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Adventures in Sleep

Three Cheers for Adapative Titration Machine

Published March 10, 2011 10:04 AM by Penny Mehaffey
I have to rave about the latest "new thing" I've done. Has anyone used any of the new adaptive titration machines?  I am very interested to hear your feedback. If not, you and your patients are in for a real treat. Recently I had a patient who needed this therapy. I was very skeptical about the whole thing going in. The only experience I'd had up to this point was a miserably failed attempt a year ago, so I was in no hurry for another night of torture.

My initiation with this machine actually started January of last year. We had a patient who qualified for the titration, so we coordinated with our medical equipment supplier to get a highly specialized PAP machine that is used in treating complex central sleep apnea. We scheduled the test for when the rep could be here. We planned a full night of training for our staff. All systems were go.  

Then the inevitable happened. The only thing you can't control -- the patient -- arrived. That is where things began to slide. The candidate was anxious to begin with and somewhat angry at having to be in the lab.  Consequently he was unable to sleep despite taking Ambien prior to lights out. He was awake and complaining throughout most of the study. We needed 40 minutes of sleep time for the machine to analyze breathing patterns. The patient did not sleep 5 minutes consecutively.  Many attempts were made to make him comfortable and to help him to sleep. Nothing helped and the test was terminated early.

Fast forward to this year.  I have another candidate: Severe OSA and complex central sleep apnea, also anxious. The scenarios were very similar with the exception that this candidate could not wait to get to the lab and start treatment. Again Ambien was taken prior to lights out. Then a miracle happened. The patient went to sleep.  I observed for 20 - 40 minutes.  NOTHING HAPPENED??  Uh oh. I  began to get nervous. Something was wrong but I couldn't figure out what it was. Where were all those events?  This patient is well known to my lab and SEVERE. Still no events...I called Beth, my rep who was on stand-by for me. I explained that I have no events to treat and it's been an hour now. 

What am I going to do?  Where are my centrals?  My OSA??  Beth took a deep breath and said, "That's because the machine is working Penny. What?  OOOOOHHH. Phewwwww. This is fabulous. A piece of equipment that did exactly what it was supposed to do and a patient that couldn't get her CPAP mask on fast enough. A polar opposite to last time.  Pinch me, please!

I am now in love with this technology. My patient actually slept all night long. The machine took care of those nasty centrals and I titrated the EEP for obstructive events. The next morning the patient said those words we love to hear. "That was the best sleep I've ever had. When can I get my machine?" I was so happy I could have cried. I didn't, but I did walk around with a big smile on my face for about a week. I was giddy.

Now I am on the hunt for people with central sleep apnea. I am confident we can help them. I think the biggest and most important part of the process is, again, patient education. You have to fully prepare them for test night. It is imperative that they are comfortable with the mask, have no leaks and come fully able to cooperate.  If not, success is not likely. You will also want to prepare yourself. It is a very different type of titration. It takes a change in mindset to become comfortable with this impressive device. 


We've done a few of these titrations every month for the past 2 years or so.  The newest guidelines suggest leaving the settings "wide open" to allow the algorithm all the room it needs to titrate, and we've had pretty good success since then, except for one patient with a beard who needed a full-face mask (the machine will not work if the leak is outside the acceptable parameters.)

Rogue March 11, 2011 3:53 PM

I;ve used it a few time and have been mostly impressed! Like you sais you have to remember to use the EEP for the obstructive events and possibly a back-up rate if the central events are really severe! The patients have liked it also!

Nick March 11, 2011 10:48 AM

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    Adventures in Sleep
    Occupation: Sleep technicians
    Setting: Various sleep facilities
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