A Question of Exhale Pressure Relief

[thecpapguy!]

http://cpapguy.blogspot.com/2016/09/a-q ... elief.html

Many newly diagnosed sleep apnea patients receive positive pressure (PAP) devices without understanding the optional features of these units. I do not feel, in my opinion, that this is entirely any particular patients fault. However, let’s face the truth - if you are to be receiving a new positive air pressure device (CPAP, Bi-level PAP, etc.), then it is up to you to do some research to what your best options are. This mindset is fully at the forefront of most minds when it comes to types of treatment, whether it is using forms of medicine to procedures. For unknown reasons a lot of new users truly do not complete any research and are blindly led to receiving any treatment suggested. To be clear, that statement is not an insult to patients. The sleep industry itself, particularly the positive pressure industry, likes it being this way! Although patients can be held accountable for a portion of their treatment in understanding options and risk, providers of any sort also have a responsibility to educate better and help patients understand their options as well. There is truly a flaw in the system that I feel most new patients are unaware of and most veteran patient are very much aware of.

Inside newer models of PAP devices, whether it is continuous positive airway pressure (CPAP), bi-level (some may call this Bi-PAP) devices or more advanced therapeutic forms of positive pressure there are several different features that are easily overlooked. Not only by new users when receiving a device, but also by the providers prescribing them. I feel that one of these features is exhalation pressure relief (EPR as trademarked by the company Resmed). EPR is a feature in most machines and can be under different labels per that particular manufacturer’s model. For our sake here, I will simply label all forms of exhalation pressure relief as simply “pressure relief”. Stay tuned to my blog as I am working on the “types” of pressure relief in each of the major brands of positive pressure devices available (Fisher and Paykel, Resmed, and Respironics)! For now, I will list a link to these manufacturers pressure relief information at the end of the article!

I would like to help bring forth some light using my experiences with pressure relief, how it can be a very important factor in success with positive pressure, and ultimately if it can shape what particular device you choose to purchase. By doing so, I hope that the information will help whoever finds this blog into a better understanding of your potential, or continuing, positive pressure therapy.

First, I’d like to discuss the source of where a new user will be diagnosed with sleep apnea – the sleep study. Pressure relief can be something that is utilized during forms of sleep studies to help with comfort and a better potential for compliance. However, this is debatable depending on the particular technologists completing the study. Let me better explain. The times that pressure relief could be utilized is a “titration sleep study.” Meaning that the patient has completed a diagnostic portion of a sleep study in some form and now has been sent a sleep laboratory to be monitored and placed on a positive pressure device for an entire night. In the “titration study,” the pressure will be slowly changed, whether increased or decreased, to alleviate the respiratory disturbances previously found in a diagnostic in-laboratory sleep study or home sleep study. The point is that you wear a positive pressure device for an entire night with a technologist adjust the pressure until the sleep apnea is treated successfully. If you are already using positive pressure therapy, then you may already be acquainted with this process.

In the earliest forms of beginning positive pressure therapy, pressure relief becomes very debatable. In the sleep laboratory study setting a patient will be fit with a mask and then pressure adjust slowly while sleeping. Pressure relief is an “optional” setting that the technologist may, or may not, use depending on their preference. To my knowledge, after doing research, I could not find any specific rule for the use of pressure relief in the laboratory setting other than each treatment center (the sleep lab.) should have a policy stating to how pressure relief should be used to assure it is utilized correctly, per management, by each technologist. That truly sheds some light on the wild-wild-west of pressure relief that is entirely up to each laboratory and even possibly each technologist. Meaning that on the same night one patient may use pressure relief, while another doesn’t.

Now if you are like me, that can seem somewhat unusual and even unsettling, but don’t let it discourage you. Pressure relief is an “optional” setting so it would make sense that it would be optional at even the beginning stages of treatment. However, I will tell you my mindset when working with a new patient in the laboratory during a titration study. I use pressure relief. Not for every single patient, but for nearly every patient that I’ve worked with and my reasoning is somewhat simple. It is highly likely that when a new user receives a new home unit, then they will likely be using this optional setting. I hope to use as close of settings during the sleep study as possible to what their home use will be to assure not only the treatment is effective, but that the patient is tolerable of the settings. In very rare circumstances, usually patients that are veteran users to positive pressure do not require, or tolerate pressure relief well, and simply want the function turned off. By using pressure relief, I hope to assess that a patient is tolerable and to “bridge the gap” between the sleep study and home use.

Just as there are no true requirements for the use of pressure relief during a positive pressure titration study, this also holds true for home use as well. For any patient to receive a new PAP device a prescription is needed from a physician. Depending on your physician’s level of understanding will likely determine whether pressure relief is required or not. If the physician indicates that pressure is to be used, then it will be required that the durable medical equipment technician (DME Tech.) should turn it on. However, there is no rule that states whether it should be turned on or off if not clinically indicated by the physician. Then it becomes a matter of the DME technician, just as it does with the sleep technologist during the sleep study.

The last point is that I feel pressure relief is a user function. Every patient has the ability, and the complete right, to adjust the pressure relief setting of their machine. If you feel that you have done research and wanted to adjust this setting, then it can be done! Sometimes it can be discouraged by technicians or providers and even other users. Those opinions should be taken into account – but in no way should altering the pressure relief setting change the effectiveness of the positive pressure device. It should only have an effect on comfort.

As you can tell, there is not a lot of regulation when it comes to the function of the pressure relief. So don’t be afraid to question your provider, your technician, or the sleep community on the function, purpose, and whether or not it is something for you. Pressure relief is very popular and seemingly used in a great number of positive pressure users!

Sleep well!

[DreamStalker]

So uhhhh .... could you repeat the question --- like what exactly was your question again?

[Sir NoddinOff]

So uhhhh .... could you repeat the question --- like what exactly was your question again?

There doesn't appear to be a question. The text above is just from the blog he linked to and the text in his CPAPtalk subject line is the name of the author's blog post. A bit confusing.

[palerider]

So uhhhh .... could you repeat the question --- like what exactly was your question again?

There doesn't appear to be a question. The text above is just from the blog he linked to and the text in his CPAPtalk subject line is the name of the author's blog post. A bit confusing.

and, that's before you read that unfettered stream of semi-consciousness.

[DreamStalker]

So uhhhh .... could you repeat the question --- like what exactly was your question again?

There doesn't appear to be a question. The text above is just from the blog he linked to and the text in his CPAPtalk subject line is the name of the author's blog post. A bit confusing.

Yes I know. I was being facetious about his long drawn out opinion of when or if exhalation relief should be used.

Obstructive or restrictive events do not occur upon inhalation. Therefore IMO, exhalation relief should be avoided because it is upon exhalation that an obstructive event will occur .... that is the worst time to reduce xPAP pressure.

[palerider]

Obstructive or restrictive events do not occur upon inhalation. Therefore IMO, exhalation relief should be avoided because it is upon exhalation that an obstructive event will occur .... that is the worst time to reduce xPAP pressure.

note for future readers.

dreamstalker is incorrect, while obstructions can occur during exhalation, they are most commonly experienced upon inhalation, and a simple examination of flow traces indicate that. also, reference this informative video from Resmed:
https://www.youtube.com/watch?v=-gie2dhqP2c

suspect any of his proclamations regarding cpap treatment.

[DreamStalker]

Obstructive or restrictive events do not occur upon inhalation. Therefore IMO, exhalation relief should be avoided because it is upon exhalation that an obstructive event will occur .... that is the worst time to reduce xPAP pressure.

you've got that all backwards.

No you're the one who's backwards.

[The Choker]

You are both wrong. Obstructive events can occur on inhale or exhale. http://doctorstevenpark.com/expiratory- ... ral-apneas

[palerider]

You are both wrong. Obstructive events can occur on inhale or exhale. http://doctorstevenpark.com/expiratory- ... ral-apneas

this is true, but obstructive events are most often seen on inspiration.

just like snoring can be both inspiratory and expiratory, but more often recorded on inspiration.

[DreamStalker]

Well then maybe I have catathrenia instead of obstructive sleep apnea because I know for certain that my occlusion ALWAYS occurs right at the start of exhale ... except that I also had a very high O2 desaturation (at least during my sleep study) which is NOT characteristic of catathrenia.

My opinion that pressure be reduced during exhale is a bad idea stands nonetheless.

[The Choker]

My opinion that pressure be reduced during exhale is a bad idea stands nonetheless.

I don't like that either and don't understand why it is so popular.

[palerider]

Well then maybe I have catathrenia instead of obstructive sleep apnea because I know for certain that my occlusion ALWAYS occurs right at the start of exhale ... except that I also had a very high O2 desaturation (at least during my sleep study) which is NOT characteristic of catathrenia.

My opinion that pressure be reduced during exhale is a bad idea stands nonetheless.

so, I suppose that in your "expert" opinion, bilevel machines are a bad thing?

[Pugsy]

If (big IF) someone uses exhale relief and the drop during exhale does happen to go below the threshold to stent the airway open and the airway collapses thus allowing some sort of apnea event to occur...it's easily fixed simply by raising the pressure just a little so that during exhale the airway still has enough pressure to hold it open.

Sometimes there's a choice....no sleep and no exhale relief or sleep and exhale relief.
Guess which I would choose.
You gotta be comfortable in the first place so you can go to sleep and if you can't go to sleep then it kinda becomes a moot point doesn't it.

Besides...not everyone will see that drop during exhale take them below the threshold.
Just because someone uses exhale relief doesn't automatically mean that they are getting sub optimal therapy.

[DreamStalker]

Well then maybe I have catathrenia instead of obstructive sleep apnea because I know for certain that my occlusion ALWAYS occurs right at the start of exhale ... except that I also had a very high O2 desaturation (at least during my sleep study) which is NOT characteristic of catathrenia.

My opinion that pressure be reduced during exhale is a bad idea stands nonetheless.

so, I suppose that in your "expert" opinion, bilevel machines are a bad thing?

I suppose that my expert opinion of you is a very bad thing.

[DreamStalker]

If (big IF) someone uses exhale relief and the drop during exhale does happen to go below the threshold to stent the airway open and the airway collapses thus allowing some sort of apnea event to occur...it's easily fixed simply by raising the pressure just a little so that during exhale the airway still has enough pressure to hold it open.

Sometimes there's a choice....no sleep and no exhale relief or sleep and exhale relief.
Guess which I would choose.
You gotta be comfortable in the first place so you can go to sleep and if you can't go to sleep then it kinda becomes a moot point doesn't it.

Besides...not everyone will see that drop during exhale take them below the threshold.
Just because someone uses exhale relief doesn't automatically mean that they are getting sub optimal therapy.

True ... and that is exactly what I used to do when I did use exhale relief early in my therapy. But that means unnecessary increase in pressure during inspiration and for me, using a nasal pillow, I noticed increased (and unnecessary) leaks. Once I turned off exhale relief I was able to get nearly flat line leak patterns and a consistent AHI of less than 1. I guess exhale relief may work different for everybody, but I still see no reason for it especially if you have to raise pressure to compensate for it.