Question for BiPap users - UPDATED 12/14/2006

[cpapjack]

I know this question has been asked quite a few times before, and everyone is different, but I searched and as usual, it returend about 5,000 results.


My titration pressure was 8. Currently I have my S8 set to 7-11 and I've consistently been getting good numbers. As some of you may be aware, I received a BiPap Auto w/Bi-flex today as a loaner to see if it helps with really bad aerophagia. What does one recommend I set my IPAP and EPAP pressures to initially?

Thanks,
Jack

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CPAPopedia Keywords Contained In This Post (Click For Definition): bipap, Titration, auto, aerophagia

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CPAPopedia Keywords Contained In This Post (Click For Definition): bipap, Titration, auto, aerophagia

[rested gal]

I'm no doctor and don't know what would be good for you. If it were me and my titration pressure from a sleep study was "8", I'd probably set my BiPAP Auto this way to start with and see how it went via checking results with Encore Pro software:

AbFLE
7.0 min EPAP
15.0 max IPAP
8.0 max PS
3 Flex
0:00 RAMP
0:00 Start
0 Patient
1 Light
the number for "nights", I'd leave as is.

If the aerophagia didn't get better, I'd try some other bi-flex settings, like 1 and 2.

If the areophagia persisted, I'd try switching the machine's operating mode to:

BFLE
7.0 EPAP
11.0 IPAP
3 FLE (and try lesser "bi-flex" settings like 2 and 1.)

If that didn't help, I'd try using it like a straight cpap with C-flex by setting it for:

BFLE
7.0 EPAP
7.0 IPAP
3 FLE (and try lesser "bi-flex" settings like 2 and 1.)

or try using it like a straight cpap without bi-flex turned on at all:

BPAP
7.0 EPAP
7.0 IPAP

In any mode that doesn't include the letters "FLE" (meaning bi-flex is enabled), you could play around with the "Rise" timer setting. If "FLE" is not in the mode, then a Rise time can be set...the length of time it take for the machine to build up from the exhale pressure to the inhale pressure when you start to inhale. For me, a rise time as long as it could be seemed smoother than a very short rise time. But for me, bi-flex was more comfortable than any rise time setting.

Anyway, as you can see, there are a lot of combos of ways to see if that machine can help relieve your areophagia.

Of course there's always the chance it might be a weak esophageal flap that isn't going to hold closed against even low pressures coming at it. Or at least not against any pressure than can treat your OSA effectively. Hope that's not the case, and hope you get relief, Jack.

[cpapjack]

I'm no doctor and don't know what would be good for you. If it were me and my titration pressure from a sleep study was "8", I'd probably set my BiPAP Auto this way to start with and see how it went via checking results with Encore Pro software:

AbFLE
7.0 min EPAP
15.0 max IPAP
8.0 max PS
3 Flex
0:00 RAMP
0:00 Start
0 Patient
1 Light
the number for "nights", I'd leave as is.

Laura,

Thanks for responding so quickly. It's funny, but I actually went throught the setup and programmed it just as you suggested with the exception of the IPAP, I set it at 11. One question though, why would you set the IPAP at 15? Also, what is the PS? It will only allow me to set it at 3.0, 3.5, or 4.0.

Thanks,
Jack

[curtcurt46]

PS is pressure support and is also the difference between IPAP and EPAP. That's why when you set it to 7 and 11 the most PS you can have is 4 or less. Respironics has a very detailed explaination in the provider manual if you want to read. I would always set the PS to the max it will allow.

[rested gal]

PS (Pressure Support) governs how far apart (and how close together) IPAP and EPAP can move away (and toward) each other. Like Curt said, I just set the PS on my machine for as much as it will allow.

Being a dog person, I think of PS as being like a leash yoking two dogs together. They can get as much as 8 cm's apart, doing their own thing. And the leash has a little stick of wood between the two collars, keeping them at least two cm's apart. (Settings-wise, 3 cm's apart is the closest it will say.)

So...if the dog named IPAP sees a flow limitation and senses a worse situation looming ahead, and wants to take off 5 or 6 or 8 cm's ahead to ward that off, it can do that. While EPAP plods along behind taking care of keeping the wolves (apneas) away. With the 8 cm's of PS slack in the leash between the two, IPAP can go about its business up ahead without always dragging EPAP along (upward) unnecessarily.

Or, if EPAP needs to go up to prevent an apnea, but IPAP doesn't see anything it needs to tend to, the 3 cm stick keeping them apart will keep EPAP from bumping into IPAP's rearend. EPAP going up will nudge IPAP to stay at least 2 cm's farther ahead where it belongs -- so they aren't running into each other. (I know..the stick between two collars visual is not quite working here. LOL! )

You can't set the PS to be farther apart than the difference between your IPAP and EPAP pressure settings. You had your settings for 11 IPAP, 7 EPAP. 11 minus 7 = 4 The PS can't be set lower than 3. That's why you saw only a few choices of numbers for setting PS.

PS can not be set lower than "3". It can be set for as much as 8. If you set IPAP 15, EPAP 7.... 15 minus 7 = 8

For that matter, if you set your machine at IPAP 20, EPAP 4 you'd still only be able to set a max PS of 8.

There has to be a built-in PS limit, because think about this unlikely but possible scenario: What if IPAP did have to climb to 20 and EPAP was using 4? That would be one heck of a jolting jump between exhaling and inhaling. So, the separate operation of IPAP and EPAP in auto-titrating mode does need to be "leashed" at least slackly together somehow. The PS setting is the leash.

No matter how far apart you set the EPAP and IPAP, or how much slack you give the PS leash yoking them together, they'll start the night out just two cm's apart. Then they'll each operate independently of each other unless one starts to get too close, or too far away from the other. PS will keep them playing well together.

I may have some of it wrong, but that's essentially the way I understand "PS".

Curt summed it up nicely. I felt like talking about dogs.

[cpapjack]

PS is pressure support and is also the difference between IPAP and EPAP. That's why when you set it to 7 and 11 the most PS you can have is 4 or less. Respironics has a very detailed explaination in the provider manual if you want to read. I would always set the PS to the max it will allow.

Gotcha, Thanks.


Jack

[cpapjack]

PS (Pressure Support) governs how far apart (and how close together) IPAP and EPAP can move away (and toward) each other. Like Curt said, I just set the PS on my machine for as much as it will allow.

Being a dog person, I think of PS as being like a leash yoking two dogs together. They can get as much as 8 cm's apart, doing their own thing. And the leash has a little stick of wood between the two collars, keeping them at least two cm's apart. (Settings-wise, 3 cm's apart is the closest it will say.)

So...if the dog named IPAP sees a flow limitation and senses a worse situation looming ahead, and wants to take off 5 or 6 or 8 cm's ahead to ward that off, it can do that. While EPAP plods along behind taking care of keeping the wolves (apneas) away. With the 8 cm's of PS slack in the leash between the two, IPAP can go about its business up ahead without always dragging EPAP along (upward) unnecessarily.

Or, if EPAP needs to go up to prevent an apnea, but IPAP doesn't see anything it needs to tend to, the 3 cm stick keeping them apart will keep EPAP from bumping into IPAP's rearend. EPAP going up will nudge IPAP to stay at least 2 cm's farther ahead where it belongs -- so they aren't running into each other. (I know..the stick between two collars visual is not quite working here. LOL! )

You can't set the PS to be farther apart than the difference between your IPAP and EPAP pressure settings. You had your settings for 11 IPAP, 7 EPAP. 11 minus 7 = 4 The PS can't be set lower than 3. That's why you saw only a few choices of numbers for setting PS.

PS can not be set lower than "3". It can be set for as much as 8. If you set IPAP 15, EPAP 7.... 15 minus 7 = 8

For that matter, if you set your machine at IPAP 20, EPAP 4 you'd still only be able to set a max PS of 8.

There has to be a built-in PS limit, because think about this unlikely but possible scenario: What if IPAP did have to climb to 20 and EPAP was using 4? That would be one heck of a jolting jump between exhaling and inhaling. So, the separate operation of IPAP and EPAP in auto-titrating mode does need to be "leashed" at least slackly together somehow. The PS setting is the leash.

No matter how far apart you set the EPAP and IPAP, or how much slack you give the PS leash yoking them together, they'll start the night out just two cm's apart. Then they'll each operate independently of each other unless one starts to get too close, or too far away from the other. PS will keep them playing well together.

I may have some of it wrong, but that's essentially the way I understand "PS".

Curt summed it up nicely. I felt like talking about dogs.

Laura,

Even if any of what you said is wrong, it sounds good to me. Really though, thanks for explaining it to me that way. That did help me to understand better what PS is.

I think I'll just try the machine out the way I currently have it setup, and see how it goes. In all actuality, a BiPap may not be needed, but it's lal the DME had to loan me. When I trialed a REMstar Auto before I received my S8, I don't recall having aerophagia, so maybe the C-Flx is all that I need.


Thanks again,
Jack

[Snoredog]

you should go see a GI Specialist you probably have GERD. If your LES is damaged no machine will help you with aerophagia. You have to heal/repair the LES first so it can seal the opening to the stomach. The LES is like a flapper valve that prevents stomach acid from refluxing up into the esophagus. You could also have a Peptic ulcer which would feel nearly the same as aerophagia.

A GI specialist will probably want to do a Endoscopy exam if you have had GERD 5yrs or more (leading cause of stomach cancer by the way), if during the exam the LES is found defective they can repair it then prescribe a acid-pump inhibitor like PrevAcid for 6-12 weeks so the LES can heal, then it can seal the opening to the stomach where aerophagia is no longer a problem.

lower cpap pressure helps resolve aerophagia. Setting IPAP/EPAP to 7cm is only 1cm lower than your titrated cpap pressure which was found during the PSG to treat your worst case SDB event while offering the best sleep. I think you need to go lower even down to 5cm if you can tolerate it.

Problem you are having with trying to control it with the Vantage is you set up the machine like a cpap with the Min. pressure being at 7cm then you let it run up to 11cm compounding the problem. Then if you snore the Vantage will ignore all SDB and only treat the snores, if that means running up to the Max. pressure of 11cm it will spend most of its time there.

Setting a bipap to 7cm is only 1cm lower than with cpap. If you want to get rid of the aerophagia, you 'll need a Remstar Auto w/Cflex and set to a range of 5cm to 8cm with Cflex on 2. Don't worry about what your AHI is going to be, you have to resolve the aerophagia first so you can use the machine. So what your AHI is 12 or 20, still better than 100 without.

The difference seen with the Remstar over your Vantage is it limits its response to events that don't resolve, the Vantage doesn't it will increase pressure as long as the event exists, if that happens to be snore it goes to the Max.

If you have already tried CPAP mode at 8cm and EPR at 2, you are spinning your wheels using a bipap at 7cm.

Cflex is unique it maintains your airway stent while near perfectly offering exhalation relief even at low pressures. I've been on cpap for years, my pressure is higher than yours, I dropped from Cflex setting of 2 to 1 to see if it would lower my snores, I had aerophagia back the next day. Put it back to 2 aerophagia was gone.

[rested gal]

I agree with Snoredog about getting your esophagus checked out...IF you don't get any relief from aerophagia with any machines at any settings that can also control your OSA.

That's why I said: "Of course there's always the chance it might be a weak esophageal flap that isn't going to hold closed against even low pressures coming at it. Or at least not against any pressure than can treat your OSA effectively. Hope that's not the case, and hope you get relief, Jack."

As Snoredog rightly pointed out, GERD can be an issue that interferes with cpap treatment in so many ways. Even without any overt symptoms of "heartburn" a person can have acid reflux causing problems. The LES is the lower esophageal sphincter:

http://www.barrettsinfo.com/content/info_2b1_les.htm

[cpapjack]

you should go see a GI Specialist you probably have GERD. If your LES is damaged no machine will help you with aerophagia. You have to heal/repair the LES first so it can seal the opening to the stomach. The LES is like a flapper valve that prevents stomach acid from refluxing up into the esophagus. You could also have a Peptic ulcer which would feel nearly the same as aerophagia.

A GI specialist will probably want to do a Endoscopy exam if you have had GERD 5yrs or more (leading cause of stomach cancer by the way), if during the exam the LES is found defective they can repair it then prescribe a acid-pump inhibitor like PrevAcid for 6-12 weeks so the LES can heal, then it can seal the opening to the stomach where aerophagia is no longer a problem.

I have no other symptons of GERD that I know of, but I'm not gonna rule this out just yet.

Problem you are having with trying to control it with the Vantage is you set up the machine like a cpap with the Min. pressure being at 7cm then you let it run up to 11cm compounding the problem. Then if you snore the Vantage will ignore all SDB and only treat the snores, if that means running up to the Max. pressure of 11cm it will spend most of its time there.

Actually my 95% pressure is right around 10.

Setting a bipap to 7cm is only 1cm lower than with cpap. If you want to get rid of the aerophagia, you 'll need a Remstar Auto w/Cflex and set to a range of 5cm to 8cm with Cflex on 2. Don't worry about what your AHI is going to be, you have to resolve the aerophagia first so you can use the machine. So what your AHI is 12 or 20, still better than 100 without.

When I trialed a Remstar Auto w/C-Flex, I don't recall having aerophagia. I think I had it set to 6-12.

If you have already tried CPAP mode at 8cm and EPR at 2, you are spinning your wheels using a bipap at 7cm.

I have, and CPAP at any pressure just doesn't do the job for me. Aerophagia is worse. What would you recommend setting the BiPap to then?


Thanks for the response.



Jack

[elliejose]

So, tell us, Jack, how did it go?

Bipap Auto has really put an end to my aerophagia. I can sleep thru the night now. And I love it. I was having problems with aerophagia and breathing against the pressure when it went up to 20 in the wee am hours. The only problem I am currently having with my bipap auto is the humidifier with the M series is not warm enough for my sinuses and they are giving me fits. My old stand alone humidifier has gone out , just Friday night. I plan on asking Santa for a heated hose in hopes that this will fix the problem. If not, I'm not sure what I will do then. RG will give me some suggestions, I hope. I had finally gotten to the place that I could use the particular humidifier with the regular Remstar Bipap that I had. However, it leaked. I had not been able to use the integrated with my auto. I just can't seem to find the perfect setup. My DME is still verrrry patient. But I am not sure how much longer they will be.

BTW, I take a Nexium everyday for gerd.
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[curtcurt46]

Read this article and then ask yourself if you may have GERD.

http://grandtimes.com/GERD.html

I hope you don't.

Good Luck!!

[cpapjack]

So after three nights using a BiPAP Auto w/Bi-Flex, my preliminary results are, that my aerophagia is almost completely eliminated. I have a just a little bit when I first wake up, but I'd say it's gone within 15 min. or so of waking. Before, it was very painful and lasted 'til at least noon. Most of the time longer. I can't believe how comfortable it is to sleep with this machine using the Bi-Flex. Wow. The one thing I did notice, and I'm not sure if this is the way it's supposed to be or if there is a problem, but I noticed that the machine wants to start blowing air back at me when I'm at the very, very end of my exhale cycle. It's not really a big deal, but I'm just not sure if that's the way it's supposed to be.

I have the machine set at EPAP of 6 and IPAP of 11.


Thanks to all,
Jack

[Wulfman]

I'm not sure if this is the way it's supposed to be or if there is a problem, but I noticed that the machine wants to start blowing air back at me when I'm at the very, very end of my exhale cycle.

Glad to hear you're getting rid of the "air".

I've never used Bi-PAP (Bi-Flex ), but that's the way C-Flex (essentially the same thing) is supposed to work so as to keep your airway open after an exhale.....since the apnea/hypopnea events occur on inhale.

Best wishes,

Den

[curtcurt46]

The one thing I did notice, and I'm not sure if this is the way it's supposed to be or if there is a problem, but I noticed that the machine wants to start blowing air back at me when I'm at the very, very end of my exhale cycle. It's not really a big deal, but I'm just not sure if that's the way it's supposed to be.

I have the machine set at EPAP of 6 and IPAP of 11.
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CPAPopedia Keywords Contained In This Post (Click For Definition): bipap, auto, aerophagia

Best thing is to ignore the machine's biflex and try to relax and breath. I think you will see this issue go away. This was an adjustment I had to make when I first start with Bipap.