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[CPAP] A little advice
#21
(06-05-2018, 08:12 AM)Sleeprider Wrote: Your addition of EPR improved most of the problems I pointed out before.  There is only a brief period from midnight for about 1/2 hour where your resp rate increases and tidal volume decreases, and the degree of that is much lower.  These are fantastic results, and in your case, this would only be possible with a bilevel machine or the Airsense 10 Autoset.  With a Philips you would be plagued with intractable hypopnea, flow limitation and other events.  I mention this because if you ever change machine, you NEED a machine with bilevel capability, even if that is limited to 3-cm of pressure support.  Don't let anyone ever dispense something less.

Why do you think lowering the exhalation pressure (increased EPR) addressed the hypopneas?  It sounds like you are saying that less IPAP is needed if you can get by with a lower EPAP.  This is interesting as the manuals just say EPR is simply for comfort - which it is not since it changes EPAP which will impact OA.  More info/links is appreciated.
Why do you think Phillips DreamStation Auto would not work as well?
Thanks
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#22
(06-05-2018, 09:20 PM)tedvpap Wrote:
(06-05-2018, 08:12 AM)Sleeprider Wrote: Your addition of EPR improved most of the problems I pointed out before.  There is only a brief period from midnight for about 1/2 hour where your resp rate increases and tidal volume decreases, and the degree of that is much lower.  These are fantastic results, and in your case, this would only be possible with a bilevel machine or the Airsense 10 Autoset.  With a Philips you would be plagued with intractable hypopnea, flow limitation and other events.  I mention this because if you ever change machine, you NEED a machine with bilevel capability, even if that is limited to 3-cm of pressure support.  Don't let anyone ever dispense something less.

Why do you think lowering the exhalation pressure (increased EPR) addressed the hypopneas?  It sounds like you are saying that less IPAP is needed if you can get by with a lower EPAP.  This is interesting as the manuals just say EPR is simply for comfort - which it is not since it changes EPAP which will impact OA.  More info/links is appreciated.
Why do you think Phillips DreamStation Auto would not work as well?
Thanks

Hypopnea is a restriction (or sometimes central) event that resulst in a reduction of flow rate.  If all we have to work with is positive pressure, then the CPAP solution is to increase that pressure in hopes of removing restriction by stenting the airway.  Bilevel titration protocols have always recommended finding the EPAP pressure that resolves OA, then using PS for hypopnea, flow limitations and snores.  The Resmed Airsense 10 offers a unique opportunity to apply pressure support (although limited) to resolve these problems.   It's a bit unconventional, but I have seen it work with a lot of people.  BTW I have never had similar success using Flex in the Philips CPAP machines, and almost categorically those users end up with higher minimum pressure. The way Flex works is unlike VPAP which follows the user's respiration lead. Flex seems to be ahead of the patient, decreasing pressure ahead of expiration, and restoring IPAP pressure before expiration is over. This causes all kinds of problems and does nothing for those needing pressure support.
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#23
(06-06-2018, 08:13 AM)Sleeprider Wrote:
(06-05-2018, 09:20 PM)tedvpap Wrote:
(06-05-2018, 08:12 AM)Sleeprider Wrote: Your addition of EPR improved most of the problems I pointed out before.  There is only a brief period from midnight for about 1/2 hour where your resp rate increases and tidal volume decreases, and the degree of that is much lower.  These are fantastic results, and in your case, this would only be possible with a bilevel machine or the Airsense 10 Autoset.  With a Philips you would be plagued with intractable hypopnea, flow limitation and other events.  I mention this because if you ever change machine, you NEED a machine with bilevel capability, even if that is limited to 3-cm of pressure support.  Don't let anyone ever dispense something less.

Why do you think lowering the exhalation pressure (increased EPR) addressed the hypopneas?  It sounds like you are saying that less IPAP is needed if you can get by with a lower EPAP.  This is interesting as the manuals just say EPR is simply for comfort - which it is not since it changes EPAP which will impact OA.  More info/links is appreciated.
Why do you think Phillips DreamStation Auto would not work as well?
Thanks

Hypopnea is a restriction (or sometimes central) event that resulst in a reduction of flow rate.  If all we have to work with is positive pressure, then the CPAP solution is to increase that pressure in hopes of removing restriction by stenting the airway.  Bilevel titration protocols have always recommended finding the EPAP pressure that resolves OA, then using PS for hypopnea, flow limitations and snores.  The Resmed Airsense 10 offers a unique opportunity to apply pressure support (although limited) to resolve these problems.   It's a bit unconventional, but I have seen it work with a lot of people.  BTW I have never had similar success using Flex in the Philips CPAP machines, and almost categorically those users end up with higher minimum pressure.  The way Flex works is unlike VPAP which follows the user's respiration lead. Flex seems to be ahead of the patient, decreasing pressure ahead of expiration, and restoring IPAP pressure before expiration is over.  This causes all kinds of problems and does nothing for those needing pressure support.
Thanks for the response.  Certainly your advice seemed to work.
Increasing the difference between IPAP and EPAP (via increasing PS, FLEX, EPR, ..) results in increasing the IPAP on a bilevel machine and decreases the EPAP on a CPAP machine (on an absolute basis).  
I have read that EPAP for OA and IPAP for H which makes sense but your advice (and evidence) suggest that this rule may not work with some people (or maybe some machines).
A friend is using 18-20 on his RemStar Auto (FLEX=2) and still gets regular clusters of OA (he can't stay off his back).
Prior to moving to a bi-level, do you think it is worth trying increased FLEX or ResMed?
TIA
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#24
Ted, the best advise I can offer for your friend is try a soft cervical collar and either get the BiPAP or a Resmed Autoset. I have developed my bias for Resmed auto CPAP for a good reason, in spite of living in Murrysville, PA. The Philips Respironics auto algorithm is not very effective, and Flex can cause as many problems as it solves, especially if the respiration rate and volume are not "textbook" predictable. It works pretty good for a majority, but for those that have uneven breathing it seems to fall apart.

With regard to rules of what works for some but not others, I use the general rules as long as they work, but am not surprised when they don't. When working with auto CPAP a couple general rules are Philips needs higher minimum pressure and Resmed needs to be limited for max pressure, however both of those rules are not applicable to everyone. I am an engineer and scientist, so have problem solving skills and the ability to apply variables and observe response. The thing is, the response of one person does not predict the response of any other. I think there are very small clues that tell us which way someone will respond to pressure , pressure support or EPR, but in the end I make the best guess I have and let the trial prove the hypothesis is true or not. I'm better than 50% on outcome, so there might be some method to the madness.
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#25
(06-06-2018, 08:50 PM)Sleeprider Wrote: Ted, the best advise I can offer for your friend is try a soft cervical collar and either get the BiPAP or a Resmed Autoset.  I have developed my  bias for Resmed auto CPAP for a good reason, in spite of living in Murrysville, PA.  The Philips Respironics auto algorithm is not very effective, and Flex can cause as many problems as it solves, especially if the respiration rate and volume are not "textbook" predictable. It works pretty good for a majority, but for those that have uneven breathing it seems to fall apart.  

With regard to rules of what works for some but not others, I use the general rules as long as they work, but am not surprised when they don't.  When working with auto CPAP a couple general rules are Philips needs higher minimum pressure and Resmed needs to be limited for max pressure, however both of those rules are not applicable to everyone.  I am an engineer and scientist, so have problem solving skills and the ability to apply variables and observe response.  The thing is, the response of one person does not predict the response of any other.  I think there are very small clues that tell us which way someone will respond to pressure , pressure support or EPR, but in the end I make the best guess I have and let the trial prove the hypothesis is true or not.  I'm better than 50% on outcome, so there might be some method to the madness.

Great insight - thanks.
My disdain for sleep professionals has greatly lessoned as I have experienced the time and energy needed in trying to help people.  There is a good reason as to why the treatment failure rate is 50%.
Coming from my experience with a PR Auto,  it seems like the only solid thing I have learned is the importance of keeping the min pressure within striking distance.  I have been able to help many people with this message.


Good suggestions: I will have my friend try a collar and then more EPR before moving up to more pressure. Worth a try.
Thanks again.
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#26
Very interesting discussion. 
We have a saying in this part of the world: “When you’re on a good thing, stick to it”. 
At the end of the day, these settings work for me so I guess that’s all that matters. Thank you.
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#27
(06-07-2018, 05:06 PM)HairPower Wrote: Very interesting discussion. 
We have a saying in this part of the world: “When you’re on a good thing, stick to it”. 
At the end of the day, these settings work for me so I guess that’s all that matters. Thank you.

You were too easy...come back when you have a real challenge. Too-funny

It's my privilege to have been able to help mate...buy me a beer next time I'm down under.
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