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A Question of Exhale Pressure Relief
#1
A Question of Pressure Relief Blog

Many newly diagnosed sleep apnea patients receive positive pressure (PAP) devices without understanding the optional features of these units. I do not feel, in my opinion, that this is entirely any particular patients fault. However, let’s face the truth - if you are to be receiving a new positive air pressure device (CPAP, Bi-level PAP, etc.), then it is up to you to do some research to what your best options are. This mindset is fully at the forefront of most minds when it comes to types of treatment, whether it is using forms of medicine to procedures. For unknown reasons a lot of new users truly do not complete any research and are blindly led to receiving any treatment suggested. To be clear, that statement is not an insult to patients. The sleep industry itself, particularly the positive pressure industry, likes it being this way! Although patients can be held accountable for a portion of their treatment in understanding options and risk, providers of any sort also have a responsibility to educate better and help patients understand their options as well. There is truly a flaw in the system that I feel most new patients are unaware of and most veteran patient are very much aware of.

Inside newer models of PAP devices, whether it is continuous positive airway pressure (CPAP), bi-level (some may call this Bi-PAP) devices or more advanced therapeutic forms of positive pressure there are several different features that are easily overlooked. Not only by new users when receiving a device, but also by the providers prescribing them. I feel that one of these features is exhalation pressure relief (EPR as trademarked by the company Resmed). EPR is a feature in most machines and can be under different labels per that particular manufacturer’s model. For our sake here, I will simply label all forms of exhalation pressure relief as simply “pressure relief”. Stay tuned to my blog as I am working on the “types” of pressure relief in each of the major brands of positive pressure devices available (Fisher and Paykel, Resmed, and Respironics)! For now, I will list a link to these manufacturers pressure relief information at the end of the article!

I would like to help bring forth some light using my experiences with pressure relief, how it can be a very important factor in success with positive pressure, and ultimately if it can shape what particular device you choose to purchase. By doing so, I hope that the information will help whoever finds this blog into a better understanding of your potential, or continuing, positive pressure therapy.

First, I’d like to discuss the source of where a new user will be diagnosed with sleep apnea – the sleep study. Pressure relief can be something that is utilized during forms of sleep studies to help with comfort and a better potential for compliance. However, this is debatable depending on the particular technologists completing the study. Let me better explain. The times that pressure relief could be utilized is a “titration sleep study.” Meaning that the patient has completed a diagnostic portion of a sleep study in some form and now has been sent a sleep laboratory to be monitored and placed on a positive pressure device for an entire night. In the “titration study,” the pressure will be slowly changed, whether increased or decreased, to alleviate the respiratory disturbances previously found in a diagnostic in-laboratory sleep study or home sleep study. The point is that you wear a positive pressure device for an entire night with a technologist adjust the pressure until the sleep apnea is treated successfully. If you are already using positive pressure therapy, then you may already be acquainted with this process.

In the earliest forms of beginning positive pressure therapy, pressure relief becomes very debatable. In the sleep laboratory study setting a patient will be fit with a mask and then pressure adjust slowly while sleeping. Pressure relief is an “optional” setting that the technologist may, or may not, use depending on their preference. To my knowledge, after doing research, I could not find any specific rule for the use of pressure relief in the laboratory setting other than each treatment center (the sleep lab.) should have a policy stating to how pressure relief should be used to assure it is utilized correctly, per management, by each technologist. That truly sheds some light on the wild-wild-west of pressure relief that is entirely up to each laboratory and even possibly each technologist. Meaning that on the same night one patient may use pressure relief, while another doesn’t.

Now if you are like me, that can seem somewhat unusual and even unsettling, but don’t let it discourage you. Pressure relief is an “optional” setting so it would make sense that it would be optional at even the beginning stages of treatment. However, I will tell you my mindset when working with a new patient in the laboratory during a titration study. I use pressure relief. Not for every single patient, but for nearly every patient that I’ve worked with and my reasoning is somewhat simple. It is highly likely that when a new user receives a new home unit, then they will likely be using this optional setting. I hope to use as close of settings during the sleep study as possible to what their home use will be to assure not only the treatment is effective, but that the patient is tolerable of the settings. In very rare circumstances, usually patients that are veteran users to positive pressure do not require, or tolerate pressure relief well, and simply want the function turned off. By using pressure relief, I hope to assess that a patient is tolerable and to “bridge the gap” between the sleep study and home use.

Just as there are no true requirements for the use of pressure relief during a positive pressure titration study, this also holds true for home use as well. For any patient to receive a new PAP device a prescription is needed from a physician. Depending on your physician’s level of understanding will likely determine whether pressure relief is required or not. If the physician indicates that pressure is to be used, then it will be required that the durable medical equipment technician (DME Tech.) should turn it on. However, there is no rule that states whether it should be turned on or off if not clinically indicated by the physician. Then it becomes a matter of the DME technician, just as it does with the sleep technologist during the sleep study.

The last point is that I feel pressure relief is a user function. Every patient has the ability, and the complete right, to adjust the pressure relief setting of their machine. If you feel that you have done research and wanted to adjust this setting, then it can be done! Sometimes it can be discouraged by technicians or providers and even other users. Those opinions should be taken into account – but in no way should altering the pressure relief setting change the effectiveness of the positive pressure device. It should only have an effect on comfort.

As you can tell, there is not a lot of regulation when it comes to the function of the pressure relief. So don’t be afraid to question your provider, your technician, or the sleep community on the function, purpose, and whether or not it is something for you. Pressure relief is very popular and seemingly used in a great number of positive pressure users!

Sleep well!
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#2
For sure, pressure relief can be of great helps for people who have problem breathing out against pressure
ResMed and Respironcis pressure relief works differently, F&P doesn't offer it but have something completely different
Personally, I don't use it and find it more of annoyance than a comfort feature but each to their own, I guess
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#3
(09-06-2016, 05:42 PM)zonk Wrote: For sure, pressure relief can be of great helps for people who have problem breathing out against pressure
ResMed and Respironcis pressure relief works differently, F&P doesn't offer it but have something completely different
Personally, I don't use it and find it more of annoyance than a comfort feature but each to their own, I guess

I am somewhere in the middle Zonk. I have used it in all three devices and turned it off as well. I don't really find a big difference, except for in the Respironics. If I have "flex" set to 3, it never really reaches a pressure drop of three. It only goes to two and that is where I set my Resmed as well. If I have it set to two, I'm pretty good. However, I can go without it just fine.

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#4
Bilevel machines (BiPAP or VPAP) do not use EPR per-se, but instead use separate IPAP and EPAP pressures. In bilevel the difference between IPAP and EPAP is referred to as "pressure support". Respironics BiPAPs also offer BiFlex, but it does not function like the Aflex or Cflex of the CPAP machines, but instead affects the rate of pressure change as the machine transitions between IPAP and EPAP. So, I think you need to remove bilevel from your discussion, or include the discussion of pressure support separately.

As you note, EPR offers up to 3 cm H2O pressure support or pressure relief in Resmed machines, and the Respironics machines offer up to 2-cm pressure difference. There are a number of good articles discussing each of those implementations, but the point of your article is less to do with those technical issues, than how they work for individuals using CPAP. EPR and Flex are considered comfort features, and they can help people who experience difficulty exhaling against pressure. It can also have unwanted effects by lowering EPAP pressures below the therapeutic threshold that maintains the airway and prevents obstruction, or in some cases can cause centrals to increase by increasing ventilation rates, reducing CO2. These features do have the potential to alter the patient's prescribed pressure, but like humidity, is something that is sorted by by trial and error. I think you need to reconsider your last paragraph as these features do have the potential to affect treatment efficacy, and one needs to understand the choices if either higher OSA or CSA occur when using EPR or Flex.

Good luck with your article, and hope this helps you in considering edits.
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#5
One problem I ran into is that the ResMed user settings only let you turn EPR on and off. The actual amount, zero to 3cm, is on the clinician menu. My machine came with EPR=3. I wanted to wean off it so I cheated and changed the EPR level to 1cm myself. In later discussion with the Dr he said he disagreed with the design to put the level on the clinician pages, because he viewed it as primarily a "comfort" setting and not of therapeutic interest, except insofar as if you are uncomfortable you might yank the mask off and end up noncompliant.
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#6
(09-06-2016, 10:27 PM)Sleeprider Wrote: Bilevel machines (BiPAP or VPAP) do not use EPR per-se, but instead use separate IPAP and EPAP pressures. In bilevel the difference between IPAP and EPAP is referred to as "pressure support". Respironics BiPAPs also offer BiFlex, but it does not function like the Aflex or Cflex of the CPAP machines, but instead affects the rate of pressure change as the machine transitions between IPAP and EPAP. So, I think you need to remove bilevel from your discussion, or include the discussion of pressure support separately.

As you note, EPR offers up to 3 cm H2O pressure support or pressure relief in Resmed machines, and the Respironics machines offer up to 2-cm pressure difference. There are a number of good articles discussing each of those implementations, but the point of your article is less to do with those technical issues, than how they work for individuals using CPAP. EPR and Flex are considered comfort features, and they can help people who experience difficulty exhaling against pressure. It can also have unwanted effects by lowering EPAP pressures below the therapeutic threshold that maintains the airway and prevents obstruction, or in some cases can cause centrals to increase by increasing ventilation rates, reducing CO2. These features do have the potential to alter the patient's prescribed pressure, but like humidity, is something that is sorted by by trial and error. I think you need to reconsider your last paragraph as these features do have the potential to affect treatment efficacy, and one needs to understand the choices if either higher OSA or CSA occur when using EPR or Flex.

Good luck with your article, and hope this helps you in considering edits.

Quick question Sleeprider. How does my last paragraph saying that if you are interested in using pressure relief that you should consult with a provider or the sleep community dimmunitive to what you are saying? I agree with you that by lowering the prescribed pressure can cause a disturbance in comfort and other clinical situations. However, pressure relief is clinically approved and I also touch on that that during the study of why I choose to use pressure relief to assure a patient can tolerate? Thanks for your help.

Also, Respironics Flex settings allow for a pressure relief setting of 3. Whether or not Flex actually reaches a lowering of 3 cm is another story, but you can set them 3. I have my Respironics Dreamstation set A-Flex of 3.
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#7
Just my personal experience: I found flex settings on the dreamstation more comfortable than the resmed (A 10 and the her setting) especially using Aflex. I found a smoother transition between inhale and exhale as well as the exhale I felt my breath wasn't pushed back at me especially at higher settings (8 cm +). In the end that is one of the reasons why I purchased the dreamstation over the airsense 10. I bought a dreamstation yesterday after nearly 3 months in trying out various machines.
Cheers
Steve
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#8
Unlike ResMed Machines, Flex settings will drop pressure at the most 1.5 to 2cm. on exhalation, and is flow based.

You can set it to 3, but it will never reach more than a drop of 2cm.

• C-Flex – Provides pressure relief upon exhalation.

• A-Flex/C-Flex+ – Provides pressure relief taking place at the end of inhalation and at the start of exhalation.
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#9
(09-07-2016, 11:43 PM)thecpapguy! Wrote: Quick question Sleeprider. How does my last paragraph saying that if you are interested in using pressure relief that you should consult with a provider or the sleep community dimmunitive to what you are saying? I agree with you that by lowering the prescribed pressure can cause a disturbance in comfort and other clinical situations. However, pressure relief is clinically approved and I also touch on that that during the study of why I choose to use pressure relief to assure a patient can tolerate? Thanks for your help.

Also, Respironics Flex settings allow for a pressure relief setting of 3. Whether or not Flex actually reaches a lowering of 3 cm is another story, but you can set them 3. I have my Respironics Dreamstation set A-Flex of 3.

My statements were with regard to this part of your article (sorry for the misunderstanding).
Quote:The last point is that I feel pressure relief is a user function. Every patient has the ability, and the complete right, to adjust the pressure relief setting of their machine. If you feel that you have done research and wanted to adjust this setting, then it can be done! Sometimes it can be discouraged by technicians or providers and even other users. Those opinions should be taken into account – but in no way should altering the pressure relief setting change the effectiveness of the positive pressure device. It should only have an effect on comfort.

The point of my comment is that a pressure reduction of 3.0 in Resmed, or 1.5 to 2.0 in PR, is claimed to be a "comfort feature" by the manufacturers, and most of the professional sleep community seems to agree. However, in the real world, we have seen that this pressure reduction has different efficacy effects in different individuals, including disrupted sleep, increased OA or CA and of course in others, it works great! This is where we need to understand the differences in EPR and Flex. I think it may be arguable that Resmed's EPR is a bilevel implementation that affects prescribed pressures while Respironics Flex is indeed a comfort feature that maintains prescribed CPAP pressure at the point inhalation begins.

Consider Resmed EPR as "bilevel lite" where EPAP is reduced by up to 3-cm to a minimum pressure of 4.0 cm. With EPR at 3.0, pressure is reduced 3.0 cm at the onset of exhalation, and it stays low until inhalation begins. During an event (H, CA or OA), the pressure stays low (at EPAP) until the event is over, so the airway may not be supported as intended by the original CPAP prescription.

Flex is different in that it is flow based; so the pressure reduction is only effective while the patient exhales, and the reduction is proportional to exhalation force. IPAP pressure is fully restored by the end of exhalation.

The differences in the pressure relief implementations need to be better understood by the professionals, and by the people that use the features to improve comfort. People using Resmed machines with low pressure prescriptions, or fully open APAP will see an EPAP pressure of 4.0 until IPAP rises above 7.0. They may have to increase pressure to get out of the hole where the airway is not supported at the moment. Resmed autoset machines increase pressure faster, and decrease pressure more slowly than PR machines, which somewhat offsets this problem, but fixed pressure CPAPs can be problematic with EPR.

In an ideal world, patients should all have full access to both pressure settings and pressure support (aka EPR or Flex), and training or collaboration with professionals to understand how to best optimize those settings. In the real world, patients are given limited access to "comfort settings", and not given the tools to resolve problems that might arise because of those.
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#10
Quote:In an ideal world, patients should all have full access to both pressure settings and pressure support (aka EPR or Flex), and training or collaboration with professionals to understand how to best optimize those settings. In the real world, patients are given limited access to "comfort settings", and not given the tools to resolve problems that might arise because of those.

I couldn't agree more Sleeprider. In my personal opinion, I feel that new users, or even veteran users with a new device are completely unaware of what pressure relief is. That is the beginning of the problem. Once that is addressed by providers in giving out information to help the patient to better understand what the option is the second phase failure becomes an issue. There is absolutely little follow up to confirm that a patient is compliant and receiving as optimum benefit as possible (given any particular circumstance).
If a patient is educated to better understand features, then the follow up procedures become the much easier. There is a huge flaw in the process starting from the handling of pressure per the AASM, to the sleep laboratories, and finally at the DME.
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