What thinkest thou, you good and knowledgeabe people? My Pulmonologist told me a short while ago:
1. If I can get my apnea events down under 10 per hour I will be fine because "that is the point at which we begin to treat OSA."
2. I asked why my settings are 13/6 if my sleep study titration showed apnea events are controlled at a setting of 13 and the sleep study RT said that means the lowest setting should be at 13, not the highest.
His reply was apnea events occur only on inhalation, not on exhalation, and, as long as my exhalation setting is not near zero I will be fine.
3. When told my DME sent an RT to visit me at home to check how I was doing, and this RT agreed with the sleep study Rt the low settind be at least nearer to 13 than 6, my Pulmonologist simply glared at me and said the RT is not an MD let alone a specialist. Glad I didn't use names.
The RT from my DME said by raising the higher setting from 13 to about 17, it would actually help make my exhalation easier than it would be at a constant cpap of 13.
And because I had a bit of trouble exhaling at a cpap of 13, the RT said a BiPap setting of 17/13 would actually be easier for me to exhale than a setting of 13/10. Supposedly, a higher inhalation setting would help the exhalation.
This point intrigues me, I have no idea if the RT is right or not, and I would really appreciate you comments especially on this on this.
If course, my Pulomologist thinks I need another sleep study in *his* sleep center because then he knows the titration data will be reliable.
What sayest thou?
Andy
Questionable advice from Pulmomologist
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wading thru the muck!
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Lose the RT! What good does a Bipap do for you if you need to use an even higher pressure when using one. We had a "sleep professional" named betterbreathinbob claim that with a Bipap, your lower setting is you titrated fixed pressure and that what shot down soundly by posters on the forum who know better. It is scary that someone (your RT) is amedical professional and has got the story completely backward. SCARRY...SCARRY...SCARRY!
To clarify regarding the Bipap. It is used (among other reasons) when a patient can't tolerate a high titrated pressure. The higher pressure setting allows a patient to get their titrated pressure for the segment of the breathing cycle including the inhalation phase and the end of the exhalation phase. During this segment is when obstructive events most often occur. The lower pressure provides releif from the high pressure during the balance of the exhalation phase facilitating more comfort.
To clarify regarding the Bipap. It is used (among other reasons) when a patient can't tolerate a high titrated pressure. The higher pressure setting allows a patient to get their titrated pressure for the segment of the breathing cycle including the inhalation phase and the end of the exhalation phase. During this segment is when obstructive events most often occur. The lower pressure provides releif from the high pressure during the balance of the exhalation phase facilitating more comfort.
Sincerely,
wading thru the muck of the sleep study/DME/Insurance money pit!
wading thru the muck of the sleep study/DME/Insurance money pit!
Andy,
What Wader says sounds correct.
I have a bipap with the 18/13 pressures. (ouch, high pressures!) The graphs accompanying the sleep study test report clearly shows the apnea episodes disappearing at the 18 pressure (not the 13, although somewhat reduced), so the 18 is what's needed to maintain my airways. They tested even beyond 18 to be certain, and the graphs clearly show this. Funny, the test report has all the important information, and recommendations to the doctor. The doctor merely agrees and signs off on it and writes a script. How can I get a job like that?! Ha!
Linda
What Wader says sounds correct.
I have a bipap with the 18/13 pressures. (ouch, high pressures!) The graphs accompanying the sleep study test report clearly shows the apnea episodes disappearing at the 18 pressure (not the 13, although somewhat reduced), so the 18 is what's needed to maintain my airways. They tested even beyond 18 to be certain, and the graphs clearly show this. Funny, the test report has all the important information, and recommendations to the doctor. The doctor merely agrees and signs off on it and writes a script. How can I get a job like that?! Ha!
Linda
BetterBreathinBob is not the only sleep tech who approaches a BiLevel titration that way. I have read of quite a few sleep techs on binarysleep.com approach a BiLevel titration as follows:
They initially titrate to clear apneas using a straight pressure. They then take that fixed pressure value as their initial EPAP setting (not IPAP) and add a nominal 4-to-6 cm to IPAP as a starting point for the BiLevel phase of titration. They continue the titration, measuring and adjusting both accordingly. My understanding is that heavy apneas begin at the end of expiration, which is why EPAP sometimes must be the equivalent pressure that was required for CPAP to clear those obstructions. Yet, if a patient does not have heavy obstructions at the end of expiration, then EPAP can be lower.
When we hear of inhaling or exhaling better at a lower or higher pressure, that advice may be relative to how hard it is to breath with uneccessarily high pressure. However, from yet another perspective that advice might be relative to how hard it can be to breath with uncleared apneas. It's harder to breath with either uncleared apneas or excessive pressure.
They initially titrate to clear apneas using a straight pressure. They then take that fixed pressure value as their initial EPAP setting (not IPAP) and add a nominal 4-to-6 cm to IPAP as a starting point for the BiLevel phase of titration. They continue the titration, measuring and adjusting both accordingly. My understanding is that heavy apneas begin at the end of expiration, which is why EPAP sometimes must be the equivalent pressure that was required for CPAP to clear those obstructions. Yet, if a patient does not have heavy obstructions at the end of expiration, then EPAP can be lower.
When we hear of inhaling or exhaling better at a lower or higher pressure, that advice may be relative to how hard it is to breath with uneccessarily high pressure. However, from yet another perspective that advice might be relative to how hard it can be to breath with uncleared apneas. It's harder to breath with either uncleared apneas or excessive pressure.
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-SWS,
They all don't know what they are talking about!
In a case where Bipap is prescribed as an alternative to cpap when the patient can not tolerate their high pressure prescription, it makes ZERO sense to then up the pressure by 3-5cm. Why would 18/15 be easier than a straight 15cm? As far as clearing heavy obstructions, if 15cm was sufficient to clear them then you don't need 18cm. If 15cm was not enough then 15cm was an inacurate titration. For this type patient there is NO other logical way to look at it.
Any other faulty logic is SCARRY!
They all don't know what they are talking about!
In a case where Bipap is prescribed as an alternative to cpap when the patient can not tolerate their high pressure prescription, it makes ZERO sense to then up the pressure by 3-5cm. Why would 18/15 be easier than a straight 15cm? As far as clearing heavy obstructions, if 15cm was sufficient to clear them then you don't need 18cm. If 15cm was not enough then 15cm was an inacurate titration. For this type patient there is NO other logical way to look at it.
Any other faulty logic is SCARRY!
Sincerely,
wading thru the muck of the sleep study/DME/Insurance money pit!
wading thru the muck of the sleep study/DME/Insurance money pit!
[quote="-SWS"] My understanding is that heavy apneas begin at the end of expiration, which is why EPAP sometimes must be the equivalent pressure that was required for CPAP to clear those obstructions. Yet, if a patient does not have heavy obstructions at the end of expiration, then EPAP can be lower.
Yes SWS, "heavy apneas begin at the end of expiration, which is why EPAP sometimes must be the equivalent pressure that was required to clear those obstructions." That is what the RT said. From what you said it seems that the RT is correct and the Pulmonologist was not correct. I do not understand why Wader disagrees.
Specifically, do you agree that there is *no obstruction in the airways* during the exhalation period? My BiPap has something called BiFlex which begins the increas of pressure a couple of seconds before the end of the exhalation period. There are three options as to the degree of increase of pressure at the end of EPAP to aid as additional cushion to clear any *coming* obstruction in the airways.
I read your and Wader's post as giving opposing opinions. Do I read them improperly?
The additional sleep study the Pulmonologist recommended was to be done as a "BiPap Titration". He would start with my current settings of 13/9 (not the 17/13 the RT thought proper) and adjust both EPAP and IPAP to determine the best settings.
He said that with my first tritation results, I should never expect to get to a consistant AHI of 3or less. I averaged one apnea event every two minutes and stopped breathing for an *average* of 45 seconds per apnea (longest was 67.5 seconds). My baseline SaO2 was 91 percent and my SaO2 nadir dropped to 69 percent.
I was put on BiPap because I experienced some difficulty exhaling against a constant 13 cpap setting.
Any further comments?
Andy
Yes SWS, "heavy apneas begin at the end of expiration, which is why EPAP sometimes must be the equivalent pressure that was required to clear those obstructions." That is what the RT said. From what you said it seems that the RT is correct and the Pulmonologist was not correct. I do not understand why Wader disagrees.
Specifically, do you agree that there is *no obstruction in the airways* during the exhalation period? My BiPap has something called BiFlex which begins the increas of pressure a couple of seconds before the end of the exhalation period. There are three options as to the degree of increase of pressure at the end of EPAP to aid as additional cushion to clear any *coming* obstruction in the airways.
I read your and Wader's post as giving opposing opinions. Do I read them improperly?
The additional sleep study the Pulmonologist recommended was to be done as a "BiPap Titration". He would start with my current settings of 13/9 (not the 17/13 the RT thought proper) and adjust both EPAP and IPAP to determine the best settings.
He said that with my first tritation results, I should never expect to get to a consistant AHI of 3or less. I averaged one apnea event every two minutes and stopped breathing for an *average* of 45 seconds per apnea (longest was 67.5 seconds). My baseline SaO2 was 91 percent and my SaO2 nadir dropped to 69 percent.
I was put on BiPap because I experienced some difficulty exhaling against a constant 13 cpap setting.
Any further comments?
Andy
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FL andy,
Please read my post previous to this one. I think you and I were typing at the same time.
To repeat: If you require a pressure higher than you titrated pressure to clear apneas, than you titrated pressure was wrong. The only case in which a Bipap prescription would require yout titrated pressure to correspond with the EPAP setting would be if the titration was incorrect!
Please read my post previous to this one. I think you and I were typing at the same time.
To repeat: If you require a pressure higher than you titrated pressure to clear apneas, than you titrated pressure was wrong. The only case in which a Bipap prescription would require yout titrated pressure to correspond with the EPAP setting would be if the titration was incorrect!
Sincerely,
wading thru the muck of the sleep study/DME/Insurance money pit!
wading thru the muck of the sleep study/DME/Insurance money pit!
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Guest
My hunch is that most patients can take an EPAP pressure downward of what would have been their fixed pressure. Yet, the premise of that titration method isn't to find a more comfortable pressure, so much as it is to see how much pressure is needed to clear the airway at the end of rxpiration where obstructions are incipient. If those incipient obstructions are sufficiently heavy at the end of EPAP (and for some patients obstructions will be) then EPAP must be the equivalent of CPAP. Plain and simple.
Yet, I am under the impression that obstructions for most patients are at their heaviest during IPAP rather than EPAP. These majority patients will have an EPAP lower than CPAP pressure. That titratrion method above is not at all illogical. It is the starting point for the BiLevel phase of titration. If a patient's heaviest airway moments are during IPAP, than EPAP can be lower than CPAP (majority of cases I believe). If the patient's heaviest airway moments are during EPAP, then EPAP must be equal to CPAP pressures that were achieved during the initial phase of titration.
Yet, I am under the impression that obstructions for most patients are at their heaviest during IPAP rather than EPAP. These majority patients will have an EPAP lower than CPAP pressure. That titratrion method above is not at all illogical. It is the starting point for the BiLevel phase of titration. If a patient's heaviest airway moments are during IPAP, than EPAP can be lower than CPAP (majority of cases I believe). If the patient's heaviest airway moments are during EPAP, then EPAP must be equal to CPAP pressures that were achieved during the initial phase of titration.
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I'm refering ONLY to conditions where Bipap is prescribed as an alternative to cpap for patients who have trouble tolerating a high pressure requirement. In that case it is COMPLETELY illogical to use the titrated pressure as the EPAP pressure setting unless the titration was wrong. So far nobody has said anyhting to convice me otherwise. Feel free to try though.
Sincerely,
wading thru the muck of the sleep study/DME/Insurance money pit!
wading thru the muck of the sleep study/DME/Insurance money pit!
[quote="wading thru the muck!"]-SWS,
They all don't know what they are talking about!
In a case where Bipap is prescribed as an alternative to cpap when the patient can not tolerate their high pressure prescription, it makes ZERO sense to then up the pressure by 3-5cm.
Hey friend Wader,
Yes, we were typing at the same time.
And, yes, what you say is logical, very logical. And that is the exact point I brought up to today's RT. That if I had a bit of trouble exhaling at 13, why on earth should the lower, EPAP pressure be set at 13?
The RT explained that if possible I should never be under 13 because that is what is required to clear airways enough to preclude obstruction and keep the airways open. In order to be able to exhale against a setting of 13 the IPAP is set about four point above 13 - *and this provides more air (including more oxygen) in the lungs with which I exhale. I have more air (pressure) in the lungs with which to exhale the CO2 that needs to be exhaled. Having that extra air pressure (raised from 13 to 17) in my lungs makes it easier to exhale against a pressure of 13.
Looking at it that way, it too sounds logical.
But I'm a simple, vanilla type guy who drank too much until he was 47 years old. Even tho that was more than 20 yrs ago, I must have lost enough brain cells that i can't seem to think through all this so that it makes sense. That's why I go to y'all.
Andy
They all don't know what they are talking about!
In a case where Bipap is prescribed as an alternative to cpap when the patient can not tolerate their high pressure prescription, it makes ZERO sense to then up the pressure by 3-5cm.
Hey friend Wader,
Yes, we were typing at the same time.
And, yes, what you say is logical, very logical. And that is the exact point I brought up to today's RT. That if I had a bit of trouble exhaling at 13, why on earth should the lower, EPAP pressure be set at 13?
The RT explained that if possible I should never be under 13 because that is what is required to clear airways enough to preclude obstruction and keep the airways open. In order to be able to exhale against a setting of 13 the IPAP is set about four point above 13 - *and this provides more air (including more oxygen) in the lungs with which I exhale. I have more air (pressure) in the lungs with which to exhale the CO2 that needs to be exhaled. Having that extra air pressure (raised from 13 to 17) in my lungs makes it easier to exhale against a pressure of 13.
Looking at it that way, it too sounds logical.
But I'm a simple, vanilla type guy who drank too much until he was 47 years old. Even tho that was more than 20 yrs ago, I must have lost enough brain cells that i can't seem to think through all this so that it makes sense. That's why I go to y'all.
Andy
They don't proceed by Wader's comfort logic! They proceed by airway physics and whether the patient's airway stays patent. If a patient's airway happens to be heaviest during the tail end of EPAP versus IPAP, then that heaviest moment was also their correctly titrated CPAP pressure. Recall the beginning of that BiLevel phase of titration was a starting point and the technician might adjust upward or downward depending on the patient's airway obstructions (heaviest moments occuring during IPAP for some patients, yet during EPAP for others). Those EPAP-heavy patients in particular would not be suitable candidates for a "comfort change" to ordinary BiLevel. They would be better, comfort-wise, either staying with CPAP or specifically getting added comfort via BiFlex or C-Flex. Recall that when/if a patient's heaviest obstructions occur during expiration, it will most often be the tail end of expiration (which is why these particular patients require EPAP pressure=CPAP pressure in the first place). Yet, C-Flex and BiFlex will both achieve an IPAP-equivalent pressure by the tail end of expiration (called Positive End Expiratory Pressure or just PEEP). If that higher IPAP-equivalent pressure is presented at the tail-end of expiration, those EPAP-heavy patients can often get by with a lower BiFlex or C-Flex EPAP than they would have using ordinary BiLevel.wading thru the muck! wrote:I'm refering ONLY to conditions where Bipap is prescribed as an alternative to cpap for patients who have trouble tolerating a high pressure requirement. In that case it is COMPLETELY illogical to use the titrated pressure as the EPAP pressure setting unless the titration was wrong. So far nobody has said anyhting to convice me otherwise. Feel free to try though.
Patients experiencing their heaviest moments during IPAP can achieve added comfort by a change to ordinary BiLevel. Patients experiencing their heaviest moments during EPAP may need C-Flex or BiFlex to achieve a "comfort change" in my way of analyzing.
Hi folks,
This thread can be confusing... lol
I think the RT is wrong. Dead wrong.
Here is how and why you titrate for a bilevel machine.
You start at 4cm for both IPAP and EPAP. You then bring the I and the E up at the same time and same pressure until APNEA events are cleared. Apnea, meaning a complete blockage with no breathing for at least 10 seconds. Apnea happens at the end of EPAP, so the EPAP has to be enough to keep your airway open.
You then leave the EPAP at the point where apnea stops, and concentrate on any flow limitation, snore, and hypopnea. This is done by raising the IPAP. There must be at least a 4cm split between the IPAP and EPAP.
In my situation, my IPAP pressure it 19cm and my EPAP is 13cm. My airway is open at 13cm, so when I let out a breath, my airway is still open so I can take another breath without obstruction.
My IPAP clears, snore, flow limitation and hypopnea at 19cm.
This is simple theory.
At the time I starting a bilevel machine my titrated pressure for a cpap was 17cm. I had gained a few pounds due to school and smoking cessation, so I told the tech that if I went over 17cm, to switch me to bilevel. He knew me as a tech, so that was not an issue. I also stated this in the preinterview with the doctor. No more than 17cm on straight cpap. It seemed to work.
I have seen quite a few RT's that don't know much about sleep, which is odd to me. The RT two year degree is brutal and full of intense ventilator theory.
The board certified sleep physicians tend to be more clued in than the garden variety Cardio, Pulmo and Neuro specialists.
It is late and I am rambling. Let's just try to get along here.
All of us have opinions and I learn something new everytime I log on. That is the beauty of such a large group.
Goodknight. heheheh
T
PS. To me, bilevel machines are under-rated on this board. The bilevel is such a comfortable sleep. It's a shame that more do not get a chance to try it.
This thread can be confusing... lol
I think the RT is wrong. Dead wrong.
Here is how and why you titrate for a bilevel machine.
You start at 4cm for both IPAP and EPAP. You then bring the I and the E up at the same time and same pressure until APNEA events are cleared. Apnea, meaning a complete blockage with no breathing for at least 10 seconds. Apnea happens at the end of EPAP, so the EPAP has to be enough to keep your airway open.
You then leave the EPAP at the point where apnea stops, and concentrate on any flow limitation, snore, and hypopnea. This is done by raising the IPAP. There must be at least a 4cm split between the IPAP and EPAP.
In my situation, my IPAP pressure it 19cm and my EPAP is 13cm. My airway is open at 13cm, so when I let out a breath, my airway is still open so I can take another breath without obstruction.
My IPAP clears, snore, flow limitation and hypopnea at 19cm.
This is simple theory.
At the time I starting a bilevel machine my titrated pressure for a cpap was 17cm. I had gained a few pounds due to school and smoking cessation, so I told the tech that if I went over 17cm, to switch me to bilevel. He knew me as a tech, so that was not an issue. I also stated this in the preinterview with the doctor. No more than 17cm on straight cpap. It seemed to work.
I have seen quite a few RT's that don't know much about sleep, which is odd to me. The RT two year degree is brutal and full of intense ventilator theory.
The board certified sleep physicians tend to be more clued in than the garden variety Cardio, Pulmo and Neuro specialists.
It is late and I am rambling. Let's just try to get along here.
All of us have opinions and I learn something new everytime I log on. That is the beauty of such a large group.
Goodknight. heheheh
T
PS. To me, bilevel machines are under-rated on this board. The bilevel is such a comfortable sleep. It's a shame that more do not get a chance to try it.
Thanks Titrator,
Your explanation is easier for me to follow (in my limited capacity to understand this stuff). I have the bipap with similar pressures as yours (mine are 18/13). So you mean the 13 is needed to keep the airways open througout, especially on exhale, and the 18 is for other stuff?
So when my bipap says it has bi-flex, is that something different? (I get easily confused) I see other bipaps don't have bi-flex, is this right?
It's been awhile since I viewed my test results and the accompanying graph (and I need to find where I hid it), but should it be the 13 that shows a change to no apnea? I had thought it was only the 18, but I'm now not sure.
After four months on this I still struggle. Don't know for sure if it's a mask problem or getting used to the pressure (doc says it's getting used to the pressure). I just know that after about an hour of sleep, sometimes more, I wake up and cuss. Then I ramp. I must ramp several times a night. Frustrating. Do you find yourself tolerating the high pressure fairly well? Did it take time? Could it also be the mask? (tightening it more helps a little) But I sense it's more the pressure and not so much the mask. Because I still wake up from it but the mask isn't always leaking. I just get overwhelmed by the the wind tunnel affect, and need to ramp. I have to fight the urge to take off the mask when I wake during this, or else I run the risk of just keeping it off and falling back to sleep without it.
Please forgive my dumb questions.
But thanks for your explanation. It helps.
Linda
Your explanation is easier for me to follow (in my limited capacity to understand this stuff). I have the bipap with similar pressures as yours (mine are 18/13). So you mean the 13 is needed to keep the airways open througout, especially on exhale, and the 18 is for other stuff?
So when my bipap says it has bi-flex, is that something different? (I get easily confused) I see other bipaps don't have bi-flex, is this right?
It's been awhile since I viewed my test results and the accompanying graph (and I need to find where I hid it), but should it be the 13 that shows a change to no apnea? I had thought it was only the 18, but I'm now not sure.
After four months on this I still struggle. Don't know for sure if it's a mask problem or getting used to the pressure (doc says it's getting used to the pressure). I just know that after about an hour of sleep, sometimes more, I wake up and cuss. Then I ramp. I must ramp several times a night. Frustrating. Do you find yourself tolerating the high pressure fairly well? Did it take time? Could it also be the mask? (tightening it more helps a little) But I sense it's more the pressure and not so much the mask. Because I still wake up from it but the mask isn't always leaking. I just get overwhelmed by the the wind tunnel affect, and need to ramp. I have to fight the urge to take off the mask when I wake during this, or else I run the risk of just keeping it off and falling back to sleep without it.
Please forgive my dumb questions.
But thanks for your explanation. It helps.
Linda
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-SWS wrote:They don't proceed by Wader's comfort logic! Laughing They proceed by airway physics and whether the patient's airway stays patent.
-SWS, AGAIN, I'm refering ONLY to conditions where Bipap is prescribed as an alternative to cpap for patients who have trouble tolerating a high pressure requirement.
I've heard direct from the mouth of the Respironics Rep. I have read it in many posts on this and other boards. I could probably find 100+ posts of people that have been switched to Bipap solely for the reason that they could not tolerate their higher cpap pressure requirements. They are being treated at 15cm on the cpap and they tell the Doc they can't tolerate it. If the Doc then prescribes a Bipap as a replacement and the RT/DME sets it up at 19/15cm that is wrong and WILL NOT provide the patient the additional comfort they need to tolerate the therapy. Nor will it provide them any necessary additional airway clearing therapy.
These are people we are talking about not airways. If this mistake is made and they quit therapy all together because the "more comfortable" alternative is worse than the original, then the medical professionals have failed at their duty.
In FL andy's specific case it is unclear what pressure he really needs because when he refers to clearing apnea events we don't know if he was told using derek's doc's, we call 'em all apneas, definition or if they were just full apneas, cleared at 13cm. My point is that whether this and other cases mentioned on the forum, have occured from lack of correct information or a misunderstanding of the correct proceedure, it is SCARY that this is occuring. To me, it is just another indication of the sad state the sleep disorder treatment industry is in.
Titrator, You are correct that the BiPAP is underrated on the forum. From my use of my APAp with C-flex, I can feel the extreme comfort acheived with a lower pressure against EPAP. 17cm on a straight CPAP must be like trying to swim up stream. Eventually we'd all turn into Jonny Weismuellers, but until we reach that point it makes for some long hard swims.
Sincerely,
wading thru the muck of the sleep study/DME/Insurance money pit!
wading thru the muck of the sleep study/DME/Insurance money pit!
Wader,
Found a reference to the Protocol used for Bipap. What Titrator is say is correct technically. The correct way to titrate a Bipap is to do as he stated. BUT BIPAP is being used as an alternative to CPAP for compliance. So, I would tend to agree that protocol goes out the window when trying to get a patient compliant.
Too bad RT's and Docs don't read, CFLEX is a cheaper alternative.
Found a reference to the Protocol used for Bipap. What Titrator is say is correct technically. The correct way to titrate a Bipap is to do as he stated. BUT BIPAP is being used as an alternative to CPAP for compliance. So, I would tend to agree that protocol goes out the window when trying to get a patient compliant.
Too bad RT's and Docs don't read, CFLEX is a cheaper alternative.