Have you ever been to a "Titration Study"?

[S. Manz]

A titration study for me was the next study after my sleep study. In short I had to go back for another night of getting hooked up, this time with the addition  of a CPAP machine .
The clinician then studied 6 hours of my sleep and recommended titration  setting.
All well and good except that he uses a Philips System-One for his titration study and then recommends pressures based on his study, while patients get their sanctimonious Rx for a totally different make of a CPAP machine and as we all know, there are vast differences between how different manufacturers machine software handles their brands of PAP equipment.

What do you think? Should the clinician not be using your own machine for his/her titration study? Doesn't that make more sense?

[Gideon]

The results of a titration are based on a fairly small option of your night as the tech picks out the right 10-30 minute segment to base your prescription on. All in a strange room wired and on camera.

Part of the problem of using your machine is that often they don't yet know what your machine will be..

[S. Manz]

Part of the problem of using your machine is that often they don't yet know what your machine will be..

True, however that is just a systemic issue that can easily be resolved by reordering the steps in the process.
Changing the steps to make this process a little more logical may look something like this:
---->Sleep study------>Obtain machine------->Titration------->live happily ever after

[Sleeprider]

To the extent that everyone gets a CPAP machine rather than BPAP, ST, ASV etc you may be right. I was diagnosed with very severe obstructive apnea and issues an Auto CPAP with instructions to self-titrate. That was in 2008 and the machine was a M-Series which was not particularly data friendly. I got the smart card and reader and used the Encore Viewer software and got good results. The machines used for titration are specifically designed for remote operation and have multiple modes so any bilevel or ventilation assist mode can be tried if needed. The control is able send instructions and receive data from multiple patients. The clinical test machines are often provided by one of the major manufacturers with the expectation it will result in brand-specific recommendations. Philips has been very aggressive in equipping clinics with their titration equipment, incentivizing doctors for prescriptions, and obtaining exclusive distribution rights at DMEs. The manufacturers do not actively promote or advertise to the public, and consider the suppliers and doctors to be their customers. Not very many patients actually have a preference, or are even aware of the differences between machines, so they tend to be guided by the doctor or supplier to one brand or another.

[SarcasticDave94]

6 Titration studies if I've counted correct. 3 at my first pulmonary sleep doctor's office, from the first straight CPAP in 2015, then BPAP, and finally ASV. Then after ASV failed to provide proper therapy, 3 other sleep pulmonary doctors offices each requiring another Titration.

And each Titration test was performed on a lab version of a PAP that has all modes and permits remote setting adjustments.

Not any of these 6 tests were done on the machine I would use at home. The decision on what machine is needed is a conclusion based on seeing the lab diagnosic and titration results, the technician's and doctor's interpretation, and from what insurance will approve if submitting it to them for payment.

Is the method flawed? In some ways yes. Will you change any of it? No. Insurance alone as multi billion dollar companies will not change it. I believe they will actively block what you intend. If I have it correct, your intention would require issuing all mode PAP to everyone. Otherwise how can you accurately know what to issue everyone before testing is finalized?

[S. Manz]

Is the method flawed? In some ways yes. Will you change any of it? No. Insurance alone as multi billion dollar companies will not change it. I believe they will actively block what you intend. If I have it correct, your intention would require issuing all mode PAP to everyone. Otherwise how can you accurately know what to issue everyone before testing is finalized?

You won't.
However everyone get's given a machine and those machines get set to the settings that were obtained by a totally different machine.
As to how you would accurately know what machine to give people, that too is pretty much determined by the time the sleep studies are completed because your doctor will only have to decide whether you need a ASV machine to treat your CSA or Complex CSA or an APAP if you only have OSA.
Let's face it, renowned manufacturers don't even make regular CPAPs anymore as these old machines are just crude therapy, so a doctor's choice after reviewing your sleep study, only comes down to two, a ASV or not an ASV.
The DME will then offer you choices of brands based on your RX.
Your clinician does your titration study, using your machine.
BTW, my clinician's machine has no remote capacity other than what all other machines made by good manufacturers already have (via cellular connection)
If anything, this will save insurance companies or in countries where healthcare is universal, the government, a truckload of money, but when it comes to government spending, that may not go down too well as saving money isn't in a bureaucrat's dictionary.

[SarcasticDave94]

There's more to choose machine wise than ASV or not. Just in ResMed's line is the CPAP group, BPAP group including VAuto, ST, ASV, ST-A. The 11 series CPAP machine changes things a bit if I'm correct, it'll have modes to cover what the 10 series AirSense did by separate units. Despite the changes the ResMed 11 brings, it's still a CPAP machine.

[S. Manz]

With the exception of old-school CPAP machines that only had one pressure to act as  both IPAP and EPAP and with slight variations in peripheral monitoring, at their core all non-ASV machines essentially do the same thing:
They provide a settable positive inspiratory pressure and a settable (to varying degrees) Inspiratory pressure (via pressure relief) to help keep upper airways open for the next breath (for Obstructive apnea patients).
BIPAPS do pretty much the same thing as APAPs do with the difference that BIPAPS allow more control on EPAP settings as their algo can follow breaths at a more rapid pace and react to it, but in essence they roughly do the same thing as one another in that they use a pressure relief mechanism to lower the IPAP for EPAP.
In the case of newer VPAP STs they are pretty much a more sophisticated form of ASVs in that not only do they monitor every breath, they also focus on maintaining volumes and then again, doctors barely prescribe ASVs , let alone VPAPS anyways.
 
It seems to me that home use machine technology is moving towards functioning like clinical Ventilators, the way a PAP machine must ultimately function in order to be fully therapeutic, but that's another topic altogether.
What I am trying to say is that the variety that a doctor has to choose from is really not as wide as it seems for majority of Apnea sufferers who have no other underlying conditions.

[SarcasticDave94]

I would at least disagree that the ST is more sophisticated than the ASV. ST has static EPAP and IPAP as I recall, so by extension static PS. And I also think the ST is rather akin to an old square wave machine. The ASV I used had both EPAP and PS ranges. It isn't a square wave action like the ST, or at least not what I'd call old square waves.

Anyway, have a wonderful evening.

[Geer1]

I've had one myself. 

The vast majority of patients only require basic CPAP/APAP to overcome obstructive apnea. In these cases it doesn't really matter what machine you are being titrated on because the goal of titration is just to find the minimum EPAP that maintains an open airway. The little differences between different manufacturers/models mostly just affects comfort except in rare cases.

In cases where extra ventilation is required and a bilevel is warranted then make/model is maybe slightly more critical as they do have different timing controls, pressure wave forms etc. For the most part the main goal is usually just to find the level of PS required to avoid arousal or maintain O2 and things like comfort and adjustments to the different timing controls usually isn't done so titration on one machine/brand over another is probably has minimal effects even in bilevel cases. 

The one time I think it would be quite advantageous to be titrated on the same brand/machine is with ASV or IVAPS/AVAPS. PR and Resmed use quite different algorithms and as we have noticed patients often do better with one brand over the other (although they often get decent enough results with either option and it is only very rare cases success isn't found on only one option). 

I can think of only a small handful of cases on here where a patient has had inadequate treatment with one brand of machine and then was successful on another brand. If I had to guess I would say being titrated on a different machine/brand than being prescribed probably would only affect fewer than 1% of patients.