Impact of EPAP on apnea???

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TedVPAP
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Impact of EPAP on apnea???

Post by TedVPAP » Tue Oct 17, 2017 7:07 pm

It appears that most CPAP machines offer some flavor of pressure decrease during exhalation. The feature can be set at a few levels, including off. What I have read is that the feature is purely for comfort. Is that true? I would think that if EPAP is too low then exhalation could get choked down causing problems. If EPAP has no impact on AHI, then why not set it down to zero? I looked in the wiki but did not see much info on how best to optimize EPAP.

Thanks

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Re: Impact of EPAP on apnea???

Post by Pugsy » Tue Oct 17, 2017 7:17 pm

Where did you get the idea that EPAP has no impact on AHI or apnea events?
Did you type EPAP but mean EPR? Sounds a bit like you are talking about exhale relief and not EPAP which of course are 2 different things.

Pressure reduction from inhale to exhale is a comfort feature but for some people it's a pretty critical comfort feature.
EPAP or the baseline pressure is actually probably the most critical pressure setting because it does the bulk of the work holding the airway open.

Now if someone uses some form of exhale relief and thus EPAP drops a bit and maybe drops below where it can do a good baseline job...and the person likes or needs exhale relief...it's easy to just increase the pressure a little to help compensate for the reduction if needed.
It isn't always needed though. It all depends on how much pressure is needed to do the bulk of the work and does that drop during exhale relief go down below the needed pressure. Some people will have a minimum pressure set so that if exhale relief is used that the drop doesn't really go down below a therapeutic level.

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Re: Impact of EPAP on apnea???

Post by TedVPAP » Tue Oct 17, 2017 7:28 pm

Pugsy wrote:Where did you get the idea that EPAP has no impact on AHI or apnea events?
Did you type EPAP but mean EPR? Sounds a bit like you are talking about exhale relief and not EPAP which of course are 2 different things.

Pressure reduction from inhale to exhale is a comfort feature but for some people it's a pretty critical comfort feature.
EPAP or the baseline pressure is actually probably the most critical pressure setting because it does the bulk of the work holding the airway open.

Now if someone uses some form of exhale relief and thus EPAP drops a bit and maybe drops below where it can do a good baseline job...and the person likes or needs exhale relief...it's easy to just increase the pressure a little to help compensate for the reduction if needed.
It isn't always needed though. It all depends on how much pressure is needed to do the bulk of the work and does that drop during exhale relief go down below the needed pressure. Some people will have a minimum pressure set so that if exhale relief is used that the drop doesn't really go down below a therapeutic level.
I think my confusions is because they are not two different things. With my PR machine, EPAP is set by the IPAP and the FLEX where FLEX is for comfort only.

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Re: Impact of EPAP on apnea???

Post by palerider » Tue Oct 17, 2017 7:31 pm

TedVPAP wrote:
Pugsy wrote:Where did you get the idea that EPAP has no impact on AHI or apnea events?
I think my confusions is because they are not two different things. With my PR machine, EPAP is set by the IPAP and the FLEX where FLEX is for comfort only.
EPAP and EPR are not the same thing, they're completely different... however, depending on the machine, they can be interrelated.

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Re: Impact of EPAP on apnea???

Post by Pugsy » Tue Oct 17, 2017 7:42 pm

When someone uses exhale relief...be it Flex or EPR the machine essentially becomes a bilevel machine and offers 2 sort of distinct pressures...One for inhale and one for exhale depending on the exhale relief.
With the Respironics machines and Flex relief the change between inhale and exhale isn't very distinct meaning you may not even notice a difference but you will see it on the software reports because they are still doing it even if you don't feel it.
ResMed machines with EPR and they way they do the reduction it's much easier to feel the difference.

Your EPAP after whatever exhale relief you are getting is the most critical pressure setting. It's the one that does the bulk of the job holding the airway open.

I don't pooh pooh off the need for comfort to sleep well. We gotta be comfortable to get to sleep and stay asleep.
Not much of this setting stuff matters if we can't fall asleep and/or can't stay asleep. Comfort is pretty critical in my book.

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Re: Impact of EPAP on apnea???

Post by TedVPAP » Tue Oct 17, 2017 8:10 pm

Pugsy wrote:When someone uses exhale relief...be it Flex or EPR the machine essentially becomes a bilevel machine and offers 2 sort of distinct pressures...One for inhale and one for exhale depending on the exhale relief.
With the Respironics machines and Flex relief the change between inhale and exhale isn't very distinct meaning you may not even notice a difference but you will see it on the software reports because they are still doing it even if you don't feel it.
ResMed machines with EPR and they way they do the reduction it's much easier to feel the difference.

Your EPAP after whatever exhale relief you are getting is the most critical pressure setting. It's the one that does the bulk of the job holding the airway open.

I don't pooh pooh off the need for comfort to sleep well. We gotta be comfortable to get to sleep and stay asleep.
Not much of this setting stuff matters if we can't fall asleep and/or can't stay asleep. Comfort is pretty critical in my book.
I do not disagree.
My question is about the advice given to issacsmith. viewtopic/t156972/Low-AHI-but-still-fatigued.html

The advice was to raise his lower pressure (Auto Min). My understanding is that this sets the floor on IPAP. A suggestion that was not given would be to decrease the A-Flex which would increase the EPAP. It looks like his A-Flex is set to 3 and I am wondering if that is just too low of an EPAP for him.

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Re: Impact of EPAP on apnea???

Post by Pugsy » Tue Oct 17, 2017 8:23 pm

TedVPAP wrote:The advice was to raise his lower pressure (Auto Min). My understanding is that this sets the floor on IPAP. A suggestion that was not given would be to decrease the A-Flex which would increase the EPAP. It looks like his A-Flex is set to 3 and I am wondering if that is just too low of an EPAP for him.
We could have reduced AFlex and it would effectively increase EPAP a little but on Respironics machines the amount of reduction during Flex relief is flow based and not a per cm reduction. With a setting of 3 Flex relief the most reduction someone can get is 2 cm and if they are a rather forceful breather. Respironics exhale relief is based on flow rate or how forcefully they breath.

I prefer to increase the minimum pressure when there is room to do so for a couple of reasons.
The person might simply like the exhale relief and it's important to their comfort so why remove it?
Plus the amount of increase is clear and not iffy because we don't always know exactly how much of a reduction is going on when Flex is used unlike with a ResMed machine.

He was using 7 cm minimum pressure...I just prefer going at the increase from that aspect instead of removing exhale relief.
I never know how much a person likes or doesn't like their exhale relief and it might be really important to them.

The end result is the same...turn Flex off and probably increase EPAP by at most 2 cm...or simply raise the minimum.
2 ways to get the same end result.

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Re: Impact of EPAP on apnea???

Post by palerider » Tue Oct 17, 2017 8:43 pm

TedVPAP wrote:The advice was to raise his lower pressure (Auto Min). My understanding is that this sets the floor on IPAP. A suggestion that was not given would be to decrease the A-Flex which would increase the EPAP. It looks like his A-Flex is set to 3 and I am wondering if that is just too low of an EPAP for him.
Since they move in lockstep on an apap, it doesn't really matter, not like on a bilevel where they're separately configurable entities.

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Re: Impact of EPAP on apnea???

Post by TedVPAP » Tue Oct 17, 2017 8:44 pm

Pugsy wrote:
TedVPAP wrote:The advice was to raise his lower pressure (Auto Min). My understanding is that this sets the floor on IPAP. A suggestion that was not given would be to decrease the A-Flex which would increase the EPAP. It looks like his A-Flex is set to 3 and I am wondering if that is just too low of an EPAP for him.
We could have reduced AFlex and it would effectively increase EPAP a little but on Respironics machines the amount of reduction during Flex relief is flow based and not a per cm reduction. With a setting of 3 Flex relief the most reduction someone can get is 2 cm and if they are a rather forceful breather. Respironics exhale relief is based on flow rate or how forcefully they breath.

I prefer to increase the minimum pressure when there is room to do so for a couple of reasons.
The person might simply like the exhale relief and it's important to their comfort so why remove it?
Plus the amount of increase is clear and not iffy because we don't always know exactly how much of a reduction is going on when Flex is used unlike with a ResMed machine.

He was using 7 cm minimum pressure...I just prefer going at the increase from that aspect instead of removing exhale relief.
I never know how much a person likes or doesn't like their exhale relief and it might be really important to them.

The end result is the same...turn Flex off and probably increase EPAP by at most 2 cm...or simply raise the minimum.
2 ways to get the same end result.
Thanks for explaining your thought process. It makes sense.

There is a lot of terminology that clouds my understanding. Resmed and PR have differences in terminology and approaches. Even my PR manual has differences in terminology depending on the mode of machine use.

I keep thinking there should be a single diagram showing all the differences in machines and terminology. Since every machine delivers EPAP and IPAP, the only difference in delivery is in how the values are established and how they may vary.

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Re: Impact of EPAP on apnea???

Post by TedVPAP » Tue Oct 17, 2017 8:52 pm

palerider wrote:
TedVPAP wrote:The advice was to raise his lower pressure (Auto Min). My understanding is that this sets the floor on IPAP. A suggestion that was not given would be to decrease the A-Flex which would increase the EPAP. It looks like his A-Flex is set to 3 and I am wondering if that is just too low of an EPAP for him.
Since they move in lockstep on an apap, it doesn't really matter, not like on a bilevel where they're separately configurable entities.
Yes. I guess my question really is how best to determine which pressure (IPAP or EPAP) should be increased.

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Re: Impact of EPAP on apnea???

Post by palerider » Tue Oct 17, 2017 9:00 pm

TedVPAP wrote:
palerider wrote:
TedVPAP wrote:The advice was to raise his lower pressure (Auto Min). My understanding is that this sets the floor on IPAP. A suggestion that was not given would be to decrease the A-Flex which would increase the EPAP. It looks like his A-Flex is set to 3 and I am wondering if that is just too low of an EPAP for him.
Since they move in lockstep on an apap, it doesn't really matter, not like on a bilevel where they're separately configurable entities.
Yes. I guess my question really is how best to determine which pressure (IPAP or EPAP) should be increased.
With an apap, it doesn't really matter, since you don't really have independent control.

With a bilevel, the general rule is that EPAP is for apneas, and ipap is for hypopnea/flowlimitaitons... broadly speaking, unless you're moving into ventilation, in which case you raise EPAP to increase oxygenation, and raise IPAP to reduce hypercapnia.

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Re: Impact of EPAP on apnea???

Post by Pugsy » Tue Oct 17, 2017 9:06 pm

TedVPAP wrote:I keep thinking there should be a single diagram showing all the differences in machines and terminology.
Other than the one in my head I have never seen one.
I do have rather extensive experience with both Respironics and ResMed brands so that helped me a lot in understanding the little differences.
No experience with the other brands but the basics are all the same and there's just some minor variations anyway.

You've heard the expression "many ways to skin a cat"...same thing applies to making modifications to cpap pressures and therapy.
There's more than one way to do a lot of things cpap/apap or even bipap and end up with the same goal being met.

Yes. I guess my question really is how best to determine which pressure (IPAP or EPAP) should be increased.
With cpap or apap...it's the minimum pressure that is the most critical pressure setting no matter if exhale relief is used or not.
You don't get epap and ipap on cpap/apap without using some form of exhale relief.
If no exhale relief is used on cpap/apap....there is one single pressure either fixed or auto adjusting. You won't have epap and ipap with single pressures and no exhale relief.

Actually same thing with bilevel in most situations unless someone is having an inordinate number of hyponeas and even then we often increase both EPAP to get a higher IPAP which is usually what is suggested for hyponeas.

So if a person is using exhale relief (and they don't want to give it up) the only choice is to be thinking increase EPAP if they want to increase the pressure.

Most of the time it doesn't matter which way you get the job done...just as long as the job gets done.

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Re: Impact of EPAP on apnea???

Post by TedVPAP » Tue Oct 17, 2017 9:26 pm

Pugsy wrote:
TedVPAP wrote:I keep thinking there should be a single diagram showing all the differences in machines and terminology.
Other than the one in my head I have never seen one.
I do have rather extensive experience with both Respironics and ResMed brands so that helped me a lot in understanding the little differences.
No experience with the other brands but the basics are all the same and there's just some minor variations anyway.

You've heard the expression "many ways to skin a cat"...same thing applies to making modifications to cpap pressures and therapy.
There's more than one way to do a lot of things cpap/apap or even bipap and end up with the same goal being met.

Yes. I guess my question really is how best to determine which pressure (IPAP or EPAP) should be increased.
With cpap or apap...it's the minimum pressure that is the most critical pressure setting no matter if exhale relief is used or not.
You don't get epap and ipap on cpap/apap without using some form of exhale relief.
If no exhale relief is used on cpap/apap....there is one single pressure either fixed or auto adjusting. You won't have epap and ipap with single pressures and no exhale relief.

Actually same thing with bilevel in most situations unless someone is having an inordinate number of hyponeas and even then we often increase both EPAP to get a higher IPAP which is usually what is suggested for hyponeas.

So if a person is using exhale relief (and they don't want to give it up) the only choice is to be thinking increase EPAP if they want to increase the pressure.

Most of the time it doesn't matter which way you get the job done...just as long as the job gets done.
When I think of minimum pressure, I think of the lowest IPAP since that is how my machine operates in auto mode. When you refer to it, you mean the lowest EPAP pressure.

I think I need to study titration protocals in order to develop a better understanding of cat skinning.

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Re: Impact of EPAP on apnea???

Post by Pugsy » Tue Oct 17, 2017 10:28 pm

If you want to study some protocols

https://www.resmed.com/us/dam/documents ... lo_eng.pdf

All I have for Respironics is the ASV protocol but it does touch on obstructives and again the basics are the same.
http://www.isetonline.org/yahoo_site_ad ... 190318.pdf
If anyone has a simpler Respironics titration guide I would love to have the link.

The minimum pressure has to be high enough to prevent the airway from collapsing in the first place.
When using auto adjusting pressures it has to be high enough that if it needs to go higher it can get there quickly enough to get the job done.
If using fixed pressures it simply has to be high enough period. People who might need higher pressures for part of the night get to use higher pressures all the night just to cover the "maybe".

I have used both epap and ipap in an effort to keep that airway open. You learn with time and experience that sometimes using both in various ways can accomplish a goal easier.
Again it doesn't really matter how we get the job done...it's just that we get the job done and there is more than one way to accomplish our goals.
How we go about it can be influenced by a person's specific needs or problems even.
Like with aerophagia...maybe we don't want ipap going very high.
Or maybe the mask leaks too much and sleep gets disrupted.
Or maybe the pressure that would do the job simply is low and not comfortable for someone. Maybe someone feels like they are suffocating at 7 cm and prefers 9 or 10. It hurts nothing to use more pressure than would technically get the job done as long as using it doesn't create a problem.

Often there doesn't have to be one set pressure set in stone to get the job done.
You can use one or both if someone is using exhale relief and thus has a little bit of bilevel situation going on.
With most of this stuff there isn't anything set in stone where someone has to just exactly so and so pressure. No hard fast rules and a lot of it is common sense anyway.

And then there are those pesky cpap pressure triggered centrals that can mess up things.
I know one person who gets 15 to 20 centrals with PS of 4 but none beyond a normal occasional sleep onset at PS 3.
She needs a high EPAP because of the obstructive stuff but we had to have some exhale relief because using 17 cm fixed...sucks.
By having IPAP available it helps with holding the airway open...so she could get the obstructive stuff well controlled with EPAP of 15 instead of 17 and IPAP of 18...She had a ResMed bilevel auto...so we used PS of 3 instead of EPR of 3 in auto mode but end result is pretty much the same. So if using fixed pressures she would need 17 but that's hard to exhale against...so we made use of PS and by having IPAP go a little higher than 17...it helps offset the lower than 17 on exhale. End result is the OAs get taken care of and she can breathe and sleep better.

We liked to never figure out that the centrals were related to PS and not the pressure itself.

So both EPAP and IPAP are important and can play significant roles in success or not but you have to start with the baseline pressure which is the minimum ...be it EPAP or whatever if exhale relief isn't used.
IPAP is just a little bit extra help if needed.

Also..you don't want too big of a difference between EPAP and IPAP....it can cause centrals. I had a friend decide to use PS of 10 on her bipap. Talk about central city....those little suckers were all over the place. To me that much difference isn't comfortable anyway.
But some people need a bigger PS for ventilation issues.

In other words when looking at what pressure to use it isn't always where we can say x amount of pressure needs to be used. Period.
Most often we can tweak one or more various settings and get the job done.
We have to look at the big picture and decide what the goals are...what potential problems we might have...and what are acceptable modifications that could get the same job done.

All this gets compounded by the fact that we don't sleep the same each night anyway and at best when we come up with these ideas were are planning for the trends and patterns we see and hope that not too many outlier weirdo nights happen.
I still get a weirdo fluke night every now and then with my current setup. Perfection for all nights is an unreasonable expectation.
Sometimes we do make compromises.
Nothing is set in stone.

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Re: Impact of EPAP on apnea???

Post by TedVPAP » Wed Oct 18, 2017 1:34 pm

palerider wrote:
TedVPAP wrote:
palerider wrote:
TedVPAP wrote:The advice was to raise his lower pressure (Auto Min). My understanding is that this sets the floor on IPAP. A suggestion that was not given would be to decrease the A-Flex which would increase the EPAP. It looks like his A-Flex is set to 3 and I am wondering if that is just too low of an EPAP for him.
Since they move in lockstep on an apap, it doesn't really matter, not like on a bilevel where they're separately configurable entities.
Yes. I guess my question really is how best to determine which pressure (IPAP or EPAP) should be increased.
With an apap, it doesn't really matter, since you don't really have independent control.

With a bilevel, the general rule is that EPAP is for apneas, and ipap is for hypopnea/flowlimitaitons... broadly speaking, unless you're moving into ventilation, in which case you raise EPAP to increase oxygenation, and raise IPAP to reduce hypercapnia.
I finally get it. That makes sense. I never thought about the physical distinction between apnea and hypopnea/flowlimitations. Although the definitions vary only in severity, they are in fact trying to identify the difference between full collapse, and partial since the remedy can be different.
Full collapse must happen towards the end of exhalation since dynamic pressure is now zero (no flow) and static pressure is at its lowest (since EPAP<=IPAP). Thanks

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