Pressure Support Question

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Dallaslady51
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Pressure Support Question

Post by Dallaslady51 » Thu Mar 15, 2018 2:27 pm

In all places where I have seen the Definition of Pressure Support on a Bilevel, it says it is the difference between IPAP and EPAP. But it really isn't. My IPAP is 20 and EPAP is 11, and Pressure Support is 2. PS can be set within its own range. To me it seems pretty much like the EPR on an Auto Cpap and can be adjusted to the comfort of the user. Even when people (and sleep doctors and techs) are discussing the Pressure Support, they mostly call it the IPAP/EPAP difference.

Is it really more like the EPR and is just a comfort setting? They tried to start me with an IPAP of 20, an EPAP of 12, and a PS of 8, but I could not even breathe that way for more than 30 seconds..The more I lowered the PS, the better my numbers were.

I guess my main question is - am I doing this wrong and messing up my therapy? Do I have to find a closer IPAP/EPAP range where the PS can be Exactly the difference between IPAP and EPAP?

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palerider
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Re: Pressure Support Question

Post by palerider » Thu Mar 15, 2018 3:11 pm

Dallaslady51 wrote:
Thu Mar 15, 2018 2:27 pm
In all places where I have seen the Definition of Pressure Support on a Bilevel, it says it is the difference between IPAP and EPAP. But it really isn't.
You'd be wrong about that. it *IS* the difference between epap and ipap, plain and simple.
Dallaslady51 wrote:
Thu Mar 15, 2018 2:27 pm
My IPAP is 20 and EPAP is 11, and Pressure Support is 2. PS can be set within its own range. To me it seems pretty much like the EPR on an Auto Cpap and can be adjusted to the comfort of the user. Even when people (and sleep doctors and techs) are discussing the Pressure Support, they mostly call it the IPAP/EPAP difference.
That's because Pressure Support *IS* the difference in epap and ipap. Your IPAP isn't 20 and EPAP isn't 11, your *MINIMUMepap is 11, and MAXIMUMipap is 20, with a PS of 2 between them, they auto adjust between those limits. Now, if you put your machine in S mode, then you have 'ipap' and 'epap' settings, and no 'ps' setting, since it's redundant if you're setting the two directly.
Dallaslady51 wrote:
Thu Mar 15, 2018 2:27 pm
Is it really more like the EPR and is just a comfort setting? They tried to start me with an IPAP of 20, an EPAP of 12, and a PS of 8, but I could not even breathe that way for more than 30 seconds..The more I lowered the PS, the better my numbers were.
EPR is a *limited* PS. (0-3cm/h2o) A PS of 8 is pretty tough for many people, easy to hyperventilate with that.
Dallaslady51 wrote:
Thu Mar 15, 2018 2:27 pm
I guess my main question is - am I doing this wrong and messing up my therapy? Do I have to find a closer IPAP/EPAP range where the PS can be Exactly the difference between IPAP and EPAP?
Again, PS *IS* the difference in EPAP and IPAP... period... it's like "a foot is 12 inches" two ways to refer to the same thing.

Unless you have respiratory issues, set the PS to whatever is comfortable for you...

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jnk...
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Re: Pressure Support Question

Post by jnk... » Thu Mar 15, 2018 3:48 pm

I am not disagreeing with PR. For one thing, he knows more about it than I do. For another, I know better than to mess with him. He is red and has a pitchfork. :shock: :)

But to state it another way, just in case it helps, I will post. I welcome PR's correction if I stray with my statements.

Bilevel is one thing. Autobilevel is another. Don't confuse the definitions for what bilevel is with the instructions for how to set up an autobilevel to provide bilevel within a certain range of pressures.

It is useful to ask questions, just as you are, to wrap your mind around it as best you can, if you are gonna fiddle with it.

Sometimes bilevel is prescribed to correct specific hypoventilation conditions that can be closely related to or combined with OSA. Other times it is prescribed mostly as a comfort feature that will allow the difference in breathe-in pressure and breathe-out pressure to be higher than 3 cmH2O to make pressure more tolerable at higher pressures. As a general rule, although EPR in a ResMed CPAP/APAP can be considered very very close to being like bilevel, a bilevel prescription is generally for 4cm or more. In fact, many consider that 4cm-or-more differential (or, delta) to be necessary for the therapy to be considered bilevel therapy, despite the fact that the bilevel and autobilevel treatment machines can be set with less of a difference than that.

More to the point of your question, though--anything you do to lower AHI shouldn't be a problem if it actually lowers AHI long-term. Just bear in mind that bodies adjust to the PS over long periods of time, so a move may worsen AHI in the short term but improve AHI in the long run. Or it can do the exact opposite--help AHI short-term and worsen it long-term. You have to give PS changes time in order to see, if you are sensitive to that. Everyone is different.

I used autobilevel for a while. My body rebelled against PAP during the titration, but settled right down once bilevel modality was tried. But now I do fine with a ResMed APAP with EPR at 3. I like that EPR gets gets suspended during events, which wasn't part of my autobilevel machine's functionality, so I went with APAP.

I haven't kept up with how modern autobilevels get set up. Back in my day, one brand locked in the exact PS so that PS never changed as the IPAP and EPAP danced together the same distance apart all night, and the other brand had a variable PS so that IPAP and EPAP could mover closer together and further apart as they danced. I'm not sure what differences there are now between brands. Personally, my feelings are that if you benefit from bilevel, it is better for PS to be locked in at one delta--otherwise technically you aren't always getting a true bilevel level of difference, according to treatment definitions. Otherwise, much as you say, using less than 4cm is bascially much the same as EPR on a CPAP/APAP. Now I think either brand is capable of specific-constant-PS autobilevel. But I'm not sure anymore. Maybe PR knows.

Anyway, hope that helps more than hinders. I wish you well with getting it all figured out.
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palerider
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Re: Pressure Support Question

Post by palerider » Thu Mar 15, 2018 5:08 pm

I don't see anything in what you said that isn't accurate.

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jnk...
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Re: Pressure Support Question

Post by jnk... » Thu Mar 15, 2018 5:29 pm

palerider wrote:
Thu Mar 15, 2018 5:08 pm
I don't see anything in what you said that isn't accurate.
Thanks, PR.
-Jeff (AS10/P30i)

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Okie bipap
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Re: Pressure Support Question

Post by Okie bipap » Thu Mar 15, 2018 8:41 pm

With an Air Curve 10 VAUTO, you set a value for the max IPAP and the minimum EPAP. Your EPAP of 11 is your minimum EPAP value. Your minimum IPAP value is the minimum EPAP (11) plus your pressure support (usually around 5). Your Maximum EPAP is your maximum IPAP (20) minus your pressure support.

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Re: Pressure Support Question

Post by ajack » Fri Mar 16, 2018 6:43 am

who titrated, set the machine up for you and gave you PS2? Generally you might as well be on apap with epr2, it would be very similar.
I'd get some sleepyhead charts up for a start

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Re: Pressure Support Question

Post by Matt00926 » Fri Mar 16, 2018 6:50 pm

If you just have your garden variety obstructive sleep apnea, if reducing the pressure support improves your AHI, then go for it. Without seeing your charts, sounds like you were being over ventilated before if the moron who set up your machine had you in spontaneous mode on 20/12.
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Dallaslady51
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Re: Pressure Support Question

Post by Dallaslady51 » Sun Mar 18, 2018 10:33 am

I've used an Auto Cpap for several years. Sleep Study in October 2017 - they said they couldn't get it "perfect" with just the Auto, so I did a Titration with the BiLevel and they were able to get the Events to zero between about 13-16. The doctor decided that since I was not on my back during the study that I should have a BiLevel that could go as high as 25 for when I "turned on my back".......Have Never needed that kind of pressure.

Have been questioning my "need" for a bilevel ever since, and they just say a Bilevel "should be" more comfortable than an Auto....The Actual Initial Prescription was 9-EPAP/25-IPAP/8-PS (incredible)....I changed the IPAP to 20 and the machine has Never gone higher than about 17, and only briefly. I reduced the PS until I could actually breathe and it brought the average events down.

I have attached last night's graph. This was actually one of my better nights. I struggle to go to sleep until 2-3. Then somewhere between 3-8, I feel like I am actually sleeping pretty deep and dreaming. I still have Never had even 1 night where I felt rested and "OK" the next day. Always tired and groggy and muscles sore, etc.

The Sleep Doctors drive me CRAZY because they look at the "average AHI" and just say "that's wonderful" - well it isn't for me. I show them the Sleepyhead Graphs, and that because I don't actually sleep for 2-4 hours a night (and events are almost zero) that they are not seeing the AHIs go to 5-15 during the main part of my sleeping.....

Is there anything else I can try in terms of settings to reduce the higher AHIs during the time when I am sleeping deeply? I think my pressure range is pretty much ok (on the Auto is was about 10-18 with EPR of 1, if I remember). Still don't know if the PS is OK, or especially if the other weird settings - Trigger, Cycle, TI Max, and Ti Min are ok - basically set at or close to factory settings.

I just know my "pretty averages" are Not the whole story for me - during my sleep time, it's more like 5-9, and spiking some nights up to 16. My years on the Auto weren't perfect (AHIs of 6-8 usually), but mostly I felt rested the next day.

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Re: Pressure Support Question

Post by Jas_williams » Sun Mar 18, 2018 10:49 am

Most of your events are hypopnea and CA’s this looks like complex sleep apnea the only way to treat hypopnea is to increase pressure support. The only way to treat CA’s is to reduce pressure support....


Do you see a conflict here. AHI of less than 5 over the whole night is considered treated. What was the AHI with your doctors settings ?


They may have been setting you up to fail BiPap so you could actually get a machine through insurance that could treat your complex apnea an ASV these are expensive and insurance will only pay when both Autoset and BiLevel have been tried and fail to treat your complex apnea.

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Dallaslady51
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Re: Pressure Support Question

Post by Dallaslady51 » Sun Mar 18, 2018 11:19 am

I could not sleep at all with a PS of 8 per the prescription - I started at 5, the AHIs at PS of 3-5 were higher - averages of 8-10. As I reduced the PS to about 2, the AHIs decreased and it felt more comfortable to breathe.

I do see a conflict with all this, and have been struggling to "work around it". I don't think they were setting me up to fail - these people didn't what they were doing - the technician at the Study tried to put all the masks on upside down.....I was glad I had used CPAPs for years.....The doctor that "read" the report and "prescribed the settings" was some random doctor in another town. My Sleep Doctor just went by what he said. The sleep study was done by a 3rd Party company. My Sleep Doctor knows nothing - just looks at a "pretty" general number generated by ResMed, and says "how wonderful it all is". She would think differently if she felt the way I do all night and day trying to get some decent restful sleep.

When I asked my Sleep Doctor if the other settings on the machine needed adjustment - the Trigger, etc., she looked surprised and said "What other settings? - there's just the IPAP/EPAP/PS....When I showed her the Sleepyhead report, she dismissed it as irrelevant and "I shouldn't be using other software, etc. because that was Their job to look at data and adjust the machine" - bet no one has ever encountered that before.....and yes, over the years I have seen about 4 other sleep doctors, and none of them seem to know what they are doing...they don't realize there is more to this than just the "pretty" summary numbers from ResMed, etc.

She at one point suggested that if I wanted to, to just set the Aircurve VAuto to operate like an Auto Cpap by setting the PS to zero and see what happens. I just don't see how that is possible with the Trigger, Cycle, etc operating in the background, and you can only adjust them - you can't turn them off, at least in VAuto mode. Oh well, I don't know what to do - it's all very frustrating lately since getting the bilevel machine. I do remember never having many centrals with an Auto Cpap - ResMed S9 Autoset - mostly only OAs.

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palerider
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Re: Pressure Support Question

Post by palerider » Sun Mar 18, 2018 4:48 pm

Jas_williams wrote:
Sun Mar 18, 2018 10:49 am
Most of your events are hypopnea and CA’s this looks like complex sleep apnea the only way to treat hypopnea is to increase pressure support. The only way to treat CA’s is to reduce pressure support....
The only way to treat hypopneas is to increase *PRESSURE*, not necessarily pressure support.

Reducing pressure SUPPORT is often helpful at reducing CAs, that is very true.

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Re: Pressure Support Question

Post by palerider » Sun Mar 18, 2018 4:49 pm

Dallaslady51 wrote:
Sun Mar 18, 2018 10:33 am
Have been questioning my "need" for a bilevel ever since, and they just say a Bilevel "should be" more comfortable than an Auto....
You have an AUTO BILEVEL. Both, best of both worlds.

I do to, it gives me more options, more ability, more customizations to make it 'just right' for me. (I've got the s9 version of what you have).

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Re: Pressure Support Question

Post by ajack » 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.

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Re: Pressure Support Question

Post by palerider » 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.

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