BiPAP vrs C-Flex/EPR

[jskinner]

BiPAP and C-Flex seem like similar technologies, both providing exhalation relief. C-Flex seems to only give a breif releif at the begining of the exhalation while BiPAP provides a lower pressure during the entire exhalation?

It seems that BiPAP is something that a doctor must decide a user needs? How does the doctor decide this. Its this normally in response to a high prescribed pressure?

Is my understanding of these differences accurate?

[Snoredog]

if you cannot tolerate cpap due to the high pressure (usually it needs to be over about 12cm), then the doctor might try a bipap.

If your pressure is up in the high teens most forego cpap and go directly to bipap.

If your pressure is under 10cm, pretty hard to convince doctor and insurance you need a bipap. this is why mfgs like Repironics came out with CFlex.

Just like cpap, there is a basic machine like the cpap called the bipap, then there is the autotitrating version like the Bipap Auto, then there are other models if you have Cheyne-Stokes Respiration which may have S/T after it. It will try and assist you in breathing when you forget and also has a backup timed mode that kicks in should the first mode fail to trigger a breath.

If your pressure is under like 12cm, I doubt very much that would benefit from the use of a Bipap Auto. A regular Auto like the Remstar offers relief on exhale like the Bipap, but it is limited.

[dsm]

This can be tricky to answer as I am no doctor or RT. BUt (can't resist) ...

Cflex is a particular type of relief and a very novel way to ease the difficulty of breathing out against pressure.

BiLevels were originally invented to help patients who were having real difficulty breathing out against pressure such as people with COPD (chronic obstructive pulmonary disease) *or* people on very high CPAP cms settings.

Also mask sealing at high CMS can be a massive challenge.

By allowing the two pressures, the lower (EPAP) pressure eases the exhale effort significantly and also reduced the negative side effects.

But just to show that cflex and Bilevel are different, Respironics included both in their Bipap Pro 2 and Bipap AUTO machines. When going from EPAP to IPAP, BiFlex will allow an additional momentary dip in pressure beyond what can be adjusted for with the rise time settings.

EPR is rather like a mini BiLevel. By allowing the user to change the cms gap from 1 to 3, they can vary the effect to suit themselves.

Both systems work well.


One additional point to remember when thinking about BiLevels, is that the EPAP (the lower exhale setting) really should be set to your titration CMS unless the machine is a Bipap Auto). The other setting is usually 4 CMS higher but that only applies if the recommending physician wants to apply real BiLevel control to a particular patient. Another reason for the recommended 4 cms min gap is if the BiLevel is being deployed as a Ventilator. If the IPAP EPAP gap is too small, it won't Ventilate very well.

Anyone requiring Timed control (People who suffer with Centrals) really need the min 4 cms gap as it is the switch from epap to ipap that attempts to trigger them breathing again if they have had a central. In reality it is a 'rough and ready' way of trying to manage centrals. Adaptive Servo Ventilation appears to be a much better way.


DSM

[jskinner]

EPR is rather like a mini BiLevel.

I assume that this is because EPR gives relief during the entire exhale rather than just at the beginning? Does this make EPR more comfortable than C-Flex?

I've sometimes felt that C-Flex makes my breathing a bit faster than it normally would be because the pressure starts back before I'm done exhaling... has anyone experienced that?

In general I LOVE C-Flex. I'm very sensitive and even at low pressure found exhalation difficult without it.

[dsm]

What makes EPR like a mini bilevel is the relief during the entire cycle.

It doesn't have (AFAIK) the range of adjustments we can get on say a PB330 or a VPAP III.

I run my PB330 like it has EPR - 3 cms gap between IPAP & EPAP. I am pretty well hooked on this set up even though my respiratory specialist would give me a hard time about having it as low as 10 cms when my titration is 13. But my excuse is that the timed mode takes care of any apneas that may slip through. My ever observant wife is at the happiest she has ever been with my sleep. She now tells me she gets good sleep because I seem to be doing so well. No more stopping breathing (one reason she pushed me to see the doc in the 1st place).

cflex has been known to cause some people to breathe faster. But at a setting of 2 I found I could use cflex ok.

DSM

[rested gal]

EPR is rather like a mini BiLevel.

I assume that this is because EPR gives relief during the entire exhale rather than just at the beginning?

Yes.

Does this make EPR more comfortable than C-Flex?

It could, for some people. EPR would definitely be more comfortable for me if I used higher pressures than I do (normally 9 or 10 would take care of me fine.) When I experimentally tried several C-Flex settings at straight pressures of 16 all the way up to 20, C-Flex could not make enough dent in the exhalation pressure to suit me at all. Probably because C-Flex is almost completely dependent on how forcefully a person exhales against a given pressure AND how long through the exhalation the force of their exhalation is maintained.

I don't exhale well at all against pressures of 14 and higher, so C-Flex gave a very momentary (and bumpy feeling) blip for me at the high pressures. I felt that the regular pressure was rushing back in much too early in my exhalation and not giving me any real relief from high pressure. Others with more forceful exhalations in the first place might find C-Flex quite comfortable at high pressures.

I've sometimes felt that C-Flex makes my breathing a bit faster than it normally would be because the pressure starts back before I'm done exhaling... has anyone experienced that?

Yes, that's been reported by some people. WillSucceed described that very thing happening to him, to the point that he was completely unable to use C-Flex. Fortunately, C-Flex can be turned off if a person doesn't like it, or it doesn't suit them.

In general I LOVE C-Flex. I'm very sensitive and even at low pressure found exhalation difficult without it.

Me too (about "love" it...I don't have any problem exhaling against pressure up to 10.) However I do love C-Flex even at the low-moderate pressures that serve me well when I use an autopap.

The first night or two that I ever used C-Flex, I made the mistake of assuming that C-Flex would hold the pressure down throughout the entire exhalation. Since it doesn't, I found the "regular" pressure coming back in before I was finished exhaling to be disconcerting. I thought something was wrong with the machine. After I found out that was the way C-Flex is supposed to work (letting the regular pressure back in before the exhalation is finished) I stopped trying to make my breathing match what C-Flex was doing. That slightly out of sync sensation was easy to ignore (for me...not for everyone) and I absolutely loved the pressure relief C-Flex gave.

[rested gal]

When weighing the plus/cons of C-Flex vs EPR, a person might want to consider the possibility that undertreating might happen when using EPR:

http://www.apneasupport.org/viewtopic.php?p=4936

True bi-level titrations are geared toward setting EPAP at a level that gets rid of apneas.

Depending on what pressure was prescribed during a straight cpap titration, the 1, 2, or 3 cm drop with EPR used later might not deliver enough pressure to ward off apneas. A person might want to consider whether their single prescribed pressure is really going to be enough if EPR is going to be used...especially if the EPR is going to be set to give a 3 cm drop.

C-Flex probably wouldn't lead to an undertreatment scenario since with C-Flex the regular pressure is back in place well before another inhalation would occur.

Just a thought.

[dsm]

When weighing the plus/cons of C-Flex vs EPR, a person might want to consider the possibility that undertreating might happen when using EPR:

http://www.apneasupport.org/viewtopic.php?p=4936

True bi-level titrations are geared toward setting EPAP at a level that gets rid of apneas.

Depending on what pressure was prescribed during a straight cpap titration, the 1, 2, or 3 cm drop with EPR used later might not deliver enough pressure to ward off apneas. A person might want to consider whether their single prescribed pressure is really going to be enough if EPR is going to be used...especially if the EPR is going to be set to give a 3 cm drop.

C-Flex probably wouldn't lead to an undertreatment scenario since with C-Flex the regular pressure is back in place well before another inhalation would occur.

Just a thought.

Agree !

This is actually a thought that people really need to take into account.

I am doing this (dropping epap down rather than ipap up) but only because I am so used to the back-up capability of my preferred machine.

The issue of dropping pressure greater than 1 below titration is one that needs very careful thinking about. This consideration is a plus for cflex.

DSM

[Snoredog]

Cflex is great in my opinion, nothing complicated to program, just 3 simple settings. They made it even easier on the new M series, dedicated button on top, you can change it on the fly while wearing the mask and tell the difference right away.

I used to use a RemstarPro with Cflex for travel, used the regular Remstar Auto as main machine, couldn't really tell all that much difference going from the Pro to the Auto, but later when I got the classic Auto with Cflex back in May, I could tell the difference right away and liked the auto with cflex better.

Exhaling against my low 9/10cm pressure is no big deal, lately I have been playing with the different Cflex settings on my M series, I normally use setting #2, I since switched to #1, so far I noticed that I don't have as many snores being detected on EncorePro (snore idex used at times 260, hovers around 220 most of the time, since playing with it, I've gotten it down as low as 17). May take it back up after a week and see if they don't climb again. Don't feel any different but reports says I do better, going to try a nasal mask tonight and see if it gets better.

[SelfSeeker]

Do not tell me that 14 min (most nights gets me by) and 18 (many naps) is a high pressure.

I thought I was being a whimp that at anything past 13 and a CFlex of less then 3, air would leak from my mouth on the exhale.

I do not mind a straight start of 14, but exhaling is difficult.


Snoredog - would increasing the pressure, help with the snoring?

[jskinner]

Cflex is great in my opinion, nothing complicated to program, just 3 simple settings. They made it even easier on the new M series, dedicated button on top, you can change it on the fly while wearing the mask and tell the difference right away.

I don't however understand why you can't turn C-Flex completely off via the dedicated button. Having to go in to the admin to do that is just annoying...

[SelfSeeker]

I totally agree, that was my only complaint. If they had put the off together it would have been great.

I think it may be done, because some Drs, do not want that option for some patients.

Cflex is great in my opinion, nothing complicated to program, just 3 simple settings. They made it even easier on the new M series, dedicated button on top, you can change it on the fly while wearing the mask and tell the difference right away.

I don't however understand why you can't turn C-Flex completely off via the dedicated button. Having to go in to the admin to do that is just annoying...

[jskinner]

I totally agree, that was my only complaint. If they had put the off together it would have been great.

I think it may be done, because some Drs, do not want that option for some patients.

Still should not have been an issue.

The dedicated cflex button should have 0, 1, 2, 3
The admin cflex settings should have unlocked, 0, 1, 2, 3 (same as today)

Complete control by admin and user (if allowed)