Palatal Prolapse: An Experiment in Reverse BiPAP

I’ve been experimenting with different methods of treating my UARS prior to (hopefully) an MMA surgery. I have anterior to posterior narrowing at the palatal area, as well as behind the tongue base and epiglottis. My palate prolapses when I fall asleep, causing therapeutic frustration (for example: by giving me chipmunk cheeks on BiPAP nasal masks and breaking the seal on the INAP, two devices I would like to use otherwise).

Lately I’ve been using the BONGO RX in combination with the INAP. You may think these would work against each other - but for my profile, I’ve found the two to be synergistic because the BONGO’s expiratory pressure permits a slightly better splinting of my palate, thereby helping the seal of the INAP.

Palatal prolapse is a tough mistress to slay, however, and even this is not enough to keep the seal from breaking on the INAP. Other therapies said to be helpful for palatal prolapse - like the velumount and the alaxo stent - are either not available in the USA or appear to me to be a kind of medieval torture.

Tonight I got to thinking about something I’ve genuinely never seen considered here for palatal prolapse (with or without further obstruction in the airways): I will call it the Reverse BiPAP.

What is the reverse BiPAP?

Whereas a conventional BiPAP set-up uses a set splinter (epap) pressure as a base splint + a pressure support mechanism to increase the inspiratory flow (IPAP), the reverse BiPAP uses the IPAP to generate excessively powerful expiratory pressure that outpaces the baseline splint of the epap. Theoretically, this should deliver therapeutic results for palatal prolapse given expiratory pressure is named as particularly useful for the condition.

What does one need to create the reverse BiPAP?

First, a BiPAP so that you can set an EPAP / IPAP differential via a Pressure Support mechanism.

Second, a pure epap device like the BONGO Rx.

The idea is to use these in conjunction with one another. You see, the BONGO Rx is able to achieve up to 15 cm of expiratory pressure. Which should be helpful for palatal prolapse. However, in order to do that, it is dependent on inspiratory flow strength.

When you are sleeping deeply, and especially if your airways are constricted, you may not have such inspiratory power so as to fully utilize the expiratory support depth of the device. Moreover, it does not scale linearly. The BONGO will produce more expiratory pressure by a modest multiple curve given scaling inspiratory pressure.

In other words: on BiPAP with higher IPAP, you’re inhaling a LARGER tidal volume. More air in means more air to push out during exhale. Higher expiratory flow through the BONGO means more backpressure.

Look at the data from the Hakim study: at low tidal volume (200ml), Bongo generated 3.75 cmH2O peak expiratory pressure. At high tidal volume (400ml), Bongo generated about 13 cmH2O.

So doubling the breath size nearly QUADRUPLED the Bongo pressure. That is exponential scaling.

Example Reverse BiPAP at 6/10 + Bongo

IPAP of 10 pushes a larger tidal volume into your lungs. You exhale that larger volume through the Bongo. Instead of quiet 200ml breaths generating 3.75 cmH2O, you might be exhaling 350-400ml breaths generating 10-13 cmH2O through the Bongo RX.

In this case, the BiPAP is ironically HELPING the Bongo generate more pressure by inflating bigger breaths that then push harder through the Bongo valves on exhale.

This actually reverses the usual concern about BiPAP for palatal prolapse. Normal BiPAP drops pressure from 10 to 6 on exhale — the effect causes the palate to “flutter like a sail.” But BiPAP + Bongo drops from 10 on inhale to 16-19 on exhale. The pressure goes UP during exhale instead of down. No sail. The palate gets splinted harder during exhale than it gets pushed during inhale.

Theoretically, then, you get the best of all worlds. You get the stronger expiratory power of the bongo for your palatal prolapse. But you also get the strong inspiration to help any other obstruction you may have.

Have I tried this myself yet? No. Could I be wrong? Absolutely. But I’ll give it a go and report back. Stay dreaming, all.

Or just get a KPAP machine.