BiPAP Cures Aerophagia

Guest-DSM · Post by **Guest-DSM** » Tue May 09, 2006 12:35 am

RG,

The second link quoting SWS is a gem. Very well covered.

>> QUOTE - SWS
A. This air-pressure threshold seems to vary from patient to patient depending on quite a few physiological circumstances. By clicking HERE you can see one college that claims: "Gastric Distention can occur in persons because the pressure needed to force air down the esophagus and into the stomach is in the vicinity of 18 – 20 cmH2O." A few days ago I happened accross yet another reference that claimed 15 cm was the magic threshold before many patients began to experience CPAP-induced aerophagia. However, depending on your own physiological architecture, you may never experience aerophagia, or you may begin to suffer from CPAP-induced aerophagia at a much lower pressure. Again I think it's absolutely amazing how many of us have posted that our own medical professionals are completely unaware of the link between CPAP and aerophagia. If your medical professional seems unaware of this medical fact, and it happens to prove both relevant and crucial to you, be sure to print plenty of reputable references from the Internet to show them.
<<

If I take SWS's comment re the 15CMS or 18CMS threshold for breaching the esophagus - it fits in with my own experiences & my comment re breathing out against 15 CMS being pumped in & that causing a compound increase in CMS in the mask (I have tried to measure this with a CMS gauge but haven't got conclusive data yet due to inadequate set up).

Am hoping that the gauge when set at the right location (near my face or tapped out from the mask), should show what peak CMS is reached when breathing out in CPAP mode. The readout on my PB330 dial shows peaks of 18 but I don't know if I can trust what I am seeing because it shows as so transient & also I had EPAP (at that time) set to 8.

If I was running an AUTO & it was ramping up its pressure in response to a bad nights sleep (as happened from time to time - esp after glasses of wine ) then the pressure could easily go higher (as it seems to have done according to some nights readouts).

It seems to me that a BiLevel by reducing the breatheout pressure, is reducing the likelihood of the esophagus being breached by high CMS during exhale. I had suspected for some time that 8 CMS EPAP whilst very nice to have, was allowing some problems to occur. I do like the idea of a BiLevel AUTO & think respironics are on a winner with that direction if they can improve their algorithms for analysing the difference between fixed-leaks & breathing & accidental leaks.

- an interesting topic

DSM

NightHawkeye · Post by **NightHawkeye** » Tue May 09, 2006 5:07 am

To add another data point:

After a week with BiPAP set to 9/6 and very little aerophagia, I changed to 10/6 last night and now have mildly painful aerophagia this morning. One thing I noticed through the night is that I kept getting out-of-sync with the machine. I may keep the pressure at 10/6 for a few days though to see if I can "condition" myself to the higher pressure and stay in sync with the machine more. As it is now, I'm not sure now how much the aerophagia was caused simply by the times I'm trying to exhale against the higher pressure at the wrong time.

It is amazing that such a seemingly small change, going from 9/6 to 10/6, has made such a large change in aerophagia for me. A threshold was definitely crossed, but there's no way to tell exactly which threshold.

Regards,
Bill

Ric · Post by **Ric** » Tue May 09, 2006 8:29 am

NightHawkeye wrote:I kept getting out-of-sync with the machine.

I don't own/use/understand BiPAP, but I thought the Digital Tracking feature was supposed to do a better job of following your breathing patterns.(?) How does that work? Is it something you can enable/disable, set tracking parameters, etc? What are the limits? Can it be set to a fixed breathing rate? What's the range? Do you consider BiPAP the way some of us advocate for APAP, that is, everyone (who could afford it) might be better off with one? Now I'm curious.

Regards,

-Ric

NightHawkeye · Post by **NightHawkeye** » Tue May 09, 2006 8:56 am

Ric wrote:Do you consider BiPAP the way some of us advocate for APAP, that is, everyone (who could afford it) might be better off with one? Now I'm curious.

Good question, Ric. I bought the BiPAP-auto to begin with because I only wanted to buy a machine once without having to upgrade, etc. My experience hasn't really borne that out though. I've had difficulties using the BiPAP several times. Based on that I can't say I'd recommend it for everybody, but I'm glad to see that some folks have been successful doing that very thing.

As for adjustments, there aren't many. IPAP, EPAP, I/E transition time (I forget the name it has), and flex level. Might be something else lurking there though. Respironics kinda assumes their algorithm works so no need to adjust tracking. .

Regards,
Bill

dsm · Post by **dsm** » Tue May 09, 2006 2:53 pm

My experience with Respironics BiPaps (vs Healthdyne BiLevel & Puritan Bennett Knightstar) is the the 2 Bipaps I have at the moment (Bipap S/T & Bipapa Pro 2 & another Pro 2 on its way for comparison) keep flipping from IPAP to EPAP very soon into the breathe out cycle if I use my normal (Mirage) F/F mask.

There is nothing I can adjust that seems to prevent this even with the Bipap S/T.

Also all of the above models dissapointingly don't provide any nightly detail data on AHI HI & AI. The Bipap AUTO is the only one that does but it too seems to have this early flipping problem.

I am still gathering data as I plan to send it to Respironics but want to make sure the info is helpful & meaningful.

I also now have a VPAP III S (not the S/T model) on the way (in a couple of weeks) & will test that as well.

I believe at this stage the Auto-track is failing to recognise fixed-leak vs accidental leak vs breathing.

DSM

rested gal · Post by **rested gal** » Wed May 10, 2006 12:24 am

dsm wrote:Bipapa Pro 2
----
Also all of the above models dissapointingly don't provide any nightly detail data on AHI HI & AI.
----
DSM

The Respironics BiPAP Pro 2 provides full details in the data download. AHI, HI, AI, leak rate ...it's all right there in the Encore Pro data download. Was in the one I used, anyway.

About the "early flipping" from IPAP to EPAP that keeps being mentioned. Unless I drew an occasional very unusually long breath, that never happened for me with any of the bi-level machines I used:

Respironics BiPAP Pro
Respironics BiPAP Pro 2
ResMed VPAP III
ResMed VPAP III ST

All of them gave me very smooth, very comfortable treatment when the settings were tweaked right. Actually, the Respironics BiPAPs worked best for me right out of the box, requiring the least amount of tweaking.

The ResMed machines needed the IPAP Max setting adjusted for its longest time to suit me, or they did cut off the inspiration pressure (IPAP) too soon. Once that was adjusted to the max, the VPAP III was just as comfortable for me as the BiPAP.

I can understand why people who need very definite relief exhaling find bi-level machines so comfortable.

If I had to start from scratch and get just one machine, I'd get the Respironics BiPAP Auto with Bi-Flex...the machine NightHawkeye and a few others on this board have. Would be nice to have the best of both worlds working at once - bi-level for wonderfully precise exhalation relief and auto for varying the pressure as needed. If a person wanted to, the machine could even be used as a straight CPAP by setting IPAP/EPAP to the same single pressure. Quite versatile.

NightHawkeye · Post by **NightHawkeye** » Wed May 10, 2006 5:01 am

NightHawkeye wrote:It is amazing that such a seemingly small change, going from 9/6 to 10/6, has made such a large change in aerophagia for me. A threshold was definitely crossed, but there's no way to tell exactly which threshold.

Well, I went to bed for the second night at 10/6 thinking things were pretty good with it, but then had a few instances through the night where I just kept being out-of-sync with the machine. Sleep had been definitely more peaceful at 9/6. I finally even gave up and got out of bed an hour earlier than usual this morning, because I just kept being out-of-sync with it. Funny thing is, this wasn't just the early flipping DSM has been talking about. Because the CL2 is so quiet, I'd usually only notice it when I was 180 degrees out-of-phase and breathing out against the full IPAP pressure

When I got up I knew I wasn't as rested as previous nights, but aerophagia wasn't as bad as the prior night, so I thought the higher IPAP might not be a bad trade-off to achieve a little better apnea treatment. Then, BAM, the oximeter data showed a deep desat down to 90%, by far the worst I've experienced in the three weeks I've been using BiPAP. The next lowest desat for this three weeks was only down to 93%. Coincidence? I don't think so, because it seemed to occur along with a mouth leak. My theory is that being out of sync allowed an apnea to occur which then triggered the mouth leak.

My preliminary conclusion is that I need to change the EPAP to 7 cm, hoping that the current issues are more the result of the higher pressure differential, rather than the higher IPAP.

I am, however, also absolutely convinced that the Respironics algorithm is not well matched to my own breathing pattern and, based on DSM's comments, also wonder how well matched it is to anyone's breathing, really. To be fair though, I'm sure that some trade-offs needed to be made in the algorithm to accomplish everything that it does, so I hope no one takes my critique as an indictment of Respironics. It is not, merely observations about my own personal experiences with it. My experience with the Respironics algorithm can be summed up by saying that adjustment of the BiPAP-auto to provide decent therapy for me is very touchy; small variations in adjustment have created large variations in the results.

Another conclusion I come to is a firm belief that the many observations made here about one machine working better than others for a specific individual is founded in fact, not merely subjective opinion. And I'm not happy about starting another collection. Maybe that won't be necessary though. 9/6 worked really well for a week.

Regards,
Bill

dsm · Post by **dsm** » Wed May 10, 2006 6:16 am

rested gal wrote: <snip>
About the "early flipping" from IPAP to EPAP that keeps being mentioned. Unless I drew an occasional very unusually long breath, that never happened for me with any of the bi-level machines I used:
<snip>

RG,

As I mentioned each time, this flipping happens on cue when I use my Ultra Mirage F/F mask. It is 100% reproduceable and has been also mentioned by several other people.

I have purchased an Ohmeda volume monitor to measure mask leak-rates so I can gather additional convincing evidence, that is as accurate as I can get it. Being an engineer I really do my best to back up my statements with detailed research.

When I bought the Bipap S/T I was *not* expecting it to exhibit this reproduceable behaviour. I was really surprised that it reacted exactly like the Bipap Pro 2 I have.

If I thought it would be of any use I would produce a video clip of the Bipap S/T in operation with the CMS pressure guage connected as well. But I am not sure that it would be enough evidence for you - would it ? - if yes I'll do it - it just seems to me that you are implying that based on your experience, what I am observing and is quite predictable (now on 2 Bipaps) is probably not happening ?.

I can assure you it is. As also mentioned I have a 3rd Bipap (another Pro 2) on the way. It will take a couple more weeks to arrive. With 3 of these similar machines I believe I will have enough data to reach very concrete conclusions.

I guess what I am also saying is that there is little doubt in my mind that the Respironics Bipaps have a flaw related to the type of mask being used. I have not come across this on any other Bilevel.

As part of my ongoing general research I also will soon have an original (the 1st one released) Respironics Bipap S/T (the big box model ) plus the 1st portable PB home Bilevel (the PB320 model) These ones are more collectors items but are very helpful in understanding how the machines evolved.

Cheers

DSM

Guest · Post by **Guest** » Wed May 10, 2006 11:09 am

viewtopic.php?p=74847#74847

Moogy wrote:The "too fast switching" inhale/exhale issue that DSM mentions has NEVER been a problem for me. I rarely even notice the switch, it is so smooth. Maybe that is the biflex working.

Moogy

dsm wrote:there is little doubt in my mind that the Respironics Bipaps have a flaw related to the type of mask being used.

So what is the story with this machine? Do a lot of people find they can't use it because of the "flipping" issue? More importantly for potential buyers, is this machine flawed or not? Is it only flawed if you use a full face mask but it works right with nasal pillows? Do the directions say not to use it with a full face mask? Has the problem been fixed in the newly produced machines? Is Respironics giving a replacement machine because of this flaw?

Guest · Post by **Guest** » Wed May 10, 2006 3:47 pm

Does anyone have a contact at Respironics who can answer the questions about masks, early flipping and how their BiPaps work.

Perhaps that is the 1st step that could be taken ?.

I don't expect that Respironics are going to step forward and publicly state they know of a problem but at least it would give people here the opportunity to raise the issues.

I am sure DSM will be willing to provide his evidence ?

dsm · Post by **dsm** » Wed May 10, 2006 5:11 pm

I agree re a contact at Respironics.

Actually, one very important question I would have for the person is ...

1) Are there software updates that are available for their machines (Bilevels & Autos).
- If yes who can we approach to get them ?
- If not then why ?

I am happy to apply them myself & to take responsibility for the effort.

Cheers

DSM

Sleepless on LI · Post by **Sleepless on LI** » Wed May 10, 2006 6:00 pm

dsm wrote:I agree re a contact at Respironics.

Actually, one very important question I would have for the person is ...

1) Are there software updates that are available for their machines (Bilevels & Autos).
- If yes who can we approach to get them ?
- If not then why ?

I am happy to apply them myself & to take responsibility for the effort.

Cheers

DSM

I like the way you think...

Guest · Post by **Guest** » Wed May 10, 2006 6:43 pm

Who are we kidding? As if Respironics would ever respond to the user. They won't even talk to us about the software, let alone somebody's conjecture about flaws in their machines. We're not the sleep doc or DME. You'll never hear a peep out of them. But it's a nice thought.

dsm · Post by **dsm** » Wed May 10, 2006 7:21 pm

[quote="Anonymous"]Who are we kidding? As if Respironics would ever respond to the user. They won't even talk to us about the software, let alone somebody's conjecture about flaws in their machines. We're not the sleep doc or DME. You'll never hear a peep out of them. But it's a nice thought.

Guest · Post by **Guest** » Wed May 10, 2006 7:54 pm

Another reality alert! Don't be misled into believing a machine is flawed just because of an individual's opinion stating they think this is the case. This has happened before and it turned out the implication of a design flaw was made because of personal preference. As always, things can work fine for some people (in this case, Moogy and rested gal) and not for others (in this case, dsm). This doesn't mean there is a design flaw in the machine. After all, remember our favorite caveat: Your mileage may vary.

BiPAP Cures Aerophagia

Re: No reason to dread the bilevel