Bi-Level Therapy Causes Leaking?

[dkeat]

Please read the following quote from the Ultra Mirage FF Mask page at cpap.com:

"Around 40% of CPAP users and almost all bilevel users lose treatment pressure through their mouths, either by mouth breathing or mouth leak.1-3 This pressure loss can result in flu-like symptoms, less effective therapy, and disrupted sleep.4 The Ultra Mirage full face mask stops this loss thereby improving comfort and therapy."

Almost all bi-level users lose treatment pressure through their mouths?

Is this true? Would that mean that I might handle mouth leaking by going to straight CPAP from CFLEX?

Thanks.

[ozij]

People are given Bi-level treatment when there pressure is high - to help them with exhaling.

I think the point is that the higher the pressure, the higher the chances of losing treatment pressure through your mouth.

O>

[rested gal]

I think ozij nailed the point.

[Sleepless on LI]

The way my son (an RRT) explains it is (I hope I'm paraphrasing correctly) BiPAP is given to those who cannot tolerate CPAP. As CPAP just sets an end pressure on exhalation, BiPAP sets an inspiration and an exhalation pressure. It is prescribed for those who have contributing pulmonary or respiratory problems, and the actual machine is more a ventilator than an ordinary CPAP machine.

Cflex, however, is used when you can tolerate CPAP and helps make patients more compliant by making exhalation against higher pressures easier. There are no other contributing medical respiratory factors other than making it easier to exhale, causing patients to be more likely to be complaint.

I am taking "bi-level" to mean BiPAP.

[dkeat]

Well thank you for your comments.

I was thinking about it myself a bit. Was wondering if the costant high-pressure of CPAP might not "splint" the airways open when shot through the nose. In the case of BIPAP there is the exhalation pressure which is much less and might cause the airway to collapse allowing the next onrush of air to pump out the mouth.

I can see your logic that BIPAP users might be getting a greater pressure than a CPAP user. But wouldn't that tend to splint open the airway even more?

Me just ignorant I guess.

David

[Sleepless on LI]

The airway does not collapse. I was surprised at the explanation when my son said the CPAP only has an end pressure set for exhalation. The question was posed, then how does it help stop people who snore on the inhale? His answer was very enlightening. When you are titrated, they determine the rate of pressure necessary to keep your airways open CONSTANTLY, which is why it's called CPAP, CONTINUOUS positive airway pressure. Makes sense. He said because it will not allow you to have any pressure less than what your end pressure is set for on your machine, your airways will remain open at that pressure regardless if you are inhaling or exhaling. With BiPAP, however, which is a different animal entirely, it regulates both the inhalation and the exhalation, sort of like breathing for you.

Hope I got it right...

[rested gal]

In the case of BIPAP there is the exhalation pressure which is much less and might cause the airway to collapse allowing the next onrush of air to pump out the mouth.

I may be very wrong about this, but I think I've read that in most bi-level titrations, the EPAP (pressure used for exhaling) is set high enough to keep the airway from collapsing. Then they go on titrating up from that.

Mar 18, 2005 subject: Questionable advice from Pulmomologist

[Sleepless on LI]

In the case of BIPAP there is the exhalation pressure which is much less and might cause the airway to collapse allowing the next onrush of air to pump out the mouth.

I may be very wrong about this, but I think I've read that in most bi-level titrations, the EPAP (pressure used for exhaling) is set high enough to keep the airway from collapsing. Then they go on titrating up from that.

Mar 18, 2005 subject: Questionable advice from Pulmomologist

Exactly right. They set the end pressure upon exhalation so that the airways can never collapse. On the money as usual, RG.

[dkeat]

I may be very wrong about this, but I think I've read that in most bi-level titrations, the EPAP (pressure used for exhaling) is set high enough to keep the airway from collapsing. Then they go on titrating up from that.

Well, I'm not really arguing with you guys. The quote that I put in my first post implies at least that people on straight CPAP only lose pressure 40% of the time and those on BIPAP 100%. That is quite a statement. They don't say why, which kind of leaves me up in the air.

I mean if I could raise my odds by 60% just by going onto straight CPAP I'd do it.

[rested gal]

I think it's interesting, David. Not arguing either. But I think the 40% figure is based more on the fact that there may be many cpap users who are prescribed a very low straight pressure in the first place.

Bi-level users generally are ones who need a bi-level simply because the single pressure they'd be prescribed is often a high pressure ("high" for that person, anyway) and would cause them too much difficulty to exhale against.

I wonder if it's like a chicken/egg thing. In this case, I think the prescribed high pressure comes first, leading to more chance of mouth air leaks. The high pressure making the mouth leaks more likely to happen regardless of which type of machine that particular prescribed-a-high-pressure person was put on.

For that matter, some people just are going to leak air out the mouth whether they are on cpap at a prescribed pressure which happens to be thought of as "low", or they are on bi-level at that very same pressure for EPAP.

Then, of course, there's the relativity of what's the definition of a "low" or "high" pressure anyway. LOL!! There are people who handle straight 18 without blinking an eye or leaking a drop out the mouth (mask can be another ballgame) and others for whom 7 is a mouth-gasping hurricane.

[rested gal]

Still not arguing...speculating about this kind of stuff is fascination to me. Just thought of this:

The ResMed quote says, "almost all bilevel users". Doesn't mean 100%. Would be interesting to know what "almost all" means to ResMed... 80%? 99%? And how they arrived at the statement.

Also...this:

The quote that I put in my first post implies at least that people on straight CPAP only lose pressure 40% of the time

I didn't take the quote quite that way. I took it that 40% of the people on straight cpap will have mouth air leaks...and 60% won't. I didn't take it to mean that all straight cpap users will leak air 40% of the time. Actually, I don't think that's how you meant it either...just came out worded that way.

[Sleepless on LI]

Rested Gal writes:

Bi-level users generally are ones who need a bi-level simply because the single pressure they'd be prescribed is often a high pressure ("high" for that person, anyway) and would cause them too much difficulty to exhale against.

From what I understand, the USUAL reasoning behind placing someone on BiPAP is due to contributing health factors that would render them intolerant of CPAP. I don't really think they put you on BiPAP because your end exhalation pressure would be too high as there is always CFlex for that. From what was explained to me, it's on account of other medical factors that would make the user CPAP-intolerant, such as pulmonary problems and the like.

HOWEVER, after researaching the issue, I found the following:

• BiPAP is also referred as non-invasive face mask ventilation. Bi-level means that with each breath the individual takes, the pressure changes. The pressure rises when inhaling and drops when exhaling, making breathing easier. BiPAP therapy is usually prescribed for patients with sleep apnea if the CPAP therapy is too difficult.

So I guess there is actually a validity to placing one on BiPAP if the pressure would be too high. Right again, RG. Both reasons, though, are valid.

[rested gal]

I don't really think they put you on BiPAP because your end exhalation pressure would be too high as there is always CFlex for that.

I think in actual practice that probably does happen a lot - moving someone to bi-level simply because they have too much trouble exhaling against a high straight pressure, even if they have no underlying pulmonary or other respiratory problems.

Reason I say this is that up until now there has been no manufacturer other than Respironics (with C-Flex) who made a straight cpap machine with any kind of relief during exhaling. However, many sleep doctors and DMEs in some areas use only ResMed machines. There would be no exhalation relief with a ResMed straight cpap, until the past few months, when EPR was introduced.

Patients who needed "comfort" relief during exhaling would be prescribed bi-level from doctors who believed in ResMed products and DMEs who carried only ResMed machines. Often, those patients had to endure straight cpap for a month to "prove" they couldn't use a single straight pressure before insurance would ok switching them to bi-level. But bi-level is what many eventually got...to make them able to use this kind of treatment at all, not because of a pulmonary problem.

Also gotta factor in the number of sleep doctors who don't "believe in" C-Flex. Those are WillSucceed's heroes on the front line!

[Sleepless on LI]

Rested Gal,

I hope you read my entire post. When I researched it, you were right. I had included the quote from the article I read saying that they, in fact, do put you on BiPAP if you will have trouble with CPAP and exhalation. I agree with you. It is one of the reasons for putting you on it.

Please accept my apologies if I didn't write it clearly enough. You are correct in that statement.

[christinequilts]

Almost all bi-level users lose treatment pressure through their mouths?

Is this true? Would that mean that I might handle mouth leaking by going to straight CPAP from CFLEX?

That was mentioned in a chat at TAS when the Activa was introduced almost 2 years ago. Since I'm on BiPAP, it caught my attention. The rep didn't answer my question in the official chat, but did address afterwards. If I remember correctly, it isn't as bad as the stats make it out to be...it basically boiled down to an old stat that is still quoted way too much from back in the early days of xPAP...before heated humidifiers and such. You also have to remember that BiPAP users are more sensative to mouth leaks because they can cause the BiPAP to get out of synch. BiPAPs are used for a lot of different breathing problems not related to OSA, so that further complicates statements like the one you quoted- is that for people with OSA? acute care settings? daytime or night time use? One major concern is that if there is a major mouth leak is that the BiPAP will not 'read' the patients breathing as accurately and not be in synch as well as it should be. Thankfully new masks more leak proof...and comfortable- I was just reading an interview with someone who had been on CPAP for over 20 years- his first masks had to be glued in place over night to seal. Compare that to what we have now...thank goodness we have lots of good masks to pick from- and no glue (unless RG comes up with some inovative ideas.... )

Found some more info on BiPAPs & masks:
Nasal versus full face mask for noninvasive ventilation in chronic respiratory failure- http://erj.ersjournals.com/cgi/content/ ... /4/605#R11 Full face masks appear to be as effective as nasal masks in the delivery of noninvasive ventilation to patients with nocturnal hypoventilation. However, a chinstrap was required to reduce oral leak in the majority of subjects using the nasal mask. ...a little more recently publication date of 2004, but by the list of masks used, the data was collected several years before. FYI- Noninvasive ventilation is another term for BiPAP/BiLevel PAP & nocturnal hypoventilation is another term for CSA

From ResMed's chat on TAS for VPAP:
Your Web site says that "Recent studies show that all patients on bilevel therapy experience mouth leaks" why is that? I wanted to try a bilevel, but now am not sure. Did I misunderstand?

This comment has just been changed to clarify that patients with "nasal masks" experience mouth leaks. The studies that the comment refers to showed that sometime during the night in virtually all the patients in the study, mouth leak was noted. In fact, this is a true statement for a high percentage of CPAP patients as well, but it is more of an issue with bilevel due to the need for a bilevel unit to know what breath phase the patient is in at all times. If there is a significant mouth leak, bilevel units are unable to accurately track whether the patient is inhaling or exhaling. The result is the patient can get out of sync with the unit. Don't be alarmed; there are a few ways to deal with this potential problem. First, there are chin straps, but these are often ineffective. Then there are full face masks, which sound worse than they are, especially if you get a Mirage full face mask. And lastly, there are features in VPAP that prevent the inspiratory time from getting out of control, which is the main manifestation of this problem as it relates to bilevel units. http://www.talkaboutsleep.com/sleep-dis ... APchat.htm