I am rebreathing exhaled air when I first go to bed and there is a period that is almost panicky.  I think the flow at 4 just doesn't clear out the old air by the time I inhale again.


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Formerly AHI 47, now AHI 3. Respironics M Auto, humidifier, Resmed cpap Simplicity mask, nasal pillow. 100% compliant.

Is the expected leak rate not determined by the mask?  I recently aquired a ComfortGel mask, and in the accompanying literature, there's a chart of expected leak rates against pressures.


My 90% is running right under the auto-max as well, according to the Encore software.  Its as though my unit just goes straight up shortly after starting and stays there.  

It's listing my AHI as 12 at the moment, which, if accurate is down from my sleep study value of 43.  I would hope for even lower once I've got everything right, close to 0 and no greater than 3 or 4.  I'm no doc tho, and until I get to see one (good old British Health Service) it's all finger-in-the-wind.