Adjusting my Clinical Pressure Settings

[rested gal]

Sleeptech010110, you might want to double and triple check some of the things you're writing before posting as a "sleep tech" -- if that's really your profession.

I'm not a doctor or sleep tech, or anything in the health care field. I can sure be wrong, too. But when a person chooses to post with the nickname "Sleeptech", I think it would be a good idea to do a bit more research about your statements before making them.

From one of your previous posts:
viewtopic/t38186/viewtopic.php?p=336250#p336250
You wrote:
"BI/level pressures are set during testing, the lower number is what you need to exhale with little effort, the higher is what prevents apneas."

I could be wrong, but it's my understanding that in a bilevel titration, it's the lower pressure (EPAP) which is set to prevent apneas. Not the "higher" (IPAP.)

If, posting as a sleep tech, you are getting something as basic as what EPAP is supposed to do, wrong....

[jda1000]

If the pressure setting were so expletive important, why is the follow-up so absolutely and completely non-existent?

What utter nonsense! Does even the excellent ResMed Autoset II adjust the output pressure relative to atmospheric pressure the night of my titration? Does it compensate for my health or fitness?

Good grief...

[Sleeptech010110]

Sleeptech010110, you might want to double and triple check some of the things you're writing before posting as a "sleep tech" -- if that's really your profession.

I'm not a doctor or sleep tech, or anything in the health care field. I can sure be wrong, too. But when a person chooses to post with the nickname "Sleeptech", I think it would be a good idea to do a bit more research about your statements before making them.

From one of your previous posts:
viewtopic/t38186/viewtopic.php?p=336250#p336250
You wrote:
"BI/level pressures are set during testing, the lower number is what you need to exhale with little effort, the higher is what prevents apneas."

I could be wrong, but it's my understanding that in a bilevel titration, it's the lower pressure (EPAP) which is set to prevent apneas. Not the "higher" (IPAP.)

If, posting as a sleep tech, you are getting something as basic as what EPAP is supposed to do, wrong....

You're right, very basic. That's what I was told when I first started here, never really thought about it or thought about double checking. Guess it just kinda got stuck. The guy who told me that got fired, so...lol. Like I said on the other post, sorry about the slip.

On a lighter note, I think Wulfman has it out for me...

Hopefully you're right, ozij. I will say this though, I'm sorry if I came across a bit strong, pressure levels and protocols are pounded into us almost like religion, so to find a site where people were discussing changing thier pressures...I may have overreacted.

When you're getting tought all this stuff, they, of course, use the extreme worst case scenarios. Good for making sure you're vigilent about making sure you don't kill a pt, but probably not so good when it comes to everyday people on an everyday site.

If you all can get a better sleep by making minor, slight adjustments to your system, ok. I'm cool with that now. You know my position of it totally freaks me out, I'll try to limit my posts to purely informational here on out, lol:-)

[TSSleepy]

There seems to be a couple ideas out there in the sleep professional community, which make no sense to me.
1) "One true prescription."
2) The way to arrive at that one true prescription is a one-night (or less) study in an artificial laboratory setting.

A sleep clinic takes a person out of their normal sleep routine, out of their normal sleep positions, and titrates them in a completely un-real setting. There could be dozens of reasons why the titrated pressure is not ideal.

For instance, many CPAPers sleep with wedge pillows or raise their heads while they sleep (either for OSA reasons or for GERD reasons). Sleeping at a different angle in the sleep lab could affect the results. A change in pillows could change whether the head tilted further backwards or forwards, which could also affect results.

Let alone all the reasons that the ideal pressure might change over time at home (weight gain/loss, aging, level of nasal congestion, hayfever season or not, blood pressure, champagne at a friend's wedding, etc, etc, etc).

I'm not trying to be snarky or mean...I just truly do not understand the rationale behind thinking that one night in an unrealistic situation is going to be better than a patient educating themselves and managing their own therapy.

I can definitely understand that not every patient wants to do that, but for those of us that do... it's a no-brainer.

[Wulfman]

On a lighter note, I think Wulfman has it out for me...

Who.....Moi???

Not having been a Bi-Level user, I didn't really understand the "mechanics" of IPAP and EPAP, either......for a long time......until ozij finally beat it into my head.
(it finally sunk in)

But......I would have assumed that a "sleep tech" would have known something that basic.....which made me suspicious.

Den

[ozij]

There seems to be a couple ideas out there in the sleep professional community, which make no sense to me.
1) "One true prescription."
<snip>
I just truly do not understand the rationale behind thinking that one night in an unrealistic situation is going to be better than a patient educating themselves and managing their own therapy.

It's a carry over from way back when, in the olden days, when ye olde sleepe labs first identified the condition, and discovered it could be solved with a tracheotomy. That was a "yes no", "open closed", "0 1" solution.
O.

[ozij]

On a lighter note, I think Wulfman has it out for me...

Who.....Moi???

Not having been a Bi-Level user, I didn't really understand the "mechanics" of IPAP and EPAP, either......for a long time......until ozij finally beat it into my head.
(it finally sunk in)

Who.....Moi???

Do you realize how long it took me to understand it ???

O.

[WichitaSleepRT]

I think you guys have a mis perception about EPR and C-Flex, the decrease in pressure happens at the start of exhalation, and as you are exhaling the pressure is already building back up. So the pressure is supposed to be at the prescribed level at the end of exhaltion and all thorugh inhilation. These technologies were developed for patient comfort, I find that when a patient has been on CPAP for a number of years and their CPAP dies and the get a new one, they do not like EPR/C-Flex.

[Wulfman]

I think you guys have a mis perception about EPR and C-Flex, the decrease in pressure happens at the start of exhalation, and as you are exhaling the pressure is already building back up. So the pressure is supposed to be at the prescribed level at the end of exhaltion and all thorugh inhilation. These technologies were developed for patient comfort, I find that when a patient has been on CPAP for a number of years and their CPAP dies and the get a new one, they do not like EPR/C-Flex.

On the contrary.......we understand it perfectly......we sleep with it every night and have answered questions about it and provide links to the source documents from the manufacturers for those who ask or don't understand it.

Den


http://aflex.respironics.com/

http://cflex.respironics.com/

http://biflex.respironics.com/


http://www.resmed.com/en-us/clinicians/ ... clinicians

http://www.resmed.com/en-us/assets/docu ... sa-eng.pdf

[WichitaSleepRT]

With a pressure of 7 and an EPR setting of 3 (EPR drops the pressure by actual cm of pressure per setting number), you're only getting about 4 cm. of therapy pressure about half the time and 7 cm. the other half..


Den

This answer is misleading to the OP. You don't need 7cm of pressure when you first begin exhaling, only when you are at the end of exhaltaion and through inhilation. So you don't need to adjust the EPAP to compensate the pressure decrese from the EPR, if this was the case, why have EPR at all?

And Den, posting the manufacturers websites about EPR and C-Flex does not explain in simple terms how these things work. I was trying to simplify how it works to the OP.

[jda1000]

Well....two weeks after raising my pressure to 8, with my EPR left at 3, and the EPR "response time" or "re-ramp" time at "fast" (rather than "medium;" there is no "slow," it seems to work pretty good.

When I exhale, my pressure drops from 8 to 5 - the manual is clear about that.

When I begin to inhale, the pressure quickly returns to 8. I have the re-ramp on "fast," and it IS fast - when awake, it's noticeably able to move the mask. I like it, though at first it was disconcerting. Now it's just a reinforcement of my sense of my own breathing rhythm.

As far as needing to maintain the "treatment pressure" of 8 while exhaling - I don't understand the rational, at least for my condition as I understand it. The pressure is provided to stent my airway open so I can get air while inhaling.

Exhaling might be a problem if my exhalation pressure were too weak to open a collapsing airway and rid me of stale air.

But if that is the case, a machine applied air-pressure sufficient to open the airway would seem to greater than my exhalation pressure.

So I end up with the idea the obstruction problem is principally on the inhale cycle. But I could be wrong.

And the literature with the machine describes the EPR feature mostly as a "comfort" feature - not something that reduces or enhances clinical aspects of treatment, aside from improving compliant use of the machines.

[Wulfman]

With a pressure of 7 and an EPR setting of 3 (EPR drops the pressure by actual cm of pressure per setting number), you're only getting about 4 cm. of therapy pressure about half the time and 7 cm. the other half..


Den

This answer is misleading to the OP. You don't need 7cm of pressure when you first begin exhaling, only when you are at the end of exhaltaion and through inhilation. So you don't need to adjust the EPAP to compensate the pressure decrese from the EPR, if this was the case, why have EPR at all?

And Den, posting the manufacturers websites about EPR and C-Flex does not explain in simple terms how these things work. I was trying to simplify how it works to the OP.

In this scenario using EPR (ResMed technology), if you need a pressure of 7 to eliminate apneas, then your EXHALE pressure needs to be that pressure......like in a Bi-Level setup......and if you are using an EPR setting of 3, it's going to drop 3 cm. of pressure through the entire exhale process, which means there's only 4 cm. of pressure to try to hold off apneas (if you're starting from 7 cm.).
This is different from C-Flex, where the exhale relief is "relative" to a person's breathing effort and is not an exact drop in pressure like EPR. With C-Flex, there's a slight drop in pressure at the beginning of the exhale but there's a little "back pressure" there......to help keep the airway propped open. I've always used a C-Flex setting of "2" and there's about a 1 cm. drop in pressure at that setting.


Den

[WichitaSleepRT]

This is different from C-Flex, where the exhale relief is "relative" to a person's breathing effort and is not an exact drop in pressure like EPR. With C-Flex, there's a slight drop in pressure at the beginning of the exhale but there's a little "back pressure" there......to help keep the airway propped open. I've always used a C-Flex setting of "2" and there's about a 1 cm. drop in pressure at that setting.


Den

Den - Breathing effort = inhilation, you don't need to work to exhale, unless there is some other obstructive disease you may have. So with C-Flex (a Respironics technology) the amount of "flex" it gives you is actually an algorithm that is based on flow. So if you are exhaling slow and long like when you sleep, there is not much "flex" going on. If you are awake and having a hard time with the PAP, the "flex" is there to make it easier.

[ozij]

True, WichitaSleepRT, except that with pressure blowing in at you , you do need to make an effort to exhale, even if you're healthy, and that's strange, or weird or disconcerting disconcerting to some, panic inducing to others.

I'm not trying to be snide or nasty - but do try a CPAP set at 8 for a 30 minutes. Eventually we get used to that, and to far higher pressure. But there's no getting away from it: using cpap means you're breathing out against resistance.

O.

[WichitaSleepRT]

True, WichitaSleepRT, except that with pressure blowing in at you , you do need to make an effort to exhale, even if you're healthy, and that's strange, or weird or disconcerting disconcerting to some, panic inducing to others.

I'm not trying to be snide or nasty - but do try a CPAP set at 8 for a 30 minutes. Eventually we get used to that, and to far higher pressure. But there's no getting away from it: using cpap means you're breathing out against resistance.

O.

I have and I know what it feels like! I have worn it for a night. It's not a lot of fun. I just read this thread and I'm thinking "wow" these people suggest increasing the EPAP if you're using EPR?! By the time you are done exhaling, ie typically when apneas happen, the C-Flex/EPR cycle is finished and the pressure is already back to the prescribed level. I know a lot of you know that if you increase the pressure too high you can start having central apneas, so I was just shocked to see you suggesting the increase.