Driving On “Auto”: Hands-On is More Effective Than Hands-Free

Abstract

l e t t e r t o t H e e d i t o rR egarding Powell et al.'s auto-bilevel study, 1 Quan, Awad, Budhiraja, and Parthasarathy wrote a commentary entitled, "The Quest to Improve CPAP Adherence-PAP Potpourri is Not the Answer" and offered a summarizing point: "Finally, such negative device trials [auto-adjusting devices, etc.] suggest that any improvement in PAP adherence rates will more likely occur by addressing social and psychological obstacles to usage rather than newer technical innovations in PAP delivery or interface design." 2 We beg to differ-not because it is less important to address social and psychological obstacles. To be sure, these aspects are critically relevant to PAP adherence. Our development of the PAP-NAP, in which patients learn imagery distraction techniques to overcome unpleasant mask and air pressure sensations as well as elementary emotional processing skills to recognize and work through resistance to PAP therapy, demonstrate our strong commitment to managing psychosocial factors. 3Our point of contention is the authors' lack of distinction on how auto-adjusting devices are currently used in research studies and clinical practice. We fi nd ourselves at odds with current practices, as described by Quan and colleagues and as reported in the literature, because we manually titrate autoadjusting devices in the sleep lab for the vast majority of our patients. Apparently, most researchers and clinicians use these devices only in their autoadjustment mode (lab or home), which bypasses the incredible talents, skills, and expertise that a sleep technologist could bring to bear when manipulating these "auto" devices to generate an exquisitely fi netuned titration.We are nonplussed by the reluctance to use this human-directed approach to the auto-adjusting technology, given the unequivocal evidence in the "auto-only" mode; these devices show: (a) no clear enhancements beyond standard PAP; (b) mixed or ineffectual responses to RERAs; and, (c) almost no useful information on residual RERAs on data downloads. Just on these three factors, auto-adjusting devices in "auto" mode do not meet AASM guidelines for titrations, let alone provide defi nitive therapy.In contrast, when manually titrated in a sleep lab-with the auto-adjusting feature still engaged and coupled with direct access to several of the advanced technological features built into these devices-the combination of man and machine can fi ne tune the pressure settings to eliminate RERAs while preventing or resolving expiratory pressure intolerance. These two effects align with AASM guidelines. 4,5 First, a PAP titration must eliminate apneas, hypopneas, and RERAs.5 Second, among patients with expiratory pressure intolerance, bilevel-type devices should be tested. 4 In our lab experience, eliminating RERAs with a fi xed pressure delivery system almost invariably triggers the side effect of expiratory pressure intolerance-either subjectively (patient complaint) or objectively (irregularities on the expiratory limb of the airfl ow curve). We fi...

Retrospective, nonrandomized controlled study on autoadjusting, dual-pressure positive airway pressure therapy for a consecutive series of complex insomnia disorder patients

“…Autoadjusting PAP devices seemed especially salient for complex insomnia patients, who were prone to anxious tendencies that may have increased vulnerability to EPI and claustrophobic feelings. Speculatively, advanced PAP technology may provide an adaptation advantage for those who might otherwise struggle with traditional PAP therapy devices 39,43,44,47…”

“…Since 2005, our policies and procedures focused on preventing or eliminating EPI and related claustrophobic tendencies in vulnerable patients with co-occurring insomnia and psychiatric conditions (Supplementary materials) 39,44,51–55. As noted in Figure 2, 3 main pathways ultimately led to CPAP failure in this study cohort, and subjective and objective EPI were the most common problems, necessitating a switch to advanced PAP devices.…”

“…In our clinical experience in working with predominantly psychiatric patients with sleep disorders, we observed frequent problems with EPI triggered by fixed pressurized airflow devices,39,43,44 and this phenomenon often heralds “claustrophobic tendencies” in relationship to or irrespective of mask issues 48–50. Since 2005, our policies and procedures focused on preventing or eliminating EPI and related claustrophobic tendencies in vulnerable patients with co-occurring insomnia and psychiatric conditions (Supplementary materials) 39,44,51–55.…”

“…These adverse effects resolved with ASV use,43 and in our clinical experience, many insomnia patients also adapt well to autobilevel PAP (ABPAP) devices 43,44. Anecdotally, manually titrated, autoadjusting algorithms embedded in these devices create a smoother airflow delivery system, which in turn diminishes insomnia patients’ anxious responses to pressurized air 43,44.…”

“…Most patients rapidly report the elimination of this discomfort, accompanied by a new sense of comfort, after switching to a dual-pressure device. Later, while asleep during the titration, we seek to eliminate all respiratory effort-related arousals (RERAs) without provoking further episodes of subjective or objective expiratory pressure intolerance (EPI), and we have found manually titrating patients on autoadjusting dual-pressure devices (adaptive servoventilation [ASV] and autobilevel PAP [ABPAP]) to be well-suited to achieve these results 4,7,8…”