Pressure Support Question

jnk... · Post by **jnk...** » Mon Mar 19, 2018 11:58 am

In harmony with PRs posts . . .

In general, as an overly-broad statement (which I am known to make from time to time), pressure support at higher levels helps lessen the work of breathing (WOB) during sleep for someone, since it helps ventilate them--not in the sense of triggering breathing but in the sense of making it easier to breathe. That may be useful for improving sleep itself for some. But that also may be useful for other conditions that are not always directly related to the obstruction part of OSA. So if a pulmo-doc dude or cardio-doc dude or hospital RRT had any input at all with a person's high-PS (auto)bilevel Rx, that person might not want to be too eager to fiddle around with PS based on AHI readings alone, unless the person knew OSA was his/their only concern. It is possible for breathing to be insufficient during some stages of sleep in a way that won't always show up as hypopneas in a home treatment machine. Some docs might want to lessen WOB as a prophylactic measure for a possible comorbidity rather than strictly as a treatment for OSA.

Sorry for all the weasel words. But I knew EXACTLY why bilevel was prescribed for me, and I had a doc who agreed wholeheartedly with my choices to adjust pressure and eventually switch from autobilevel to APAP.

ajack · Post by **ajack** » Wed Mar 21, 2018 5:47 am

palerider wrote: ↑
Mon Mar 19, 2018 11:11 am

ajackass wrote: ↑
Mon Mar 19, 2018 5:32 am
go see your doctor, there was a reason they had you on "The Actual Initial Prescription was 9-EPAP/25-IPAP/8-PS (incredible)."
They don't put people on PS 8 for the fun of it, you would have issues and need it. The generic PS is 4, unless otherwise indicated.
Alternatively, ignore that, and get better sleep.

I don't know why the titration required PS:8 and I'm sure you don't. Opinions like that can lead to serious harm when based on no knowledge.

palerider · Post by **palerider** » Wed Mar 21, 2018 10:50 am

ajack wrote: ↑
Wed Mar 21, 2018 5:47 am

palerider wrote: ↑
Mon Mar 19, 2018 11:11 am

ajackass wrote: ↑
Mon Mar 19, 2018 5:32 am
go see your doctor, there was a reason they had you on "The Actual Initial Prescription was 9-EPAP/25-IPAP/8-PS (incredible)."
They don't put people on PS 8 for the fun of it, you would have issues and need it. The generic PS is 4, unless otherwise indicated.
Alternatively, ignore that, and get better sleep.
I don't know why the titration required PS:8 and I'm sure you don't. Opinions like that can lead to serious harm when based on no knowledge.

You don't know that it did, all you know is what the OP said the machine was set for... Certainly wouldn't be the first person that had their machine set wrong.

Unless the OP weighs 600lbs, there's no reason for a PS of 8.

jnk... · Post by **jnk...** » Wed Mar 21, 2018 11:28 am

Weight is not the only cause of nocturnal hypoventilation.

http://aaspweb.org/wp-content/uploads/2 ... -Sleep.pdf

ajack · Post by **ajack** » Wed Mar 21, 2018 10:42 pm

palerider wrote: ↑
Wed Mar 21, 2018 10:50 am

ajack wrote: ↑
Wed Mar 21, 2018 5:47 am

palerider wrote: ↑
Mon Mar 19, 2018 11:11 am

ajackass wrote: ↑
Mon Mar 19, 2018 5:32 am
go see your doctor, there was a reason they had you on "The Actual Initial Prescription was 9-EPAP/25-IPAP/8-PS (incredible)."
They don't put people on PS 8 for the fun of it, you would have issues and need it. The generic PS is 4, unless otherwise indicated.
Alternatively, ignore that, and get better sleep.
I don't know why the titration required PS:8 and I'm sure you don't. Opinions like that can lead to serious harm when based on no knowledge.
You don't know that it did, all you know is what the OP said the machine was set for... Certainly wouldn't be the first person that had their machine set wrong.

Unless the OP weighs 600lbs, there's no reason for a PS of 8.

people who think they know, are very dangerous. Your unfounded opinions are useless. Again I would suggest she sees her doctor or DME about the issues she is having with the pressure. She will get use to it very quickly. She needs help and monitoring, not some foolish advice of just turning down the PS.
I won''t speculate on why ps:8 was determined it was needed in the titration. It's not a number someone plucks out of the air. The default is ps4

palerider · Post by **palerider** » Wed Mar 21, 2018 10:51 pm

ajackass wrote: ↑
Wed Mar 21, 2018 10:42 pm

palerider wrote: ↑
Wed Mar 21, 2018 10:50 am

ajackass wrote: ↑
Wed Mar 21, 2018 5:47 am

palerider wrote: ↑
Mon Mar 19, 2018 11:11 am

ajackass wrote: ↑
Mon Mar 19, 2018 5:32 am
go see your doctor, there was a reason they had you on "The Actual Initial Prescription was 9-EPAP/25-IPAP/8-PS (incredible)."
They don't put people on PS 8 for the fun of it, you would have issues and need it. The generic PS is 4, unless otherwise indicated.
Alternatively, ignore that, and get better sleep.
I don't know why the titration required PS:8 and I'm sure you don't. Opinions like that can lead to serious harm when based on no knowledge.
You don't know that it did, all you know is what the OP said the machine was set for... Certainly wouldn't be the first person that had their machine set wrong.

Unless the OP weighs 600lbs, there's no reason for a PS of 8.
people who think they know, are very dangerous. Your unfounded opinions are useless. Again I would suggest he sees his doctor or DME about the issues he is having with the pressure. He will get use to it very quickly. He needs help and monitoring, not some foolish advice of just turning down the PS.

And yet, you know nothing, and keep spouting nonsense.

"he"

Dallaslady51 · Post by **Dallaslady51** » Wed Mar 21, 2018 11:30 pm

Um, as I mentioned, the prescription by the 3rd party doctor Was pulled out of the air......He clearly stated that even though the sleep studies did Not show a need for high pressures or pressure support, he decided that If I turned on my back, I would require a huge upper pressure and a huge pressure support.....the reality supports None of this - my average pressure hovers between 13-15, and any pressure support above 2 resulted in my not being able to breathe properly and very large event numbers. I sleep 1/3 of the night on my back, and it does not cause a need for a higher pressure.

I appreciate the advice to consult with these "doctors" and "experts", but I feel they are as clueless as rocks - they don't even know there are other settings on my bilevel machine besides the IPAP/EPAP/PS, and their "learned technicians" are determined to put all masks on upside down....and when I do call, they say they can "fit me in" in 4-6 months (so I can meet with a rock). No thanks - I can talk to the rocks and trees in my backyard.

So, I'm taking my chances with my own research, and the more knowledgeable folks on the forums that have actually slept with these machines and have sometimes figured out ways to improve sleep based on real results. Most of the advice I've received has been quite helpful. Sorry to cause arguments, but thanks for your opinions and insight!

palerider · Post by **palerider** » Thu Mar 22, 2018 12:03 am

Dallaslady51 wrote: ↑
Wed Mar 21, 2018 11:30 pm
Um, as I mentioned, the prescription by the 3rd party doctor Was pulled out of the air......He clearly stated that even though the sleep studies did Not show a need for high pressures or pressure support, he decided that If I turned on my back, I would require a huge upper pressure and a huge pressure support.....the reality supports None of this - my average pressure hovers between 13-15, and any pressure support above 2 resulted in my not being able to breathe properly and very large event numbers. I sleep 1/3 of the night on my back, and it does not cause a need for a higher pressure.

I appreciate the advice to consult with these "doctors" and "experts", but I feel they are as clueless as rocks - they don't even know there are other settings on my bilevel machine besides the IPAP/EPAP/PS, and their "learned technicians" are determined to put all masks on upside down....and when I do call, they say they can "fit me in" in 4-6 months (so I can meet with a rock). No thanks - I can talk to the rocks and trees in my backyard.

So, I'm taking my chances with my own research, and the more knowledgeable folks on the forums that have actually slept with these machines and have sometimes figured out ways to improve sleep based on real results. Most of the advice I've received has been quite helpful. Sorry to cause arguments, but thanks for your opinions and insight!

You have to consider the source of advice... some people here have a long history of not bothering to read the posts thoroughly in their rush to share their 'wisdom'. the one telling you you're going to hurt yourself and to go back to the doctor is one of them.

Dallaslady51 · Post by **Dallaslady51** » Thu Mar 22, 2018 9:38 am

I always make my own judgments and consider all aspects. Advice that seems safe and logical usually works out just fine and I have made progress "tweaking" different things - settings, masks, etc. Thanks!

jnk... · Post by **jnk...** » Thu Mar 22, 2018 10:20 am

My understanding of how a bilevel titration is often done is that they set PS at 4, EPAP at 4, and IPAP at 8. They raise the IPAP and EPAP together (keeping PS at 4) until apneas are eliminated. Then, if the airway seems unstable and hypopneas or effort-related arousals or snores continue, they may choose to leave EPAP where it is and only raise IPAP, which in turn increases the PS (since PS represents the difference between IPAP and EPAP). This can result in a PS higher than 4.

Translating that to settings on a ResMed autobilevel means setting the prescribed PS and then finding the most effective range for minimum EPAP and maximum IPAP, which is similar to the principle of setting a minimum pressure and maximum pressure for an APAP. Just remember that if you want your autobilevel to function as an AUTObilevel, the difference between minimum EPAP and maximum IPAP must be more than what you have PS set at, or there won't be any room for the machine to react to indications of impending events and it will then basically be straight bilevel.

That assumes that the writer of the bilevel Rx got the PS correct. But yeah, even many DME RRTs don't know how to translate a bilevel Rx into autobilevel settings for a given machine.

palerider · Post by **palerider** » Thu Mar 22, 2018 11:10 am

jnk... wrote: ↑
Thu Mar 22, 2018 10:20 am
My understanding of how a bilevel titration is often done is that they set PS at 4, EPAP at 4, and IPAP at 8. They raise the IPAP and EPAP together (keeping PS at 4) until apneas are eliminated. Then, if the airway seems unstable and hypopneas or effort-related arousals or snores continue, they may choose to leave EPAP where it is and only raise IPAP, which in turn increases the PS (since PS represents the difference between IPAP and EPAP). This can result in a PS higher than 4.

That's straight out of the Resmed bilevel titration guide, so your understanding matches the manual

jnk... wrote: ↑
Thu Mar 22, 2018 10:20 am
That assumes that the writer of the bilevel Rx got the PS correct. But yeah, even many DME RRTs don't know how to translate a bilevel Rx into autobilevel settings for a given machine.

Yeah, considering the number of flat out wrong APAP prescriptions we see around here... assuming the initial Rx is correct is iffy. And you're correct, setting up an autobilevel seems to be beyond the abilities of most DME RRTs,

jnk... · Post by **jnk...** » Thu Mar 22, 2018 11:42 am

In my opinion, the PROBLEM with the suggested/common bilevel titration protocol (which too often happens when a tech is unfamiliar with how to do it after already having struggled with a failed attempt at finding an effective CPAP pressure earlier in the night) is that EPAP gets chosen at a time other than supine REM and then, just about the time the tech is trying to figure out how to get hypopneas under control, PS becomes high enough to start a few central apneas going and that, in turn, distracts the tech from addressing the obstructives with EPAP once supine REM is going on, which all allows just about enough time for the patient to wake up with eyes wide open wondering what the heck is going on. So then later the doc has to throw a dart at a chart to choose the EPAP.

Oh. Wait. Maybe I just dreamed that. Never mind. I'm sure that sort of thing never actually happens in real life.

palerider · Post by **palerider** » Thu Mar 22, 2018 2:39 pm

jnk... wrote: ↑
Thu Mar 22, 2018 11:42 am
In my opinion, the PROBLEM with the suggested/common bilevel titration protocol (which too often happens when a tech is unfamiliar with how to do it after already having struggled with a failed attempt at finding an effective CPAP pressure earlier in the night) is that EPAP gets chosen at a time other than supine REM and then, just about the time the tech is trying to figure out how to get hypopneas under control, PS becomes high enough to start a few central apneas going and that, in turn, distracts the tech from addressing the obstructives with EPAP once supine REM is going on, which all allows just about enough time for the patient to wake up with eyes wide open wondering what the heck is going on. So then later the doc has to throw a dart at a chart to choose the EPAP.

Oh. Wait. Maybe I just dreamed that. Never mind. I'm sure that sort of thing never actually happens in real life.

:lols:

Yeah.. add that to the fact that, as anybody that's been around here looking at nightly charts for any length of time, and has even a passing familiarity with sleep cycles knows, your sleep isn't a constant throughout the night, it varies as the night goes on.... so even the best titration is a hit or miss proposition.

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