Let’s talk bipap and EPR

[Doce]

Help me understand them better and their applications, comparisons, and differences to sleep disordered breathing.

I understand that EPR is Resmed’s exhale relief that essentially turns the machine into a bipap with a pressure support limited to 3 and that bipaps can provide a much higher level of pressure support.

From what I’ve gathered, EPR is sometimes introduced when a patient is having issues exhaling against the pressure, when a patient is having aerophagia, and generally comfort. However, there is some debate that is better to use it off or limited to one as it could possible cause instability in the airway or increased central’s.

Then comes bipap... my understanding on this is more limited. Apparently it is used when patients are having a difficult time with CPAP/APAP and need higher pressures and a greater difference in exhale and inhale pressures than 3. Sometimes it is used when a patient is having lots of centrals.

This is what really gets me is if EPR can trigger centrals and is advised to turn it off, why then is BIPAP recommend? Wouldn’t it potentially cause more centrals? It seems contradictory.

Explore this example with me and point out what I’m overlooking. Let’s say someone is having issues with CPAP/APAP and needs to be on bipap because of an issue (what issue? I’m not sure). It was determined their ideal pressure is 14. Wouldn’t their exhale pressure have to be set to at least 14 to keep their airway stabilized? (exhale at 14, inhale at 18 for example) So then what benefit does it provide the patient to have an inhale pressure greater then 14? Wouldn’t that just lead to aerophagia or disturbed sleep because the pressure is too high?

There is something I’m overlooking or not understanding. Please explain.

[Pugsy]

Not everyone has a problem with aerophagia at higher pressures.
Not everyone has a problem with pressure support causing centrals.

I have a friend whose mother is using fixed pressure of 20 cm. No exhale relief....no aerophagia....no centrals either.

Now if someone did have a situation where pressure support caused centrals (like using EPR) then obviously using a regular bilevel machine is going to create a similar problem....if it's too big of a problem and a compromise can't be made then maybe time for the ASV bilevel machine.

[SleepGeek]

From what I’ve gathered, EPR is sometimes introduced when a patient is having issues exhaling against the pressure, when a patient is having aerophagia, and generally comfort. However, there is some debate that is better to use it off or limited to one as it could possible cause instability in the airway or increased central’s.

I'm not willing to comment on this hypothetical and hope it's not real. Certainly not anything I've ever seen mentioned on this forum.

IMO bipap is the ultimate in exhale relief.

Are you having a problem? If so, lets talk about that instead.

[palerider]

However, there is some debate that is better to use it off or limited to one as it could possible cause instability in the airway or increased central’s.

There's no debate, with a relatively small percentage of people (something under 15%), the extra ventilation that the pressure difference causes results in their CO2 levels dropping enough that their respiratory drive is depressed enough that they have central apneas.

For most people, the extra ventilation from EPR, or bilevel doesn't cause any problem.

Then comes bipap... my understanding on this is more limited. Apparently it is used when patients are having a difficult time with CPAP/APAP and need higher pressures and a greater difference in exhale and inhale pressures than 3. Sometimes it is used when a patient is having lots of centrals.

"bipap" (besides being a trademark of Philips Respironics) is a generic term for a machine with separately settable inhalation and exhalation pressures. there are several very different types of bilevel machines, that each treat a different sort of breathing disorder.

This is what really gets me is if EPR can trigger centrals and is advised to turn it off, why then is BIPAP recommend? Wouldn’t it potentially cause more centrals? It seems contradictory.

Because only certain types of bilevel are used for central apneas, preferably an ASV, which can deliver up to 21cm of pressure support in a single breath, to *force* air into your lungs when you don't try to breathe on your own.

Explore this example with me and point out what I’m overlooking. Let’s say someone is having issues with CPAP/APAP and needs to be on bipap because of an issue (what issue? I’m not sure). It was determined their ideal pressure is 14.

There's no such thing as "ideal pressure", pressure needs vary from hour to hour depending on what stage of sleep you're in, and from night to night, as well as what position you're in.

[Miss Emerita]

Doce, as others have mentioned, bilevel machines are unlikely to be effective for central apnea, though weirdly enough, they are indeed sometimes recommended within the medical profession.

You might be thinking of ASV machines (adaptive servo-ventilation machines), which are useful for treating central or mixed apnea.

ASV machines are expensive, so there are hoops to jump through. Often the patient is asked to try regular APAP, then bilevel PAP, and only after "failing" both, ASV. A better approach is to titrate during an in-lab sleep, moving through those options and trying various settings for each.

[palerider]

Doce, as others have mentioned, bilevel machines are unlikely to be effective for central apnea, though weirdly enough, they are indeed sometimes recommended within the medical profession.

You might be thinking of ASV machines (adaptive servo-ventilation machines), which are useful for treating central or mixed apnea.

ASVs are one type of bilevel.

bilevel types I can think of offhand, S (plain), Auto (auto), ST (like S but with timed backup rate), ASV, and *VAPS. ST and ASV treat central apnea, ST being the old nasty way, and ASV being the modern, smart way. VAPS machines are for various lung diseases, not so much apnea.

Think of "bilevel" like "truck" there's lots of different types of trucks.

[Miss Emerita]

Thanks, PR!