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Optimum pressure caveats, indeed!!

Posted by - Sleepy Coote on February 12, 2003 at 07:18:25:

Many posters here discuss experimentally raising or lowering their pressures (ideally with direct approval of their physicians!). Quite often this experimentation is necessary, as an OSA patient's prescribed pressure may prove inadequate over time for a multitude of reasons. Reading the Sleep Technicians forum one can easily tell that "optimum pressure" is an absolutely crucial issue. To grotesquely over simplify the issue: a pressure that is too low will more often than not bring on obstructive sleep events; a pressure that is too high is at risk of inducing central apneas via the hering-breur reflex----other physiological caveats will factor in as well. That is why uncontrolled or unsupervised pressure experiments can be disasterous! Most of us are really not trained in the art or the science of titration, or for that matter, in recognizing the more subtle consequences of incorrect titration. With that said the science or algorithm of titration sometimes falls short, and the "art of titration" then comes into play. Therein lies much of the discussion and academic debate among sleep professionals---the (at times) much needed "art of titration".

I had been running a set pressure of 10 cm since my lab titration in October. Despite sleeping very well at night, I still frequently felt very poor during the day. I changed from fixed CPAP to Auto-PAP to collect three weeks of auto-titration data at home on my doctor's approval. Indeed that home collected data nicely corroborated 10 cm as being my "optimal" fixed pressure. Interestingly, I started feeling *significantly* and progressively better during those three weeks at home in auto-titration mode. With the corroborated titration data, however, I went back to using my first CPAP at 10 cm (without data collection capability unfortunately). To my GREAT suprise I immediately started to feeling much worse on a fixed 10 cm pressure. I went back to using Auto-Pap and one again immediately started feeling better! In a post below Rebecca has hypothesized that despite the corroborating titration data, I still just might be experiencing central apneas via the hering-breur reflex (thanks so much for the insight, Rebecca!!). I'm VERY inclined to agree with her for lack of data. Eventually I will run my auto-PAP at a fixed 10 cm and review the data to test this hypothesis. Aside from placebo effect, does anyone else have any theories as to what happened here? I rule out placebo effect because I started the in-home titration experiment with a heavy bias in favor of fixed pressure benefits.

For anyone interested in reading an old post describing this hering-breur reflex, the best one, in my opinion, is way back in forum 2:

http://www.sleepnet.com/apnea2/messages/399.html


For anyone interested in reading a couple more details about my doctor-approved experiment in home titration:

http://www.sleepnet.com/apnea110/messages/846.html

Thanks in advance for any insight!

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