BIPAP: Should we all use it?

[dsm]

[quote="ladytonya"]I have a ResMed S8 with EPR and I haven't noticed any loss of pressure between breaths. My pressure is set at 9 cm and EPR is at 3. I have played with the EPR by breathing in and out both very fast and very slow. It always reacts quickly and changes with me. I have also tested it by exhaling and then holding my breath. It reduces pressure on the exhale and then when I don't inhale after probably 30 seconds it will automatically increase the pressure again. I am actually really enjoying the EPR function and I have only used this machine for 3 nights. Fron what I've read about the differenced between EPR and Cflex, I think I would prefer EPR anyway, but I've never used Cflex. I can say that in my opinion EPR feels great and I wouldn't want to stop using it even after just 3 nights.

[NightHawkeye]

Thanks Bill, that's what I thought. BTW, which machine/model are you using?

I'm using the BiPAP-auto.

Any idea how much noisier, if at all it is compared to the Resmed Auto w/CFLEX?

I have no experience with another BiPAP, but I can say that the BiPAP-auto is extremely quiet. Generally, all I hear is mask noise, and I've been using masks which are pretty quiet themselves. Currently, I'm using the Comfort Curve mask, but previously I was using the Comfort Lite 2 which was the quietest mask I've ever used.

Regards,
Bill

[Guest]

Someone else will be able to help with that. I've read that some people notice a bipap a little more because of the changes in pressure. My auto is so quiet I can't really hear it operating. I bet the auto is equally quiet.

Thanks. I called Cpap.com and the fella there sounded like he didn't know much about this model. I may have to call again and speak to someone else.

But, as I understand it, this Auto BIPAP is the same as the CFLEX version AUTO, but the inhalation pressure is fixed (I would want it at at 4) and the maximum is variable up to the setting, say 15)? Is this correct? This unit also has levels 1,2,3 as well which is confusing me.

[Moogy]

But, as I understand it, this Auto BIPAP is the same as the CFLEX version AUTO, but the inhalation pressure is fixed (I would want it at at 4) and the maximum is variable up to the setting, say 15)? Is this correct? This unit also has levels 1,2,3 as well which is confusing me.

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Both inhale and exhale pressures will be automatically adjusted on the Respironics Auto BIPAP, unless you put it into a different mode of operation.(Depending on settings, it can work like an auto cpap or like a straight cpap).

You will set minimums and maximums, and the machine detects your pressure needs throughout the sleep period. It will adjust inhale pressure and exhale pressure separately, within the confines of the pressure support setting (2 cm-8 cm).

A setting of 4 is extremely low for INHALE pressure. Did you mean exhale pressure? The Auto Bipap will not allow you to have exhale pressure more than 8 cm lower than your inhale pressure. I suppose this is to prevent a huge pressure change that would be hard to handle. The minimum difference between inhale and exhale will be 2cm.

The BIFLEX feature is considered similar to CFLEX, but is is more complicated than that. My brain is not functioning well enough right now to give the long answer , but in short, BIFLEX smooths the transition of pressure between inhale pressure and exhale pressure. BIFLEX is probably the setting you saw that is numbered 1, 2, 3.

Moogy

[rested gal]

I've used both EPR and C-Flex. Tried EPR for a short time with a ResMed S8 Elite (straight cpap machine) and briefly with an S8 Vantage (autopap.) However, the Vantage has to be switched to straight cpap mode to use EPR, so I might as well have been using the Elite twice.

EPR feels very nice...maintaining an exact 1, 2 or 3 cm drop throughout the entire exhalation. If I had to use a straight cpap machine, EPR would be a consideration. However, since I prefer using autopaps, and ResMed's EPR cannot be used at all with their S8 Vantage autopap in auto mode, ResMed's EPR is useless to me.

If a person wants auto-titrating capability AND wants exhalation relief at the same time, Respironics makes machines that are designed to do both at the same time:

The Respironics REMstar Auto with C-flex. Or for setting exact cm's of lower exhale pressure in a true bi-level while auto-titrating -- the Respironics BiPAP Auto with Bi-Flex. Bi-Flex gives a bit more pressure drop to the beginning of the already-set-lower exhale pressure. Icing on the cake comfort when breathing out.

[Artwood]

restd gal or anyone else:

I've read that BiPAP is great for OSA but that it can actually make central apneas worse. When they do your sleep study can they tell whether you are having obstructive apneas or central apneas?

My pressure was titrated to be 9 and they gave me a range of 5-15 in my auto c-pap. What most likely would my pressure be if I bought a BiPAP machine? How would they be able to tell--could they use my old sleep study results or not or could they just take a guess and trial and error determine what the pressures should be?

Is there anything more advanced than BiPAP with BiFLEX?

[NightHawkeye]

When they do your sleep study can they tell whether you are having obstructive apneas or central apneas?

Yes, they distinguish between them. Get a copy of your sleep study and it will have the two types listed and how many of each you had. Only a few folks have predominantly central apneas.

My pressure was titrated to be 9 and they gave me a range of 5-15 in my auto c-pap. What most likely would my pressure be if I bought a BiPAP machine?

With a regular BiPAP, your pressure would likely be 9 or 10 on IPAP and two or three less on EPAP. Since you're using APAP now though, a comparable pressure range for the BiPAP-auto would be 5 to 15 for IPAP with the machine finding the correct EPAP levels.

For me, the BiPAP-auto found about the same 90% pressures as the Remstar-auto did.

How would they be able to tell--could they use my old sleep study results or not or could they just take a guess and trial and error determine what the pressures should be?

Judging from reports on this forum, BiPAP pressures are normally set during the titration study, same as with CPAP. A few folks, however, have reported going directly to the BiPAP-auto from CPAP without going through another sleep study.

Is there anything more advanced than BiPAP with BiFLEX?

There are other types of machines with unique features for special apnea needs, but for a general purpose machine, no, there's nothing better. The BiPAP-auto is about as good as it gets.

Regards,
Bill

[rested gal]

When they do your sleep study can they tell whether you are having obstructive apneas or central apneas?

Yes, they can tell which type of apneas you have during a PSG sleep study. The belts they put around your abdomen and chest give them that info.

No movement of tummy and chest against the belts means brain is not telling you to breathe. Central apnea.

Tummy and/or chest making efforts to move, but no (or very little) air flow happening means you're trying to breathe but your obstructed airway won't let you. Obstructive apnea.

My pressure was titrated to be 9 and they gave me a range of 5-15 in my auto c-pap. What most likely would my pressure be if I bought a BiPAP machine?

I'm no expert, but as I understand it, during a PSG titration with a bi-level machine, the EPAP pressure (the lower pressure) for is set for the amount of pressure it takes to prevent apneas. If it took 9 cm H2O to prevent you from having apneas, that would be your EPAP pressure.

After the EPAP pressure is set to prevent apneas, the IPAP pressure is set higher -- at a level that gets rid of all remaining events (hypopneas, limited air flows, snores.) Usually an IPAP pressure 3 - 4 cm's above the EPAP pressure will take care of those things.

Here's a link to a PDF file of titration guidelines from the University of Florida Sleep Disorders Center (5/31/2000)

How would they be able to tell--could they use my old sleep study results or not or could they just take a guess and trial and error determine what the pressures should be?

They could probably make a pretty good educated guess about how to set EPAP and IPAP from your previous sleep study titration results. It would be better, of course, to have a PSG titration specifically with a bi-level machine for a night, but trial and error using software to see how it goes would be ok for most people.

Is there anything more advanced than BiPAP with BiFLEX?

Well, the Respironics BiPAP Auto with Bi-Flex adds a little more "advancement" over BiPAP with Bi-Flex, in that it can be set to do two things at once....work as a bi-level to give precise exhalation pressure relief while working like an autopap to find what pressure is needed throughout the night. But it really isn't necessary to get "the most advanced machine" in order to receive effective, comfortable treatment.

I do think an autopap is a wise choice for most people. If a person wants to use an autopap AND wants the comfort of breathing out against less pressure, then either of the two Respironics machines (REMstar Auto with C-Flex or the BiPAP Auto with Bi-Flex) would be good.

[dsm]

Re centrals,

Just be aware that these are not usually treated by a cpap, an auto or a Bilevel (unless that BiLevel has timed control added).

If someone is diagnosed with centrals - the usual therapy will be a machine with timed control & as up until today only some Bilevels have that feature.

All current Autos (as spelled out in their patent applications) do *not* try to treat centrals as increasing pressure on a central does nothing other than to compound it or do other harm.

Timed control basically works by introducing a back-up breathing rate of x breaths per minute (BPM) - if the person fails to breathe within that limit, the machine switches from epap to ipap. If ipap and epap are set very close together (say 1 or 2 apart), this may have no effect (just not enough of a change to have any effect).

The hope with BPM is that by switching from epap to ipap the change in pressure is enough to get the person breathing again, as quickly as possible, before serious SpO2 desaturation sets in (this is usually below 88 SpO2). But it is no guarantee that the user will resume breathing. Most timed Bilevels keep repeating the change between ipap/epap until the person breaths normally again. Serious central disorders (i.e. Cheynes Stokes - often tied to Heart problems) may require a full ventilator (which drives the person's breathing).

If someone has mixed Obstructive/Central Apnea, the centrals will normally go untreated on standard & auto cpaps and also standard Bilevels (defined by 'S' or 'Spontaneous' mode).

The challenge with centrals is knowing what the cause is as it can be several factors and one of the worst factors for apnea suffers is 'pressure induced centrals' - this is where the pressure from the cpap or auto is high enough on this user to trigger a central in the user (user basically gives up trying to breathe against the pressure) thus turning what might be only obstructive apnea into both types. Under these circumstances the user's therapy is likely to go backwards. This effect will vary greatly among people. Auto's can increase pressure to a point that they trigger these types of centrals but this is rare. This effect also varies between brands of Auto.

To add complexity to this - there is evidence that for some people on bilevel vs cpap (2 diff and distinct pressures vs one) that they will experience breathing complexities that others on one pressure won't. This is not a simple formula.

Unfortunately there is a lot of confusion over centrals, their meaning & their causes. The above is a simplified description and is only presented as such, but is defensible in the context of this forum.

Cheers & good luck

DSM

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CPAPopedia Keywords Contained In This Post (Click For Definition): CPAP, auto

[Guest]

EPR is a full bi-level function - C-flex is a momentary attempt to delay the inevitable.

Or, one can say that EPR is simplistic and fixed (you always get X cm of drop), while C-Flex is more intelligent and sophisticated (the drop amount you get varies breath-to-breath, depending on your breathing effort for each exale and some other tracking factors).

[christinequilts]

Re centrals,


Unfortunately there is a lot of confusion over centrals, their meaning & their causes. The above is a simplified description and is only presented as such, but is defensible in the context of this forum.

I would add that everyone has some central apneas every night, whether they have OSA or not, or are on xPAP or not. Occasionally we see poster who focus in on the fact they had a few centrals during their PSG and are more worried about the centrals then the 20 obstructive apneas they have per hour. If you have OSA, even a significant number of centrals can be a symptom of the OSA, and not a problem on their own for the most part. It really depends on when the centrals are happening- if they occur when you are transitioning from one stage of sleep to another, they usually are not anything to worry about.

Even with a diagnosis of Central Sleep Apnea or Mixed Apnea, other xPAPs besides BiPAP ST can be used successfully in some cases. Even in my case, where it was apparent I had CSA with over 60 centrals per hour & less then 2 obstructive apneas per hour, my titration study had to start with CPAP, then move to BiPAP and then BiPap ST. They do that because sometimes what looks like a central apnea can be an obstructive apnea or in the cases where the central are a symptom of the OSA, a CPAP may be all that is needed.

I like this analogy to plumbing & electrical problems from an article last month on the Medicare requirements for BiPAP ST-

The Nuances of Sleep Apnea

Think of sleep apnea as a family tree. At the top of the tree is the large classification of sleep-disordered breathing. From sleep-disordered breathing, the sleep apnea family branches off into two types — obstructive, which is very common, and central, which is rare.

"The easiest way that I think about these are that in the case of obstructive sleep apnea, the patient can't breathe," says Dr. William Abraham, professor of internal medicine; director, Division of Cardiovascular Medicine; deputy director, Davis Heart & Lung Research Institute, The Ohio State University, Columbus; and council physician on the "Sleep Well, Be Healthy" public relations campaign to help raise awareness of sleep apnea. "(The person's) thoracic and abdominal muscles, which are used for respirations, continue to try to breathe but the upper airway is collapsed. … Central sleep apnea is due to an alteration in the signals from the brain from the central nervous system that tell the body to breathe. So, essentially, those signals become abnormal and periodically, the patient does not receive a signal from (the) brain to breathe. So, I like to describe that as the patient won't breathe."

Daly describes these two forms of apnea as plumbing and electricity. "We are saddled with a little bit of a design defect as mammals," he says. "And the design defect is that we breathe through the same tube that we eat through. And that requires that that tube be collapsible. … That also implies, and it is true, that there are complex muscles which actually actively hold that airway open and muscles (that) can close it. … That's how come I say it involves both plumbing and electricity because if the electricity goes off the muscles (that) are holding it open will no longer hold it open. If the plumbing is a problem, meaning that the pipe is too small or something's squishing it … that can be a problem, too.

"Plumbing's pretty easy to understand," continues Daly. "You've got this limited space that has to contain both this pipe and your tongue; you're getting heavy, you've got a lot of testosterone because you're a man; that tongue muscle is a very bulky thing, it's about the size of your fist actually… As they say, there's only enough room in this town for one of us. Right? So, unfortunately it can tend to be the tongue, especially when a patient is on their back and that big muscle sort of wants to flop down onto the tube. The muscles holding it open may not be strong enough to counteract that and it may collapse.

"All the way on the extreme side is a condition that is called central apnea. Central apnea as it is understood out there is viewed almost entirely an electrical problem. And … for reasons that are complex, every so often the power to the entire system gets shut off, meaning that the brain stops sending the entire lung plant signals to breathe. And your diaphragm is not attempting to move because it's got no electricity; your chest wall is not attempting to move; and very importantly … the muscles which are supposed to hold your airway open also have the power to shut off. So the question is should we be calling a plumber or should we be calling an electrician?"

Branching off obstructive and central sleep apnea on the tree is another type of sleep apnea — complex, also known as mixed. This form, the child of obstructive and central, has characteristics of both.

"Up until not all that long ago … it was viewed that 98 percent of the problem was the plumbing problem and 2 percent was the electricity — and by electricity what I mean is nerve impulses," says Daly. "What has emerged is that in fact all sleep-disordered breathing actually exists on a spectrum where it is probably unusual for somebody to be entirely plumbing and have no electric problems or for someone to be entirely electrical and have no plumbing problems."

http://www.mergenetsolutions.com/press-035.htm

[dsm]

Christine,

A good article.

I would guess that the doctor could add that people with serious acid reflux difficulties may find over time, that this too will impact the type of apneas they experience and can be the cause (directly & indirectly) of more centrals for them.

DSM

[Artwood]

What does BiPAP ST do that regular BiPAP doesn't do?

Are there any auto BiPAP machines that also do ST?

[dsm]

Artwood.

The Bipap S/T machines typically include :-
a breathing rate set as either max/min Inhale times, or, a value for setting the ratio of inhale period to exhale period,

plus

a back-up breathing rate expressed as minimum BPM breaths-per-minute,
a rise time. (some also have additional finer adjustments on both the inhale/exhale rise/fall waveform as does the Puritan Bennett Knightstar 330).

The machines can operate in
S (spontaneous mode),
S/T (spontaneous and timed),
or just T (timed).

T:
The purpose of Timed only is to pace the user - that is by switching from Ipap to Epap at a fixed breathing rate, the machine tries to keep the user in sync with it. These machines are acting as a 'ventilator'

S:
In Spontaneous mode the user's breathing going from exhale to an inhale, triggers the machine to switch from epap to ipap cms.

S/T:
In Spontaneous and timed mode the machine relies on the user to trigger the epap to ipap switch, but if their breathing rate falls below the min BPM value (lets say its set to 6 breaths per min) the machine will switch from epap to ipap at the backup rate until the user resumes a faster breathing pattern.

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The purpose of the switch from epap to ipap is (in the case of centrals) a signal to try to get the user breathing again. The effect of the switch is greater if the CMS gap between ipap & ipap is big but, setting a gap that is too big also can cause HI & AI events (I may have just proven this but am still gathering data - I was suing 8/15 - the high HI & AI scores I have recorded may have been due to the high ipap setting & not the gap between ipap & epap - further tests may clarify this).

Setting a gap between Ipap & Epap cms that is too small, may have no effect on the user (doesn't notice it & stays inactive until their nervous system kicks in when the brain detects declining blood oxygen saturation (SpO2)).

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Is there an Auto Bilevel S/T - yes, it is called the Resmed VPAP Adapt, also Respironics have a machine called the Bipap SV that has similar intention (can't recall its market name). IIRC The Respironics machine is currently offered for use with patients having Cheynes/Stokes CSDB.

DSM

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CPAPopedia Keywords Contained In This Post (Click For Definition): respironics, resmed, bipap, Puritan Bennett, auto

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CPAPopedia Keywords Contained In This Post (Click For Definition): respironics, resmed, bipap, Puritan Bennett, auto

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CPAPopedia Keywords Contained In This Post (Click For Definition): respironics, resmed, bipap, Puritan Bennett, auto

[christinequilts]

What does BiPAP ST do that regular BiPAP doesn't do?

Are there any auto BiPAP machines that also do ST?

A regular BiPAP has 2 pressure- IPAP (inhale) & EPAP (exhale) and it changes pressure Spontaneously between the two as you inhale & exhale- you are always the one triggering the change. BiPAP ST has the 2 pressure, but it also has a backup rate, expressed in breaths per minute. It will spontaneously change between IPAP & EPAP as you breath, but if you don't breath for so many seconds, based on your backup rate, it switches to Timed mode, where the BiPAP ST controls the changes from IPAP to EPAP & back until you start breathing again on your own. ST's are used with Central Sleep Apnea (CSA), but they are not always effective in getting the person breathing as well as we should...I guess I'm not just forgetful, but stubborn too They are also used with other breathing problems were the person has difficulty maintaining respiratory drive, like ALS, MD, COPD, etc.

The new VPAP Adapt that is just coming out in the US could be considered an autoBiPAP ST, but it is much more then that. DSM can give you the whole run down on the technology involved, but as you can imagine, it is a pretty amazing machine that can monitor and make changes with so many different variables at once. I'll probably be having a titration with it in the next few weeks and as long as it helps more then my BiPAP ST.