apap vs cpap [merged with 'CPAP vs Autoset']

[robysue]

It's like there's this unbelievable trust and faith in a titration study - I just don't understand that. Unless you're having a titration study every week, how to you expect the titrated pressure to adapt to the patient's needs every day or even during the night?

While our sleep does change from night to night, a good titration study does manage to identify a pressure that is sufficient to deal with the OSA when it is at is worst AND that is tolerable to the patient in terms of being able to sleep peacefully with the machine.

Now I will admit, many of us do NOT have good titration studies. (I've had a total of four titration studies and none of them were really good; but hubby's one titration study was a great titration study.) And so the titrated pressure from any titration study really is only a starting point for determining what the pressure needs actually are on a nightly basis.

And for people who do NOT have good titration studies and/or who cannot tolerate their titrated pressure APAP and BiPAP Auto come into play as very useful tools. If you need 9 cm to control your OSA when it's at its worst, but you just can't tolerate 9cm of pressure full time, then an autotitrating machine can allow you to sleep more comfortably and only deal with the need for having the pressure at 9cm when you absolutely need it.

But not everyone prefers APAP over CPAP. And there does seem to be a presumption on this board that APAP will solve problems that it may very well NOT solve.

In particular, patients with low pressure needs may prefer CPAP (See www.journalsleep.org/Articles/300208.pdf for one study that indicates people with pressure needs less than 8 cm may prefer CPAP to APAP.) It could simply be that at low pressures most people simply don't benefit as much from the reduction in overall pressure that is achieved by using APAP in terms of managing aerophagia or other problems. [And I say that as someone who USES low pressures and NEEDS an Auto adjusting machine just to tolerate therapy.]

People who are very light sleepers OR people who are very sensitive to sensory stimuli may find the constantly changing pressures more disturbing to their sleep when using APAP. And if the perceived additional sleep disruptions come with little or no perceived benefits? Then the light sleep or highly sensitive individual may very well do better on straight CPAP rather than APAP. [And I say that as someone who is highly sensitive to sensory stimuli and has frequent arousals when using my machine in Auto mode.]

And finally it's just as easy to get the settings on an APAP wrong as it is to get the settings on a CPAP wrong. There are a lot of people out there who believe that since the APAP is an autotitrating device that it can (even should) be left wide open with a pressure range of 4-20 cm. And then they wonder what the heck is wrong when their AHI is too high or they have significant problems with leaks because they fit the mask at 4-5 cm of pressure and their machine is regularly increasing the pressure up to 14cm or more.

[Sleepster]

The only caveat I have is that it's best that the user have their data monitored so that changes to the pressure settings can be made when necessary. This takes some knowledge and expertise.

Agreed 100%, no matter what kind of machine you have - it ought to be fully data-capable at a bare minimum.

My point, though, is that the patient has some responsibility. New users should be aware that to take full advantage of APAP therapy, someone should be monitoring the data and making adjustments.

You can't automatically expect that an APAP is going to work better for you than a straight CPAP if you don't monitor the data.

Pressures that are too high, or too low, are going to cause problems. And it may be that neither a straight CPAP or a APAP will be the best machine for you, as there are other complicating factors.

[robysue]

And finally I want to respond to this:

APAP responds on an ongoing basis and adjusts accordingly to nightly events and also responds to changes with the patient, such as weight loss, physical condition, drug use, foods ate and a host of other changing variables that a one-pressure-all-the-time CPAP cannot ever do.

In the 3.75 years I have been PAPing I have used straight CPAP, APAP wide open, APAP in a tight range, fixed BiPAP, BiPAP essentially wide open, and BiPAP in a (ridiculously) tight range. I've used each of these modes for at least 2 weeks, and except for the "wide open modes), I've used them all for at least a month or more.

In terms of treating my OSA, my best objective results in terms of AHI, snoring, and flow limitation data recorded by my PAP machine night after night in my own bed has been when I used straight CPAP and straight BiPAP at pressures identified on my in lab titration studies. On straight pressure settings, my AHI was almost always below 1.5 and usually below 1.0 with little or no snoring and little or no flow limitations. Whereas on APAP and BiPAP Auto, my AHI bounces around much more frequently and it usually runs between 1.0 and 2.5. And there's more snoring and more flow limitations.

The reason my AHI data and my snoring data is marginally worse in APAP and BiPAP Auto is this: When running in Auto, the machine must wait for events to occur before bumping up the pressure just a bit to resolve my SDB once my airway starts to collapse. When running in fixed pressure mode, the pressure is always high enough to do a great job of controlling the SDB and so I have fewer events overall.

And if I could manage to fall asleep, stay asleep, and NOT get aerophagia when using my titrated BiPAP settings of 8/6, I'd switch back to straight BiPAP at 8/6.

But an extremely important part of making any kind of PAP therapy work is figuring out a way of falling asleep comfortably with the mask and being able to sleep all night with a minimum number of wakes/arousals. And (unfortunately) for me, I can't do that when using fixed pressures of 8/6, which is enough to control my OSA: When I use my titrated pressures all night long, I have severe aerophagia (as in I wake up with my stomach rock hard and in so much pain that it is difficult to move) and I have a great deal of difficulty falling asleep because when I'm awake and the pressure is at 8/6 I can feel the air being blown down my airway and it is uncomfortable enough to cause problems with getting to sleep.

And so, in order to be able to get to sleep and NOT experience severe aerophagia night after night, I use Auto mode in consultation with my sleep doctor. And the kicker is, I still wake up more than I should on Auto, and a lot of the time it's because the machine has increased the pressure and the pressure is starting to trigger some aerophagia. But overall, I'm getting better quality sleep on BiPAP Auto than I did on BiPAP, but it's still not great sleep on most nights.

Hubby on the other hand is about 1 1/2 months into CPAP therapy. He's using a PR System One Auto running in CPAP mode with a pressure of 8cm. He has no comfort problems at night AND he's sleeping well AND he's waking up feeling refreshed and rested AND he's already feeling much better on PAP than he's felt in several years AND his leak line is great AND his AHI is typically lower than mine---it's usually below 1.5 and often below 1.0.

So why is there any need for for hubby to switch to APAP mode just because his machine has it? As I see it, the APAP mode is there if he ever runs into problems. But for now? Why run the risk of messing up his high quality sleep by introducing changing pressures?

To conclude: I'm not saying all people with ordinary OSA would do better on CPAP than on APAP. And I'm not even saying most people will do better on CPAP. I am saying that some people will do better on CPAP and that if a person starts out on straight CPAP and does fine with it, there's no real point in switching to APAP. But at the same time, I also think that if a person doesn't do well on straight CPAP, then it's well worth exploring whether s/he will do better on APAP than s/he's done on CPAP.

[SuperSleeper]

The reason my AHI data and my snoring data is marginally worse in APAP and BiPAP Auto is this: When running in Auto, the machine must wait for events to occur before bumping up the pressure just a bit to resolve my SDB once my airway starts to collapse. When running in fixed pressure mode, the pressure is always high enough to do a great job of controlling the SDB and so I have fewer events overall.

All well and good for you, but please re-read the two original posts. This does not address my point, which is that we're doing a disservice to brand new OSA patients who don't yet have a machine of their own when we tell them that CPAP is "good enough" when they could easily get an APAP which offers more flexibility and treatment options should the need arise.

Especially since it's of no additional cost to them or their insurance company. And it's not really helping the situation when folks are telling these two OPs that by accepting an APAP, it might be "dangerous" or "make their treatment worse". That has nothing to do with the type of the machine they accept, since APAP can be operated in both CPAP and APAP modes.

If they have insurance or they're on Medicare here in the U.S., let them ask for an APAP - (or better yet, demand an APAP, since it's the same billing code and cost) If they get one, and the doc thinks that right now, it should be used in CPAP mode fine... but if the doc later things trying APAP might help, that option is there. If they accept a single-pressure CPAP machine, they're basically stuck with NO auto options for 5 years, unless they pay the full cost of a new APAP machine out-of-pocket. That's one of the main things I'm trying to get folks to avoid.

I wish someone would have told me that I could have insisted that my DME give me a fully data-capable APAP back when I was issued a dumb brick CPAP. I feel I got taken advantage of... and was never told of any other options that I could have had-- and at no extra cost to me or my insurance company. I personally don't want to discourage newbies here from standing up for themselves and telling the DME to take a hike when they lie through their greedy little teeth to patients about this issue.

[PaytonA]

To sum this up. The question here is whether to have an APAP or CPAP machine not whether to use APAP or CPAP. If one has an APAP machine, one can use it in APAP mode or CPAP mode thus saving time and money (for the patient) if the need arises to go from CPAP to APAP. With an APAP machine one is also able to do their own mini-titration.

The problem for newbies is that they may not know that there are different machines available and that they should have a choice. I was very lucky as a newbie. My primary care physician I think felt guilty for not suspecting sleep apnea over the years (my heart specialist was the one that blew the whistle on sleep apnea). I was titrated for a bilevel machine. My PCP got me an auto bi-level machine so I have the option and for that I am thankful but this is definitely not the norm.

PaytonA

[Sandra_ON]

I have a Resmed S9 autoset machine on loan right now. It's set on CPAP.

So you've been using it for 4 months, it was originally set at 9 and a month ago they lowered it to 8 to help with aerophagia? Did it help? Do you have EPR set at its maximum of 3?

The EPR is set at 2 and yes originally I started at 9, then he changed me to 10, back to 9 and now at 8. The aerophagia is a little better but I still have ab pain most days (I also have food sensitivities so it's hard to tell if the problem is food or aerophagia).

[Sleepster]

Your analysis is spot on.

I was titrated for a bilevel machine. My PCP got me an auto bi-level machine so I have the option and for that I am thankful but this is definitely not the norm.

You're likely in a similar situation to my son. They gave him a PRS1 set at the same pressures, but I don't know if it's an auto. I've never seen it and he's not the geek I am.

[archangle]

I was told by my doctor’s office that cpap auto will not work for me because I need to loose weight. They recommended that I use regular cpap I search the I-net but was unable to find any supporting opinion . So I decided to try the cpap auto. Any comments out there.

FIND
ANOTHER
DOCTOR

That one's a quack.

That said, APAP is not always better. It's just that the idea that APAP doesn't work on fatties is stupid. He sounds like one of those quacks who takes the easy path and blames everything on the patient being fat. Drop him and find a real doctor, because he'll just be lazy and blame all your medical problems on weight and not look for the real cause. You could die from something easily treatable because he didn't really look at what's wrong.

Anyone on CPAP, whether APAP or manual should be monitored after treatment starts by looking at the data from a fully data capable machine. Real results in your home often vary from the results of one night in the lab. Your results also often vary over time as your body adapts to CPAP or your other medical conditions change.

It's a crime that every CPAP patient isn't dispensed a fully data capable APAP machine. It can always be set to a reduced pressure range, or even set to manual CPAP mode if APAP won't work. The cost difference of APAP vs. CPAP is minimal, and, used properly, will probably pay for itself in reduced office visits.