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Cpap vs. Bi-Pap
#1
I've been using C-Pap for at least six months now, and am not having any adjustment problems, but the following issues prevail.

1) I'm still exhausted (although I no longer need to pull over for a nap), 2) I often feel like I don't get enough air (Not gasping, but not enough), and 3) maybe 4 times a week, both my wife and I are awakened by a "fluttering" sound that I think comes from the back of my throat.

A friend who is a tech in a sleep lab told me that she thinks I need a Bi-pap (more expensive i guess than C-Pap) that would deal with at leasf #2 and 3 (and maybe #1).

I have previously mentioned B-Pap to my sleep Doc (not these issues, but others), and got no support.

Tomorrow I have a "phone" appointment with my sleep Doc, and I'm trying to get as clear on all this as I can.

Any input here?

Thanks in advance.

Phil

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#2
I think the term BiPAP is being misused here. Check out the difference, for example, between the Respironics BiPAP and the Respironics BiPAP autoSV Advanced. The former is simply a bilevel machine that delivers one pressure when you inhale (IPAP) and a lower pressure when you exhale (EPAP). The latter on the other hand does much more in that it initiates breathing for you when it detects you're have a central apnea event.

I suspect it's this latter type of machine your friend was talking about. It's more generally referred to as an ASV (auto servo ventilator) machine that's used to treat sleep disordered breathing (SDB) conditions that are more complicated than simple obstructive sleep apnea (OSA).

The fact that you've seen some improvement in six months is a positive sign. It may be that you simply need more time for your body and mind to adjust to the new circumstances. It used to be that your brain had to wake you up every few seconds or minutes to breathe, and now it doesn't quite realize that it no longer needs to do that.

What does your data look like? It would help if we knew.

You should discuss the situation with your doctor, preferably one who knows how to interpret the data.
Sleepster
Apnea Board Moderator
www.ApneaBoard.com


INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#3
I don't see how a bilevel PAP would help with #2. It would make it worse.

Bilevel is different than regular CPAP in typically two ways. One, they go higher than 20cmH2O (not all of them do). And two, the difference in exhale vs inhale can be greater than 3.

CPAPs can vary in the exhale and be 0-3 points less. Let's say you have a ResMed S9. The treatment pressure (the inhale) is set to 12. The EPR (exhale pressure relief) is set to 2. You inhale at 12. The machine detects when you are finished inhaling, and drops the pressure to 10. Then raises it for the inhale, drops again, etc.

Bilevel can go more than 3 and are recommended for folks with higher pressures, cannot tolerate the pressures, or have a lung condition that prevents them from breathing out against even a 3 point drop. Going by the same inhale of 12, if the EPR is set to 5, your exhale would be 7.

If you feel you are not getting enough air, that's the inhale and the bilevel is not going to help with that. The only way it would help you is if you feel you are not exhaling enough (not pushing out enough air on the exhale) so the inhale has less room in your lungs and it feels like you get less air.

I see from your profile that you have a Respironics. For your machine, the A-Flex is their exhale relief. Some people don't like the machine's method of choosing for them when to breathe. First try turning the A-Flex off and see if that makes a difference. You could also try adjusting it vs turning it all the way off. You can do this while awake but try it for several minutes so that you and the machine can match rhythms correctly.

Do you use the ramp feature? If you do, then turn it off or short then time or raise the starting pressure. I have gotten so used to my higher pressures that I feel smothered with the ramp on! Even during those first few seconds until the machine wakes up, I don't put the mask on.
PaulaO2
Apnea Board Moderator
www.ApneaBoard.com


Breathe deeply and count to zen.

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.




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#4
It doesn't help that I'm having trouble with my computer as well, and am unable to either read or forward my SD card to my Doc or Sleepyhead.

Previously my air pressure was reduced to 7 because air was ending up bloatjng my stomach.

Maybe my question should be when is the Bi-Pap appropriate?

Phil



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(08-11-2013, 08:24 PM)Sleepster Wrote: I think the term BiPAP is being misused here. Check out the difference, for example, between the Respironics BiPAP and the Respironics BiPAP autoSV Advanced. The former is simply a bilevel machine that delivers one pressure when you inhale (IPAP) and a lower pressure when you exhale (EPAP). The latter on the other hand does much more in that it initiates breathing for you when it detects you're have a central apnea event.

I suspect it's this latter type of machine your friend was talking about. It's more generally referred to as an ASV (auto servo ventilator) machine that's used to treat sleep disordered breathing (SDB) conditions that are more complicated than simple obstructive sleep apnea (OSA).

The fact that you've seen some improvement in six months is a positive sign. It may be that you simply need more time for your body and mind to adjust to the new circumstances. It used to be that your brain had to wake you up every few seconds or minutes to breathe, and now it doesn't quite realize that it no longer needs to do that.

What does your data look like? It would help if we knew.

You should discuss the situation with your doctor, preferably one who knows how to interpret the data.

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#5
(08-11-2013, 08:10 PM)pdeli Wrote: 1) I'm still exhausted (although I no longer need to pull over for a nap), 2) I often feel like I don't get enough air (Not gasping, but not enough), and 3) maybe 4 times a week, both my wife and I are awakened by a "fluttering" sound that I think comes from the back of my throat.

A friend who is a tech in a sleep lab told me that she thinks I need a Bi-pap (more expensive i guess than C-Pap) that would deal with at leasf #2 and 3 (and maybe #1).

Hi pdeli,welcome to the forum!

Your 7 cmH2O pressure is quite low. Is your machine running in CPAP mode, or Auto mode?

You may be more comfortable (easier to breath in) with a higher pressure, such as 9, especially if you feel at all like you have been needing to work to suck in enough air during inhale.

(08-11-2013, 08:27 PM)PaulaO2 Wrote: I don't see how a bilevel PAP would help with #2. It would make it worse.

Hi PaulaO2,

Actually, standard bilevel would probably help with #2, because, unlike standard CPAP or APAP machines which can only use EPR or C-Flex or A-Flex (which lower the pressure during exhale by up to 3 cmH2O), all bilevel machines have another setting which is called Pressure Support. Pressure Support boosts the pressure during inhale to make inhale easier.
[/quote]

(08-11-2013, 08:27 PM)PaulaO2 Wrote: Bilevel can go more than 3 and are recommended for folks with higher pressures, cannot tolerate the pressures, or have a lung condition that prevents them from breathing out against even a 3 point drop. Going by the same inhale of 12, if the EPR is set to 5, your exhale would be 7.

Actually, in Respironics bilevel machines, the Flex is still limited to 3, but Pressure Support can be added to increase the pressure difference (between inhale versus exhale) to more than 3.

I've read conflicting descriptions of Bi-Flex. On some Respironics machines Bi-Flex is described as affecting (only) the smoothness versus abruptness of the transitions in Pressure Support. On others, it is described as being the same as C-Flex or A-Flex, which actually lower the pressure during exhale, but only during the first fraction of the exhale period. (ResMed EPR is different in this regard, because EPR lowers the pressure during the whole time we are exhaling, not just during the first second or so.)

The PRS1 BiPAP Auto clinician guide says it can use both Bi-Flex and Pressure Support at the same time, and the Flex setting only lowers the exhale pressure by up to 3 cmH2O during the first early portion of exhale, not during the whole time we are exhaling.

Pressure Support can raise the pressure (by up to 10) during the whole time we are inhaling.

So a bilevel example for the PRS1 BiPAP Auto would be, if the inhale pressure setting (IPAP) is 9 and the Flex setting is 2, and the PS setting is 4, then the pressure during exhale would drop to 7 but only during a short portion of the exhale time (returning to 9 for most of the exhale time), and the pressure during inhale would increase to 13 and stay there until the inhale time was finished.

Take care,
--- Vaughn
Membership in the Advisory Member group should not be understood as in any way implying medical expertise or qualification for advising Sleep Apnea patients concerning their treatment. The Advisory Member group provides advice and suggestions to Apnea Board administrators and staff on matters concerning Apnea Board operation and administrative policies - not on matters concerning treatment for Sleep Apnea. I think it is now too late to change the name of the group but I think Voting Member group would perhaps have been a more descriptive name for the group.
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#6
(08-11-2013, 10:32 PM)pdeli Wrote: Previously my air pressure was reduced to 7 because air was ending up bloatjng my stomach.

Maybe my question should be when is the Bi-Pap appropriate?

Hi pdeli,

I see. Well, if I remember correctly, I think PaulaO2 and others have discovered strategies to reduce bloating without turning the pressure down, and hopefully will suggest what worked for them. Personally, I pretty much just ignore it when air is forced into my stomach. Causes belching and whatnot when I get up, though.

Using A-Flex should also help with bloating. If you are not using A-Flex, I would suggest gradually adding some A-Flex, while gradually increasing your pressure to 8 or 9 to eliminate that occasional feeling of being slightly suffocated.

Regarding a bilevel machine, I think a small amount of Pressure Support (for example, 1 or 2) would likely make it a lot easier to breath in, without increasing bloating very much if at all.

Take care,
--- Vaughn
Membership in the Advisory Member group should not be understood as in any way implying medical expertise or qualification for advising Sleep Apnea patients concerning their treatment. The Advisory Member group provides advice and suggestions to Apnea Board administrators and staff on matters concerning Apnea Board operation and administrative policies - not on matters concerning treatment for Sleep Apnea. I think it is now too late to change the name of the group but I think Voting Member group would perhaps have been a more descriptive name for the group.
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#7
(08-11-2013, 08:10 PM)pdeli Wrote: 2) I often feel like I don't get enough air (Not gasping, but not enough), and 3) maybe 4 times a week, both my wife and I are awakened by a "fluttering" sound that I think comes from the back of my throat.

A friend who is a tech in a sleep lab told me that she thinks I need a Bi-pap

Maybe your friend is correct. Or maybe your pressure is to low. That fluttering may be a partially inflated airway.

As for BIPAP, it allows increased pressure support (difference between inhale and exhale pressure). I'm told that increased pressure increases ventilation, while increased pressure support increases respiration.

A data capable bipap gives the best of both worlds. It can dumb down as a cpap or function as a bipap. The data capable part and some software makes every night a sleep study if you have the time and patience to learn. If you get an auto bipap, then it will pressure adjust to meet your sleeping conditions. Without data, doctor visits become very subjective. But these features (bipap, auto, data capable) cost money.

But It seems you are uncomfortable, and pressure relief (cpap or Bipap) can mean more comfort. Bipaps have increased pressure relief if desired. Room to grow so to speak.

My decision was to get a data capable auto bipap and some sleepyhead software and go out there and learn. The learning is the point of this forum.





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#8
(08-11-2013, 11:26 PM)martinsr00 Wrote: As for BIPAP, it allows increased pressure support (difference between inhale and exhale pressure). I'm told that increased pressure increases ventilation, while increased pressure support increases respiration.

Hi martinsr00,

Or maybe increased Pressure increases respiration, while increased Pressure Support increases ventilation? (Perhaps I am mixing up respiration versus ventilation?)

The way I think of it, Pressure keeps the airway open, allowing respiration to occur at all, and Pressure Support increases how much air is actually breathed in and out during each breath, increasing the amount of ventilation.


(08-11-2013, 11:26 PM)martinsr00 Wrote: If you get an auto bipap, then it will pressure adjust to meet your sleeping conditions.

The bilevel PRS1 BiPAP Auto has a great feature which the bilevel ResMed VPAP Auto does not have. The PRS1 BiPAP Auto can automatically (gradually, not breath-by-breath) adjust the Pressure Support higher when it senses more PS is needed. On the ResMed VPAP Auto, the PS can only remain fixed at one value for the whole night.

In contrast, on ASV machines the PS will automatically adjust instantly, breath-by-breath, whenever needed to compensate for a central apnea/hypopnea.

Take care,
--- Vaughn
Membership in the Advisory Member group should not be understood as in any way implying medical expertise or qualification for advising Sleep Apnea patients concerning their treatment. The Advisory Member group provides advice and suggestions to Apnea Board administrators and staff on matters concerning Apnea Board operation and administrative policies - not on matters concerning treatment for Sleep Apnea. I think it is now too late to change the name of the group but I think Voting Member group would perhaps have been a more descriptive name for the group.
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#9
Well, there's a lot to digest here and I thank you all for your input.

Don't know if I mentioned this previously, but the way the Kaiser system works on this subject (and Medicare?) is that one never sees the Doc (at least I haven't). The Techs handle the testing and the adjustments. I only talk to the Doc after I complain about having a problem the techs can't deal with.

Bear in mind, the staff is quite pleasant and very responsive, but there are tons of patients being referred to this Kaiser clinic and processing everyone results in a "mill" like atmosphere.

I have been successful in pushing up my month long gaps between appointments, and getting now 4 5-10 minute phone appointments with the Doc, but without a real good understanding of some of the important details, it is easy to get "shut down" by either the Doc or the techs as they fly through their very busy day.

My sense is that there may be some cost issues in the background here since I only have a co-pay involved in this equipment. I have previously mentioned Bi-Pap and was told that I didn't need it.

So we'll see what happens in an hour from now when the Doc calls.

Phil
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#10
Just to follow up on all of the previous discussions, the conversation with the Doc was over 20 minutes (that's a good thing).

Another point that I had neglected to mention here was that when I was first tested, my AHI was 30+ and now my 30 day average is .9. The Doc said that means that the C-Pap is working. And there's no need for further testing.

Be that as it may, none of that really matters because I'm still generally exhausted.

I was successful however, in setting up a 7 day Bi-Pap trial which will commence after Labor Day when we get back from a trip.

Oh yeah the "fluttering", the Doc says that is related to me opening my mouth. I use a nasal mask mostly because with a full face mask I can't yawn, or talk, or kiss my wife (which is minimized when she sees me coming with a mask on). I do sometimes open my mouth, but the rush of air wakes me up. This audible "fluttering" thing seems to be the cause of my mouth opening and is different somehow from just opening my mouth.

So we'll see what if anything happens with the Bi-Pap test, and again I appreciate all of the feedback here.

Phil







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