Is BiPAP not for mouth breathers?

[oneantonee]

Okay, I've been reading a lot about all the different technologies and features and figuring out what I need and want. Although I don't think I need nor want the BiPAP at this point, because my pressures are low (9cm) and I would probably do better with an Auto with C-Flex, as this will compensate for increased sedation from pain or sleep meds, as well as different sleep patterns from what I experienced in the "lab".

However, I want to clarify something that I was told by my RT. He said that BiPAP could not be used with mouth breathing. Is this correct? I just want to know so that I will know what my options are if Auto with C-Flex doesn't go well.

Thanks again,

Antonio

[dsm]

What the RT said may well be true - but with lots of qualifications. But from my own extensive experience as a regular user of a f/f mask (due to constant bouts of nasal congestion) the reverse is true if applied to use of 'BiLevel' vs BiPap.

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Notes:
- BiPap is a Respironics brand. Vpap is a ResMed brand. BiLevel is a generic term.

- Some BiLevels have a 'T' after the model name - this stands for 'Timed' mode which allows for setting a period or rate that is used to flip the machine from breathing IPAP (in) to EPAP (out). Most BiLevels are what we call 'S' mode. S stands for Spontaneous which means that the BiLevel has a 'flow sensor' that it uses to detect your changing breathing (in flow / out flow) and this 'spontaneously' flips the machine's airflow from IPAP to EPAP.
Most modern machines *should* have very good flow sensing circuitry.


I use as my regular xPAP, a PB330 Knightstar BiLevel. This is set for 15cms for IPAP and 8 for EPAP. It works perfectly and can handle *all* the conditions I throw at it including ..
- Very slow breathing
- Very shallow breathing (often constrained by my nasal congestion)
- Very deep breathing (when I 1st go to sleep)
The PB330 is what is known as an 'T' mode machine as it can be used to set a breathing rate that encourages the user to breath again if they are prone to 'centrals' (reduced or stopping breathing *not* due to an aponea blockage)

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I also own a (Heathdyne - now Respironics) Tranquility BiLevel and this machine too works as well as the PB330 in the same conditions (very nice machines these. Absolute bargains for anyone who can get their hands on one). These are not 'T' capable but just flip from IPAP to EPAP in 'S' mode.

I also own a Respironics BiPap Pro 2 (S) and a Respironics BiPap (S/T)

I purchased the BiPap Pro 2 after it had been damaged by water. I refurbished it and replaced the motor bearings but despite my repair efforts, I concluded it was defective because it kept flipping from IPAP to EPAP when I used my f/f mask and I had any nasal congestion. But, it did work as expected in all modes if I used a Breeze nasal pillows mask. But as said I considered it was defective.

Then last month I bought a brand new unused Respironics BiPap S/T (their most up to date model). Inside. it is mechanically identical to the BiPap Pro 2 except it has more sophisticated electronics and more controls.

To my chagrin, I found that it behaved almost *exactly* the same way my supposedly 'defective' BiPap Pro 2 does. I have attached a Manometer to observe the airflow CMS & although it is supposed to be one of the most sophisticated BiLevels on today's market, I haven't yet used it because of its poor results when I test it. It flips far too quickly from IPAP to EPAP if I use my F/F mask and I breathe slowly through my nose.!!!. In fact the same happens if I use my Activa mask as well.

I did get the new BiPap S/T to *mostly* work if I dropped my upper pressure from 15 to 14 and increased my lower pressure from 8 to 10. Then it started to behave more as it should. However if I use a nasal pillows mask (Breeze or Adams Circuit) it behaves pretty well as hoped for even at my original pressures.

So I have requested yet another BiPap Pro 2 just to compare it with these other 2 as if it behaves in the same way then I will conclude that Respironics BiPaps may have some issues in just what conditions they can handle.

It will be about 2 weeks before I get to evaluate the third Respironics BiPap and I must admit I don't want to guess as to how it will behave when I test it. I am not very optimistic. If it behaves the same as the other 2, I will try experimenting with different masks to see if it really is a flow related failure. AUTO-Track is *supposed* to be able to recognise constant leaks. All masks have a fixed leak rate. My suspicion is that the BiPaps may work best at low CMS settings, i.e. not for people like me on 14-15 CMS.

I want to get my hands on a ResMed VPAP II or III (S or S/T Models) but that opportunity has not yet arisen.

I had wanted to switch from my PB330 to the BiPap S/T because of the detailed datacard recording the BiPap machines do but I am sticking with the PB330 until I can come to some firm conclusions about what may be right or wrong with the Respironics BiPap models.

SUMMARY:
If this RT was talking about my Respironics BiPap machines, he may well be 100% correct. But I can assure you that mouth breathers would have no trouble using a PB330 or a Heathdyne BiLevel. I can't yet speak for the ResMed units.


DSM

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CPAPopedia Keywords Contained In This Post (Click For Definition): respironics, resmed, bipap, breeze, manometer, Nasal Pillows

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CPAPopedia Keywords Contained In This Post (Click For Definition): respironics, resmed, bipap, breeze, manometer, Nasal Pillows

[oneantonee]

DSM,

Thank you for the reply. From your response, I remembered that the BiLevel Respironics machines turned around from I to E on me too quickly also, so it was forcing me to breathe faster than I normally would and I could not tolerate it. Since you had the same problem, I am wondering if the machine you are on would work for me. I will keep it in mind as I am trying the APAP I am getting. Hopefully, THAT, or straight CPAP with C-Flex will work and I won't need a different machine.

Best wishes,

Antonio

[rested gal]

Antonio, I've used 4 bi-level machines. Didn't "need" them, just wanted to try them to see how they felt.

Respironics BiPAP Pro with Bi-Flex
Respironics BiPAP Pro 2 with Bi-Flex
ResMed VPAP III
ResMed VPAP III ST

On all of them, there is a setting for "rise" time. Getting that setting right is crucial for getting a bi-level machine in synch with the length of time you normally inhale.

Unfortunately, many DME's probably are not aware of the "rise" setting. They probably set a bi-level for IPAP pressure, EPAP pressure, and that's it. The factory default setting for "rise" time may not suit a person...in which case the machine will, indeed, cut out too early during inhaling.

There is a poster nicknamed christinequilts who has pure Central Sleep Apnea and uses a Respironics Synchrony BiPAP ST. In one of her posts, she mentioned that she has to set the "rise" time to its maximum...maximum length of time to allow the higher IPAP (inhaling) pressure. Christine's full post about that is here:

christinequilts discussing "rise" time and bi-flex.

I found that to be true of all 4 bi-level machines I used. Once I set the "rise" time to its maximum length of time, the machines did not cut out on me during inhaling unless I drew an unusually long breath.

There are some additional settings on all those machines, but rise time is the most important one for having a bi-level machine feel comfortable and not switch to the exhale pressure prematurely while you're still inhaling.

The Bi-flex feature on Respironics BiPAP's also needs to be set to suit a person or be turned off. Bi-Flex has 3 settings to give a momentary dip at the beginning of the exhale pressure. Makes the start of the already lower exhale pressure a tad lower even.

All that said, I agree with you that at your prescribed pressure of 9, you probably don't need a bi-level machine at all. Autopap is a good choice as you can operate the autopap as an auto or as a cpap. The machine you have in mind, the Respironics REMstar Auto with C-Flex, is very versatile and should do fine for you.

As for and RT telling you that bi-level machines are not suitable for mouth breathers, that's a puzzling statement. If a person is wearing a full face mask, it doesn't matter whether they breathe through the mouth with any machine. But if a person is NOT wearing a full face mask and starts breathing through their mouth with ANY machine, they are not going to get treatment air going where it's supposed to go.

What matters with mouth breathers is what type of mask they are using or what control they use to make mouthbreathing impossible; not what type of machine they are using.

Gotta have a full face mask if the mouth breathing and/or mouth air leaks cannot be controlled in other ways -- for example with a chin strap (largely ineffective, imho), or taped mouth (very effective.) Or by some means to make the tongue maintain a seal within the mouth, like the DIY homemade mouthguard described here:

mouth leak solution, cheap DIY oral appliance Topic started by frequenseeker

[Bella]

I have been using the Synchrony BiPap S/T since late November. Actually, I've had two - first the rental, and then my own. When my second one arrived I found that the machine flipped way too quickly between IPAP and EPAP. DSM, I'm probably silly to mention this to you, but what I did was adjust the rise time. That gave me much more space between breaths.

I find that the Autotrak feature on these machines adjusts to my natural breathing rate very easily. Too easily perhaps - after years of shallow breathing, and central apneas, I found the precision of the timed IPAPs to be so rhythmic, that was sleep inducing in itself! I miss that now that I seem to be breathing better on my own while falling asleep.

[Bella]

Just as she said I set my machine to max rise time. And like christinequilts, I have pure central sleep apnea. (Christine's postings have been of great help to me.) My second machine came with the rise time set mid-way and I thought I would choke using it. I grabbed the manual and figured out what to do. I couldn't have slept with it like that. I also have a full face mask. I don't use it much any more, but the only problem I had was leakage - noisy leakage. And I certainly breathed through my mouth when I had a bad cold.

[NightHawkeye]

It too flips quickly from IPAP to EPAP if I use my F/F mask and I breathe slowly through my nose.!!!.

Interesting stuff, DSM. I noticed a similar phenomenon with my BiPAP-Auto. I experienced early triggering of IPAP, which was not only annoying, it also led to runaway pressure increases. I suppose this is all just a measure of how well a particular machine can adapt to the breathing pattern of an individual patient.

FWIW, I also notice the same phenomenon in the Remstar-Auto. I experience it with C-flex, of course, since C-flex is kind of a mini-BiPAP function, but I also experience it in normal CPAP mode with the Remstar-Auto sometimes. In CPAP mode, it is merely annoying as the machine attempts to maintain constant pressure but is out of phase with my breathing slightly. In auto mode, however, at times it leads to runaway pressure increases just as happened with the BiPAP-Auto.

All of this makes me think that the Respironics algorithm may not be the best one for me. Just another reason for me to try other machines, just as you have, DSM. Well . . ., maybe not quite like you have, as I'm not sure I want to take 'em apart and take pictures of 'em. (But, hey, I'm not really opposed to doing that either.) For travel, the PB-420E seems to be the way to go, so I'm thinking now that I'll probably get one of those when I'm ready to turn loose of the cash.

I can hardly wait until I've built up my trading stock as you have, DSM. .

My apologies to you, Antonio, if this seems a little off-topic. However, I thought you might appreciate hearing about a not-so-great C-flex experience. Although most folks do well with C-flex, there is no guarantee that you will. If you do not do well with C-flex, be advised that there's a good chance you won't do well with any BiPAP machine made by Respironics either, because it appears that their C-flex and BiPAP algorithms are similar. My recommendation to you or anyone who's C-flex experience isn't so great, would be to first try a different manufacturer's machine.

Regards,
Bill

[oneantonee]

[quote="Bella"]I find that the Autotrak feature on these machines adjusts to my natural breathing rate very easily. Too easily perhaps - after years of shallow breathing, and central apneas, I found the precision of the timed IPAPs to be so rhythmic, that was sleep inducing in itself! I miss that now that I seem to be breathing better on my own while falling asleep.

[ufo13]

Such great information from Rested Girl, Doug (DSM), and NightHawkeye! And as you point out NightHawkeye, some people had trouble with the c/flex, me included! I got to the point where i just shut it off completely! While this machine gave fine treatment to me set at 13 to 18 cm as opposed to the straight cpap I had, set at a fixed 18cm H2O, I did have trouble with the c/flex timing and up & down noise.
I recently had the opportunity to get a Res-med S8 vantage auto w HH which I use as a passover which works great for me. It is a great unit to travel with due to it's size, and it reports enough information in the clinical menu reference treatment results which I record each morning. This eliminates the software, computer, smartcard downloads which when traveling is very convienient for me. When I got this machine I spoke with Doug (DSM) and he was kind enough to share much information with me which made my treatment even more benificial and gave me a better understanding of what the results were telling me! It also has the flexability to be used as a straight cpap w/ the EPR feature, which I have not had to utilize yet!
So great info from everyone and I just pass the above info along as it colaberates what has been reported by others as well as giving some new information for anyone interested!
I might add if anyone is considering the resmed S8 vantage, I like the auto on/off feature on this machine much better than the rest. When you put your mask on it starts treatment almost instantly! When you take the mask off it stops in aprox 3 to 5 seconds!
I know this is a little off topic but I felt it would help Antonio and others.


best to all,

Steve,
ufo13

[Guest]

If you have trouble with or don't like the Respironics cflex feature on a cpap or apap machine, then you probably wouldn't like the biflex feature on their bipap machine. But disliking the feeling of cflex doesn't mean you'd dislike the bipap machine. That's a different animal altogether. A bi-level machine's preset decreased exhalation pressure is not comparable to the short-lived and variable exhalation relief of cflex.

[rested gal]

True, Guest. Besides, the Bi-Flex feature can be turned off completely with the Respironics BiPAP, just as C-Flex can be turned off with their other machines.

[dsm]

I found the Bi-Flex feature on the Respironics BiPaps to be ok. I tend towards the middle to low setting.

Re the rise time on the Respironics BiPaps, I tried every combo of settings and still had trouble with the IPAP to EPAP flipping. It seemed to me that the Respironics BiPap models are not coping with the fixed-leak rates of the masks as well as the PB330 & Healthdyne machines do. In the PB330 there are 6 settings to choose from that cater for low to high fixed-leak rates. The Healthdyne BiLevel hasn't got this option but it flips between IPAP and EPAP without any trouble!.

I did a *lot* of testing before I settled on a final config with my PB330 which is significantly more complex than the Respironics BiPaps when it comes to mixing all the possible settings (even more than the new BiPap S/T). So making adjustments such as the rise time on the Respironics BiPap models is a very simple exercise by comparison but I do appreciate the comments offered re this as a possible cause.

It does interest me that others here find the same problem. Once I validate my findings with a 3rd BiPap I will be writing to Respironics to discuss the problem.

Cheers

DSM

[NightHawkeye]

But disliking the feeling of cflex doesn't mean you'd dislike the bipap machine. That's a different animal altogether. A bi-level machine's preset decreased exhalation pressure is not comparable to the short-lived and variable exhalation relief of cflex.

I stand by my original statement

My point was about the timing, not the flex feature though. Respironics timing algorithm just happens to trigger prematurely on my own personal breathing pattern sometimes. It happens with CPAP, APAP, BIPAP, C-flex, and Bi-flex. I hoped I'd made that clear earlier.

For those that may not be aware of it already, a CPAP machine does in fact have timing, and not only responds to a person's breathing but also must predict the breathing and decide when to increase and decrease the amount of air it is delivering. A CPAP machine delivers constant pressure, but that is not a constant amount of air, not by a long shot. The amount of air being delivered by the machine is designed to vary as one's breathing varies with every inhale and exhale. Respironics algorithm anticipates one's breathing based on a number of factors including the rate at which one has been breathing.

At any rate, my point was not to bash Respironics. Their algorithm works wonderfully for most folks. C-flex appears to be a blessing for many. However, the Respironics algorithm is not ideal for DSM, and apparently not ideal for me either, although I can't compare it against another machine, at least not yet.

Just relating my own personal experience as I thought it might further the discussion.

Regards,
Bill

[Guest]

For those that may not be aware of it already, a CPAP machine does in fact have timing, and not only responds to a person's breathing but also must predict the breathing and decide when to increase and decrease the amount of air it is delivering. A CPAP machine delivers constant pressure, but that is not a constant amount of air, not by a long shot. The amount of air being delivered by the machine is designed to vary as one's breathing varies with every inhale and exhale. Respironics algorithm anticipates one's breathing based on a number of factors including the rate at which one has been breathing.

A straight cpap -not an apap- machine does all that?
Everything I thought I understood about the difference between cpap and apap was wrong. Now I am really confused.

[dsm]

Bill meant to say xPAP rather than CPAP. Bill is pretty well informed & what he has said is correct for certain models of xPAP. CPAPs don't all have pressure-sensors or flow-sensors fitted & these devices are a prereq for the measurements mentioned.

Cheers

DSM