Indolent Tuberous Sclerosis

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MD, FCCP, Pulmonary Department, Creighton Medical Center, 8552 Cass St, Omaha, NE 68114, USA The incidence of sleep apnea is estimated to be as high as 25% in males and 9% in females. The complications associated with sleep apnea are well recognized and therapy is usually required [1,2]. Continuous positive airway pressure (CPAP) has been the most successful noninvasive therapy in these patients. Auto CPAP devices have been introduced over the last few years and unfortunately the trend has been towards initiating these devices prior to manual CPAP titration. Suboptimal CPAP pressures have been shown to be inadequate in treating this disease and can be potentially dangerous [3,4]. Insurance companies have got on board for cost savings and insist on auto CPAP therapy and are refusing to cover manual CPAP titration in the sleep laboratory. In fact, some medical reviewers have even suggested not performing an initial evaluation but initiating patients on auto CPAP if sleep apnea is suspected. Rarely sleep certified physicians are involved with these patients and respiratory therapists have been adjusting the basal CPAP pressure if the AHI calculated by these auto devices were elevated. These changes are made anywhere from 2 -4 weeks to 24 months until the AHI is “adequate”. There is usually no physician input and no data or evidence to documents these manures were effective and justified. The accuracy of AHI scored by these auto devices is yet to be fully evaluated, though a couple of studies show them to be accurate [5]. These auto devices do not score AHI the same way as manual titration. The auto devices adjust their pressures using different algorithms and mainly rely on flow and vibration and impedance and they can vary significantly with different devices [6-9]. Other than changes in flow, the oxygen desaturations and arousals are taken into account in manual titration. Snoring can occur in patients even at optimum pressures and CPAP pressure need not to be titrated up.