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General Discussion on any topic relating to CPAP and/or Sleep Apnea.
glassjules
 

Exhale Puff index? What does it mean?

Postby glassjules on Thu Aug 27, 2009 9:34 am

I've been on CPAP For five years, but just got a new machine (intellipap) and of course it comes with the nifty smartcodes stuff.

Anyway, I have questions on a couple. One is the exhale puff index -- mine has average 12/hour -- is that bad or good? I don't know how to interpret that data. IT seems high?

The second is the percentile pressure -- mine stays at 14 -- they said they set my machine at 14, which is actually my original prescription, a couple of years ago it was adjusted to 16, but they don't seem to have that on file so they kept it at 14. Its an autoadjust machine, so I asked them if they set a range, and they said again they "set it at 14". However, the AHI is 1.5, so I guess 14 is doing okay? But should that percentile pressure be varying instead of just staying flat?

These are pretty specific questions, but just curious.

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Re: Exhale Puff index? What does it mean?

Postby Guest on Thu Aug 27, 2009 9:51 am

I should add, I know the technical definition of EPI from the devilbiss site, what I want to know is what does it mean to my therapy, and should I be doing something about it :) :) Thanks in advance!

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Re: Exhale Puff index? What does it mean?

Postby El Pap on Thu Aug 27, 2009 11:53 am

Exhale puff is when you breath in from your nose, and breath out from your mouth. My EPI number is consistently between 0 and 0.2. I'm guessing those are probably times that I cough with the mask on. 12/hr seems very high. You may want to ask your sleep partner or use a camcorder to see what you're doing.

AHI of 1.5 is pretty decent. If you want to experiment with APAP, I'd probably set it for 13-20.

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Re: Exhale Puff index? What does it mean?

Postby TenmaNeko on Thu Aug 27, 2009 1:05 pm

Hmm, well, this is weird. My EPI has been as high as 33, usually in the upper 20's. However, my AHI has never gotten above 4. In fact, my average over the past 30 days is 20 for my EPI and 1.5 for my AHI.

I was slightly concerned about my high EPI's, but then it doesn't seem to be negatively affecting my therapy at all.

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Re: Exhale Puff index? What does it mean?

Postby JimIllinois on Thu Aug 27, 2009 2:16 pm

My philosophy is that people change, and whatever you think your appropriate pressure is today might not be the same in the winter, on rainy days, or after that second glass of beer or wine.

I think it's good to have at least a small range, so that the machine can help you get the best results if and when things are different. Your graphs (if you have the data software) will show you what's happened, and if your average result starts to move, you can decide whether to change anything. If you set a single pressure, it's much harder to control the results when your needs change.

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Re: Exhale Puff index? What does it mean?

Postby timbalionguy on Thu Aug 27, 2009 4:14 pm

I am not sure how DeVilbiss 'measures' EPI, but I think it may be a bogus number for many users.

I use a full face mask, and have used two different masks in the four months or so I have been on pressure therapy. With both masks, I have had a measureable EPI, even though mouth breathing with a FFM is technically not possible. This EPI number varies all over the place, from a low of about 1.8 through a high of about 33, with something around 4 being typical. All my other numbers vary significantly as well. With leaks fairly well controlled, I ma getting AHI's of around 8 to 9, with occasional spikes as high as 16 or 18. Pressure is currently 11 to 16, and average pressures vary widely each night. My doctor said I was 'hard to titrate' and so far she has been right!

So, I suspect that if you are seeing significant EPI numbers, and your mouth breathing is well-controlled (or you use a FFM), you are seeing something that is an artifact of the machine. Much as I am satisfied with the IntelliPAP, it does sem a little weak on data reporting. I hope that improves as DeVilbiss gets more 'in the field' experience with that machine.

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Re: Exhale Puff index? What does it mean?

Postby mray300 on Thu Aug 27, 2009 7:13 pm

I've had my Intellipap for a month or two. My EPI is usually 1 or under but my AHI goes up and down from 4 to 16 with my Swift Lt. I wish I could get my AHI down consistently. I've tried many different settings and I can't figure out what changes from day to day. Maybe some day I'll have a low AHI.

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glassjules
 

Re: Exhale Puff index? What does it mean?

Postby glassjules on Fri Aug 28, 2009 8:46 am

Thank you all for your responses. I do know that I am breathing through my mouth, and I have been worrying about whether I am losing the effects of my therapy as a result. The AHI seems to still be quite good, so I guess not, but I am curious. I can't tolerate Full Face Masks, and the chin strap hasn't seemed to help at all. So I am not exactly sure what, if anything, I should do about it.

How can I tell if my intellipap auto adujust is actually set for a range of pressure or a single pressure? I thought the whole point of them prescribing an auto adjust machine would be for the benefits of it adjusting to what you need?
Thanks in advance for all the answers and help!

geogao
 

Re: Exhale Puff index? What does it mean?

Postby geogao on Tue Oct 06, 2009 7:43 pm

The machine does allow you to set a range, under the APAP mode. For example, mine is set at 5 to 15. In the report, you will see the 95th and 90th percentile pressure indicators. If the higher boundary of the range is set at 15, and your 90th Percentile Pressure figure is constantly reported at 15, that means there are times (at least 10% of the time) that the machine needs to go higher in pressure but is not allowed because the range is maxed out. If that's the case, you need to increase the ceiling figure. Mine is set at 15 and my 90th Percentile Pressure is usually 10. So I know if the machine needs to go higher pressure to handle my AHI events, it still has enough head room.

As to the Exhale Puff, I am constantly getting around 30. I do believe DeVilbiss owes to us a clear explanation.

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Re: Exhale Puff index? What does it mean?

Postby DeVilbiss Marketing on Sat Oct 10, 2009 9:15 am

I would suspect the high exhale puff index is due to mouth-breathing, which can be addressed by using a full face mask.

Glasjules - have you ever tried a dual airway interface such as the Hybrid? Interfaces like this are often a suitable solution for those who cannot tolerate a full face mask.

Please let me know if I can assist you further.

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Re: Exhale Puff index? What does it mean?

Postby Scarlet834 on Sat Oct 10, 2009 9:52 am

I'm going to throw something out there because my RT told me it was OK to exhale through the mouth because the therapy had already taken place (inhale). For me he was definitely wrong, I must do more than a little exhaling, and I tape my mouth in the center to ensure therapy. But if the AHI is low and the person is feeling good perhaps there's nothing to change? If the person is tired I'd try some of the things mentioned.

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Re: Exhale Puff index? What does it mean?

Postby timbalionguy on Sat Oct 10, 2009 10:50 am

Ths may seem like it is a bit OT, but I will come around to the point I am trying to make. Also, if you see some odd typos, it was because two of my cats were demanding 'pressure therapy' (in the form on a hand applied firmly to the back, and moved backwards) while I was typing, and tried to walk on the keyboard ;-)

As I get more experience with the IntelliPAP machine, I have personally observed that this machine can be 'squirrely', as was reported occasionally in the product challenge reviews on the machine. This condition is typified by the machine going to max or near max pressure and more or less staying there. I have since (at least for me) discovered why this is happening. If you are significantly below your 'titrated pressure', it can cause this machine to experience this 'runaway pressure syndrome'.

I have recently gotten my sleep study results, and was surprised by what I wasn't told. They could not successfully titrate me, and were recommending BiPAP or even Adaptive servo veltilator BiPAP titration if the high rate of pressure induced centrals could not be controlled.

I think my sleep doctor, in the interest of avoiding one or two additional expensive sleep studys and the possibility of having to have me use a machine that is priced in the mid thousands, decided to try an autoadjust CPAP set to just below the pressures where centrals were dominating the treatment picture. This was 10-13 cm/H2O.

I have always used a full-face mask of some sort. I currently use the Hybrid, which has worked very well for me.

After taking some time to get used to the IntelliPAP (my choice-- bought online), I found that the machine was 'maxing out' at the top end. I slowly increased the top end until I had a range of 10-16. I frequently maxed out this range as well. But after about two months of experimenting with variables such as hose length (and a lot of disruptive travel), I finally started walking up the minimum pressure. Each time I did this, I would have one terrible night with very high (12-16) AHI's. I would often see runaway pressure, and lots of NRI's. (NRI is what DeVilbiss considers to be a 'central'-- more later.) However, the NRIs were nowhere near the level of what was seen on my sleep study.

When I finally reached 12 cm/H2O, suddenly there was a change in the way the machine operated. The 'runaway pressure syndrome' seemed to be a lot less frequent, and seldom lasted most of the night. There was a significant reduction in my AHI (average 8 to average 6-- my AHI varies all over so it takes at least a couple of weeks to see a statistical change). The NRI rate has decreased, but EPI has become more variable, sometimes wildly variable.

My sleep doctor suggested (and I agreed that this seemed to me to be where I was 'headed') that I work up to a pressure range of 14-18. I first increased the high end from 16 to 17 and left it there for 3 nights. No real change, and the mask seemed to be able to deal with the pressure. So last night, I increased the low end to 13 cm/H2O. Much to my surprise, I had a AHI of 3.3, and an average pressure of just 13.5. No NRI's, and an EPI of 1.8. I also observed that the higher pressure was very comfortable in the sense it wasn't varying a lot.

So based on the above, I have reached a number of conclusions. The first conclusion is that the IntelliPAP is a great machine, provided that your minimum pressure is set high enough. Below that pressure, there is a tendency of this machine to experience 'runaway pressure'.

The second is that EPI is of questionable value. Why I am I showing any EPI at all with a full face mask? The average EPI is around 4, and it seems to have peaked right about the time I reached 12 cm/H2O. At that point, it would vary from about 1 to 14. I have one instance of 30. Only one instance of 0. How can this be? I did not see any clear correlation with mask leakage. It will be interesting to see if EPI stays this low as I work up in pressure.

The third conclusion is that NRIs are not necessarily centrals. I know that making a positive determination of a central is a very tough thing to do, short of having thoracic and abdominal movement sensors. In looking at my graphs, some NRIs are almost certainly centrals-- occurring at times when pressure is steeply increasing, or in clusters of what the machine flags as snores and obstructive apneas. Others just randomly occur (and these are infrequent). So, I suspect that like EPI's, a certain percentage of NRIs are some event the machine cannot fully 'understand'.

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Re: Exhale Puff index? What does it mean?

Postby ozij on Sat Oct 10, 2009 12:03 pm

DeVilbiss NRI's are simply those where flow is than 95%. If your total obstuction happen to very total, the DeVilbiss will flag them as NRI's.

Recent research (quoted by Muffy, maybe when he was StillAnotherGuest) has shown that some people diagnosed with CompSAS need time to ajdust to higher pressures -- which is happily what happened to you. There's actually an argument if this is not true of most people diagnosed with that...
O.

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Re: Exhale Puff index? What does it mean?

Postby timbalionguy on Mon Oct 12, 2009 3:04 pm

ozij wrote:DeVilbiss NRI's are simply those where flow is than 95%. If your total obstuction happen to very total, the DeVilbiss will flag them as NRI's.

Recent research (quoted by Muffy, maybe when he was StillAnotherGuest) has shown that some people diagnosed with CompSAS need time to ajdust to higher pressures -- which is happily what happened to you. There's actually an argument if this is not true of most people diagnosed with that...
O.


I am not sure that CompSAS applies in this case, as I do not really seem to fit the profiles of most CompSAS patients I have read about (no other major medical issues other than obesity). Also, the centrals problem seems to have gone away with the start of regular therapy. And interestingly enough, the NRI score seems to have decreased significantly with my move up to 13/17 cm/H2O. (Has decreased from .3 to about .1). AHI has been much better, and my weekly average has now stayed under 5 for more than one day for the first time ever. I have been restless the last few nights, but that may be attributable to non-xPAP related issues.

So, I think my sleep doctor was right in trying a simpler solution first, and dealing with CompSAS only if it really was happening.

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Re: Exhale Puff index? What does it mean?

Postby Sillyme on Fri Oct 08, 2010 5:50 am

DeVilbiss Marketing wrote:I would suspect the high exhale puff index is due to mouth-breathing, which can be addressed by using a full face mask. . . . Please let me know if I can assist you further.

Swiched to AUTO for the first time last night. EPI went to 31. It's usually around 5. My lips were still securely taped shut in the morning so I know I was not mouth breathing. What else can affect this number? :? Used Swift FX laast night.
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