Just a thought: Isn't BiPAP more logical in general?

I was just thinking about BiPAP versus CPAP/APAP. It seems to me that BiPAP makes more sense in general: the ability to set your machine to the pressures that work for you and feel the best for inhale and exhale. Why aren't all machines BiPAP? Wouldn't that eliminate the need for exhale relief altogether?

Admittedly, I'm not an expert on BiPAP machines, nor do I know their intricacies and shortcomings. I'm sure Velbor, -SWS, or RG (et al) do!

Nor am I well-versed on BiPap. But it seems to me that any machine with EPR or x-flex pretty much IS a bi-level! The only difference is a "true" bi-level goes higher than 20cm on inhale.

I guess, but it seems awful redundant to me. Why make a completely different machine?

tattooyu wrote:I was just thinking about BiPAP versus CPAP/APAP. It seems to me that BiPAP makes more sense in general: the ability to set your machine to the pressures that work for you and feel the best for inhale and exhale. Why aren't all machines BiPAP? Wouldn't that eliminate the need for exhale relief altogether?
Admittedly, I'm not an expert on BiPAP machines, nor do I know their intricacies and shortcomings. I'm sure Velbor, -SWS, or RG (et al) do!

It's called money. I had an original sleep study that called for re titration 120 days after beginning cpap therapy. The DME was supposed to call and have me bring in the machine and have them read the data from it. They were supposed to call the sleep center and request another titration study. The original study recommended Bi-Pap but the DME stuck me with the cheapest bottom of the barrel Cpap machine. Then they bill over a total of $1500.00 to my Insurance after the collected a $200.00 check for deductable from me. Then they rented the Cpap machine to my Insurance for 15 months @$105.00 a month and they billed me a copay of $10.50 a month. Then being as I got that machine in June and January rolled around another $200.00 deductable to the DME that shall remain nameless.
Sorry for the rant. Bottom line is when people start cpap therapy a lot of them have a fear that they are going to die and what ever the DME tells them is the word of God. The final part is the almighty dollar. They charge what they can get away with and then they say if you don't like it go some where else and most insurance companies are contracted with only one or two DME. They should go to only DME's that specalize in Cpap equipment only.

Jesus, Patrick, that's just horrible. I got so lucky with my DME. I came in all nervous (thinking I was going to die) and ranted off that I absolutely wanted a data-capable machine, yada-yada-yada, and my rep., stopped me and said, "Don't worry. We're going to get you the top-of-the-line machine."

After all the stories I heard about DMEs, I was floored. He's not perfect, but if you're in the L.A. area, I highly recommend Western Drug, if your insurance company uses them.

Glad you have your BiPAP!

I'll bet the machines are a lot more similar than they are different. Functionally, a BiPAP can blow harder, and the "exhale relief" is adjustable to more than just three settings. Probably most of the parts are interchangable. Maybe a beefed up blower and different circuit card...

The biggest difference is the price, as Patrick suggests.

(I suspect we hear the DME horror stories more often than the good experiences.)

tatooyu
The sleep center and DME they use are far better than the first DME I used in 2005. I got a telephone call from the sleep center this morning said I should have my new machine by tomorrow if not by Monday at the latest. As I am writing this the DME called asked if they could deliver the machine this afternoon, I have an appointment this afternoon, so they will deliver the machine tomorrow, they said that they would call before they deliver. Their office is in Mira Mesa, I'm at the border. Their on top of it. I can't believe this and I asked if they were going to deliver as what the doctor wrote on the prescription, they said yes. The Sleep center said they recommended the Respironics Bipap S/T System. I am currently using and M-Series Bipap Auto. So I guess he wrote it for the Respironics Bipap S/T System, I asked them also if they would reprogram my current machine and my back up and they said that they would set all of my machines to the same settings, the doctor changed my settings I guess he raised them up a little I don't know for sure, they didn't tell me the settings, but they said that they were raised a little.
Also they are going to bring me 2 masks to try. A Swift LT and a Respironics Optilife .

Tatooyu,

I tend to agree with you & basically started off my therapy using straight cpap (was part of a study being conducted on new users) - after the 3 month study I switched to apap. Problem was that after 6 months the initial surge of well being began to fade & I began to panic (a bit). I though about the way the machines worked & decided to go for a bilevel & bought a few. The magic one for me was a Knightstar 330 (S/T) as it is the single most tunable bilevel I have ever owned. I was unable to use the early Bipap Pro II & some similar models (they always switched to epap too early for me & I could do nothing about it). The PB330 made a world of difference & eventually allowed me to adjust my pressures to where it seemed to work most effectively. A later sleep study produced the same numbers. The only problem with it was it didn't provide nightly data so then later I went to a VPAP III. Another very tunable bilevel. But wife didn't like the whine in the Vpap III. So tried a Bipap AutoSV. That was magic from day 2 on.

I agree too that if you have bilevel & the risetimes are acceptable, *you don't need any other exhalation relief* - I am convinced it is mere gimmickry & perhaps a placebo for some. But am sure there are *a few* people with respiratory issues who do need any extra exhalation relief they can get but am sure they are in the minority.

But, there are gotchas with bilevels.

To really get started right you need to do a Bilevel setup - not really too hard.

1. Set epap to a level that clears the majority of your OSA events &
2. set ipap *at least 3 CMs' above epap & try that out. If it works well then you have your settings.

Adjusting ipap to a gap of 4 or higher needs to be done cautiously & over time to see if any side effects appear (such as increasing hypopneas or obstructions - which are likely to be centrals)

The other problem from too big a gap is mask management. 15 CMs seems to be a common threshold for when mask leaks can start. So if you ahd epap at 11 CMs & set a gap of 4 your ipap would be 15 CMs which is approaching the threshold. (I am thinking of full face masks here rather than nasla masks or prongs).

I switched to ASV because I was finding that after 9 or so months on bilevel, wife complained that I seemed to be stopping breathing again & as she put it 'resisting the machine'. The ASV is really more like a tri-level machine - explained this way ...

1. You have epap
2. You have ipap

So under normal circumstances the machine runs like a bilevel cycling between epap & ipap

3. If during any *one* breath, the machine decides you are not going to reach a calculated av peak flow (or volume), it will just raise the pressure *in that breath* by up to 3 CMs to try to push you into meeting the target it is tracking. So this is what I call the tri level.

(the following info varies a bit by brand of ASV)
If you still didn't meet the target, the machine will boost ipap yet again by up to 3 more CMs & will have a third go on (your 3rd breath after a missed target) should you again not be meeting the tracked target. So an ASV can add in the vicinity of 10 CMs to the ipap pressure in 3 breaths, in order to command you to breathe more air

Here it is in numbers

>Breath 1 - you meet target flow

>Breath 1+n - you meet target flow then

>Breath 1+n+1 - machine while in the breathe in cycle looks at the flow pattern & says 'user aint gonna make the target' & based on how much it thinks user is off target instantly boosts pressure by up to 3 CMs

>Breath 1+n+2 - machine while in the breathe in cycle looks at the flow pattern & says 'user aint gonna make the target' & based on how much it thinks user is off target instantly boosts pressure by up to A FURTHER 3 CMs (it will do this boost once more before holding ipap to the new boosted pressure even if target may not be met).

>Breath 1+n+3 - lets assume you breath to the target - machine adjusts ipap to what it believes is needed to meet target

>Breath 1+n+4 - machine will keep adjusting ipap up or down depending on if you are below or above target.

In addition to the target flow sampling, the ASV machine also checks your breathing rate & if that fails to meet a rate target (which can be manually set or AUTO set and is called BPM (Breaths Per Minute)) then it can & will switch to ipap + apply SV pressures if needed, to get you back to meeting the target Respiratory rate OR the target volume.

ASV is a very effective machine for those of us who aren't the typical garden variety OSA people but who get into periodic breathing patterns or cyclic patterns other patterns where the av peak flow or the volume wander off target in a short pattern (typically inside a 4 min sampling window).

DSM

LinkC wrote:I'll bet the machines are a lot more similar than they are different. Functionally, a BiPAP can blow harder, and the "exhale relief" is adjustable to more than just three settings. Probably most of the parts are interchangable. Maybe a beefed up blower and different circuit card...

The biggest difference is the price, as Patrick suggests.

(I suspect we hear the DME horror stories more often than the good experiences.)

You may well be right.

Resmed: In taking apart a Vpap III bilevel, I once swapped the blower from an S7 spirit Auto into it & powered it up & it worked as normal.

Respironics: But prior to the M series, the Bipaps were quite different inside to the cpaps & Autos.

I can't say I know if the S8s are the same inside as the s8 shaped Vpaps, I suspect they may be.

DSM

Wow, thanks dsm. You are one brilliant MUTHA (and I mean that in the Motown kind of way)!

For me, I need EPR, but it's to help prevent bad gastric insufflation. What I did was turn on EPR at level one AND increased my pressure by 1 cm, and for the most part, the insufflation went away. I still wake up with the occasional burp or wind, but not discomfort or paint any more.

tattooyu wrote:Wow, thanks dsm. You are one brilliant MUTHA (and I mean that in the Motown kind of way)!

For me, I need EPR, but it's to help prevent bad gastric insufflation. What I did was turn on EPR at level one AND increased my pressure by 1 cm, and for the most part, the insufflation went away. I still wake up with the occasional burp or wind, but not discomfort or paint any more.

Tatooyu

I used to get awful aerophagia. C-Flex was the worst culprit for me but I was a GERD sufferer & that tends to make it easy for high C-0Flex settings to breach the opening to the stomach - the worse the aerophagia the worse the GERD symptoms were.

Later I found a setting of C-Flex '1' was ok. With EPR, that was always like a mini bilevel I always ran it at 3 & yes the aerophagia was there but was tolerable. I did also find that I was getting mild aerophagia from the various bilevels BUT, for me, loosing a lot of excess weight has all but eliminated the aerophagia.

DSM

dsm wrote:I used to get awful aerophagia. C-Flex was the worst culprit for me but I was a GERD sufferer & that tends to make it easy for high C-0Flex settings to breach the opening to the stomach - the worse the aerophagia the worse the GERD symptoms were.

Later I found a setting of C-Flex '1' was ok. With EPR, that was always like a mini bilevel I always ran it at 3 & yes the aerophagia was there but was tolerable. I did also find that I was getting mild aerophagia from the various bilevels BUT, for me, loosing a lot of excess weight has all but eliminated the aerophagia.

DSM

You know, I started out this whole therapy thing at 220 lbs., and now I'm 204 lbs., so maybe that has something to do with it more than the EPR, considering I am a sufferer of reflux as well.

I have an M series BiPap auto that I was put on because I was unable to successfully use CPAP. I could not exhale against the pressure. I was put on 20/16 then 21/17 and it was working but still wasn't right. I eventlually turned the expiratory reliefe on and it worked great.
Now that my pressure is much lower, I could probably go with straight Cpap but I am not having any problems and don't really want to mess with it and cause any at this time.

But BiPap does work for those who need it.

Gerry

ResMed's version of expiration relief is very close to bilevel, but not quite. A bilevel is more comfortable. Bilevel may be prescribed if a person fails with CPAP, since it is thought that it then becomes worth the extra money. That was the approach put in place back when bilevel was significantly more expensive than CPAP to manufacture. I doubt that to be the case today. But in line with Patrick's comments, money is money.

Bilevel may also prescribed when someone needs relatively high pressures, generally more than 15 cm. It is assumed that the bilevel will make the higher pressure more tolerable to the patient. But a bilevel does not necessarily put out more pressure than a CPAP. My autobilevel only goes up to 20 cm.

I agree that it would make more sense to make only bilevels, ones that could also run as CPAPs. That might be cost effective for the consumer, but not profit-effective for the manufacturers, DMEs, insurance, et al. What would motivate the industry to do what everyone knows make sense? I honestly don't know. It is funny how standard bilevel starts at 4 cm pressure support and CPAPs with EPR only go to 3 cm of relief. What a coincidence, eh?! They had to leave a way to appear to differentiate the one type of machine from another. Tricky, tricky, tricky! Money, money, money!!!

I just wish my bilevel was smart enough to raise EPAP, without raising IPAP, to head off an apnea, which is what the CPAPs with EPR basically do when they suspend EPR. The cheaper machine is capable of a pretty nifty trick there that my bilevel is incapable of. Oh well.

jeff

Gerryk wrote:I have an M series BiPap auto that I was put on because I was unable to successfully use CPAP. I could not exhale against the pressure. I was put on 20/16 then 21/17 and it was working but still wasn't right. I eventlually turned the expiratory reliefe on and it worked great.
Now that my pressure is much lower, I could probably go with straight Cpap but I am not having any problems and don't really want to mess with it and cause any at this time.

But BiPap does work for those who need it.

Gerry

Gary

That is very informative feedback as you are endorsing the value of exhale relief even on bilevels. It helps greatly to hear this sort of info as it tells me that in your case it isn't any gimmick and I need to rethink my comments

Tks for that very practical input.

DSM