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Isn't Resmed's Expiratory Pressure Relief really Inspiratory Pressure Support??
#51
RE: Isn't Resmed's Expiratory Pressure Relief really Inspiratory Pressure Support??
(11-23-2017, 01:33 PM)Walla Walla Wrote: IPAP increases for flow limitations.

On the Resmed VAUTO, S, and ST , IPAP never increases without a corresponding increase in EPAP.  Pressure support is always fixed on those machines.  Because both IPAP and EPAP change together, you cannot infer from the behavior of the machine which one is being changed to address a particular event.

On the Resmed ASV, EPAP is increased for inspiratory flow limitations, and not IPAP (per the clinician guide I posted earlier).

The Dreamstation provider guide does not explain how its Bi-Level auto works, and so I cannot say how DreamStation Bi-Level Auto responds to inspiratory flow limits.  There is a separate titration guide for use when manually titrating a person, and it indicates that all obstructive events should be treated by increasing EPAP.
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#52
RE: Isn't Resmed's Expiratory Pressure Relief really Inspiratory Pressure Support??
(11-23-2017, 01:45 PM)Walla Walla Wrote: I own the VAUTO also. The IPAP responds to the flow limitations the EPAP goes up with the IPAP due to the PS. The EPAP is not responding to the flow limitations it's being drag up by the IPAP. Now when the EPAP responds to OA's it pushes up the IPAP due to the PS.

IPAP and EPAP are locked together on the VAUTO in order to keep pressure support at the fixed level, and so you cannot infer from the behavior of the machine which one is being adjusted to address a particular condition.

Thus, when you say that IPAP is adjusted and EPAP is "being dragged up by IPAP," you have no basis for that statement.  Since IPAP and EPAP change equally to keep pressure support the same, you could just as easily say that EPAP is being adjusted to respond to flow limitations and that IPAP is "being dragged up by EPAP."  

The Resmed Aircurve 10 ASV manual (which I quoted previously) makes clear that Resmed thinks that EPAP, not IPAP is what addresses inspiratory flow limitations.  In addition, both the ResMed Sleep Lab Titration Guide and the Respironics Titration Guide both instruct sleep technicnians that EPAP should be increased to address any kind of obstructive event and IPAP should be adjusted to address hypopneas.

However, in re-reading all this stuff, I think that there may be some confusion about "inspiratory flow limitations" and "obstructive hypopneas," and what they mean.  That may be the source of our disagreement.  Resmed publishes some things that indicate that EPAP is adjusted automatically to address inspiratory flow limitations, and Resmed publishes other stuff that indicates that a sleep lab tech should adjust IPAP to address obstructive hypopneas.  

Can anyone tell me if there is a difference between an inspiratory flow limitation ("IFL") and an obstructive hypopnea ("OH")??  Based upon what I've read, it seems that IFL is inspiration that is complete, but not well-rounded, suggesting that an airway collapse may be eminent.  An OH is a limitation sufficient to reduce the tidal flow, i.e., an actual collapse during inspiration.  If that's right, that may explain why Walla Walla and I are disagreeing.  We're using the words differently.

If by flow limitation, Walla Walla means an obstructive hypopnea, and we actually both agree that the machines which are designed to treat that appear to treat that using IPAP.  

But, that's not how Resmed and Respironics use the term "flow limitation."  According to the AirSense 10 AutoSet Clinician Manual, Resmed uses the term to refer to a situation where the shape of the inspiratory flow time curve has changed from it usual shape.  According to the ASV manual (which is the only Resmed machine that adjusts IPAP and EPAP separately), Resmed believes that EPAP addresses that concern, and not IPAP.  The rest of Resmed's machines adjust IPAP and EPAP together, and so its impossible to infer from their behavior which of the two that Resmed believes addresses those concerns.
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#53
RE: Isn't Resmed's Expiratory Pressure Relief really Inspiratory Pressure Support??
What You Why don't we just explain exactly how you go about in an example form,how you answer these situations. 
1. Patient on apap and on epr for instance and getting too high clear airways.  What do you recommend?
2. Patient on apap and epr and getting too high of OA.  What do you recommend?
3. Patient on apap and epr and flow limitations are the problem.  What do you recommend?
Let's for example beginning iPap of 12 with epr of 2 and using airsense 10 autoset.
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#54
RE: Isn't Resmed's Expiratory Pressure Relief really Inspiratory Pressure Support??
(11-23-2017, 01:33 PM)Reznik Wrote: ReznikThe Respironics Bi-Pap Auto machine is marketed for the treatment of central apneas.  According to holden4th's post, it adjusts IPAP independently (i.e., Pressure Support) to address hypopnea and central apneas, which is exactly what ResMed's ASV manual says should be done for central apneas.

Maybe it is suitable for the job, but does not appear to marketed this way.
The DreamStation BiPAP is grouped with the regular DreamStation auto without any mention all central apneas

https://www.usa.philips.com/healthcare/p...eamstation

While the DreamStation BiPAP autoSV description mentions centrals

https://www.usa.philips.com/healthcare/p...pap-autosv
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#55
RE: Isn't Resmed's Expiratory Pressure Relief really Inspiratory Pressure Support??
(11-23-2017, 03:00 PM)yankees123 Wrote: What You Why don't we just explain exactly how you go about in an example form,how you answer these situations. 
1. Patient on apap and on epr for instance and getting too high clear airways.  What do you recommend?
2. Patient on apap and epr and getting too high of OA.  What do you recommend?
3. Patient on apap and epr and flow limitations are the problem.  What do you recommend?
Let's for example beginning iPap of 12 with epr of 2 and using airsense 10 autoset.

In all of these cases, I would recommend that the patient consult with a medical professional, and not rely upon advice that he or she reads on an internet forum.  

I would also recommend that the patient not necessarily rely upon the information supplied by the machine.  The methodologies used by the machines to distinguish between CA and OA is not 100% accurate.  The only way to determine for sure if you're having CA or OA is to have a sleep study, where the sleep technician actually measures your chest movements and observes your respiratory efforts.

While I'm happy to discuss how these machines work, and how a hypothetical person might use them, I would never offer an individual patient medical advice.
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#56
RE: Isn't Resmed's Expiratory Pressure Relief really Inspiratory Pressure Support??
(11-23-2017, 03:54 PM)yrnkrn Wrote:
(11-23-2017, 01:33 PM)Reznik Wrote: ReznikThe Respironics Bi-Pap Auto machine is marketed for the treatment of central apneas.  According to holden4th's post, it adjusts IPAP independently (i.e., Pressure Support) to address hypopnea and central apneas, which is exactly what ResMed's ASV manual says should be done for central apneas.

Maybe it is suitable for the job, but does not appear to marketed this way.
The DreamStation BiPAP is grouped with the regular DreamStation auto without any mention all central apneas

https://www.usa.philips.com/healthcare/p...eamstation

While the DreamStation BiPAP autoSV description mentions centrals

https://www.usa.philips.com/healthcare/p...pap-autosv

These machines are primarily marketed to medical professionals through the use of trained sales professionals, and not via web-sites.  

But, it is true that both Resmed and Respironics are heavily pushing the new and very expensive Bi-Level ASV models for people who have central apneas.  Given that both companies have an ultimate goal of generating a profit, that doesn't surprise me.
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#57
RE: Isn't Resmed's Expiratory Pressure Relief really Inspiratory Pressure Support??
(11-23-2017, 01:45 PM)Walla Walla Wrote: I own the VAUTO also. The IPAP responds to the flow limitations the EPAP goes up with the IPAP due to the PS. The EPAP is not responding to the flow limitations it's being drag up by the IPAP. Now when the EPAP responds to OA's it pushes up the IPAP due to the PS.

This as I was trying to get at. As mentioned, the variable PS on the Respironics gives EPAP some leeway to move if it needs it. If it doesn't it stays constant which to me meands that all events are treated by an increase in IPAP.

It is the reason that I bought a BiPAP as opposed to a BiLevel. To me this seems to be a better way to approach the treatment. The downside is that the Respironics doesn't respond fast enough for many users and I suspect that I'm one of them. I've also recently noticed IPAP spikes that aren't connected to any events so I'm going to get a Resmed just to see what it does for me.
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#58
RE: Isn't Resmed's Expiratory Pressure Relief really Inspiratory Pressure Support??
(11-24-2017, 03:07 AM)holden4th Wrote: It is the reason that I bought a BiPAP as opposed to a BiLevel. To me this seems to be a better way to approach the treatment.

Well, the Respironics BiPAP is a bi-level machine, so is the ResMed VPAP.

In addition to the variable PS that you like, Respironics also has B-Flex, which alters the shape of the expiratory pressure graph making things more comfortable (for some people).

I have a fixed-pressure Respironics BiPAP as a back up machine and I set the pressure at 12/9 with BiFlex on 3. This lowers the expiratory pressure by a maximum of about 1.5 cm, so I figure it's roughly equivalent to a ResMed VPAP set at 12 with a PS of 4.5.
Sleepster

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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#59
RE: Isn't Resmed's Expiratory Pressure Relief really Inspiratory Pressure Support??
(11-24-2017, 11:23 AM)Sleepster Wrote:
(11-24-2017, 03:07 AM)holden4th Wrote: It is the reason that I bought a BiPAP as opposed to a BiLevel. To me this seems to be a better way to approach the treatment.

Well, the Respironics BiPAP is a bi-level machine, so is the ResMed VPAP.

In addition to the variable PS that you like, Respironics also has B-Flex, which alters the shape of the expiratory pressure graph making things more comfortable (for some people).

I have a fixed-pressure Respironics BiPAP as a back up machine and I set the pressure at 12/9 with BiFlex on 3. This lowers the expiratory pressure by a maximum of  about 1.5 cm, so I figure it's roughly equivalent to a ResMed VPAP set at 12 with a PS of 4.5.

I only touched upon this early on, but Respironics isn't quite the same as Resmed.  It is definitely more like what I would expect an expiratory pressure relief to be.  It's hard to know for sure how Bi-Flex works because the DreamStation Provider Guide doesn't really explain how it works in detail.  But, the BiPap Auto Biflex (an older model) Provider Guide DOES explain it in detail on page 7.  

So, assuming that Bi-Flex is the same in the newer models, the Bi-Flex mode causes the IPAP to taper off before you're done inspiring.  It then gives you a relatively short period of time where the pressure goes below EPAP and then tapers back gradually to EPAP.  The 1, 2, or 3 setting on Bi-Flex reflects how deep the pressure goes below EPAP for that short period of time, but those numbers do NOT correlate to cm/water pressures as is the case with ResMED EPR, and the Respironics Bi-Flex mode does NOT hold the pressure at that lower level, but instead tapers back to the prescribed EPAP.  And then as soon as you start to inspire, it ramps up gradually to the prescribed IPAP, rather than jumping there immediately.  Then the cycle begins again.

The net effect is that you spend very little time at IPAP, and you get a burst of pressure relief below EPAP.  The machine spends very little time at either prescribed pressure, but is instead constantly adjusting between the two.

I've added an attachment showing Respironics description of Bi-Flex.  In the graph, the dashed lined shows BiPap without Biflex, and the solid line shows how the machine operates with Bi-Flex enabled.  These graphs do NOT represent how ResMed EPR works on the AutoSense 10 machines...


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#60
RE: Isn't Resmed's Expiratory Pressure Relief really Inspiratory Pressure Support??
(11-23-2017, 01:24 PM)Reznik Wrote: EPAP addresses obstructive apneas and flow limitations, and IPAP addresses hypopnea and central apneas.

If we assume that's true then that might explain why raising IPAP to compensate for raising EPR might (in many if not most cases) be unnecessary.

If a person is titrated at some pressure then it may be that pressures significantly lower will result in obstructions, but slightly lower will result in hypopneas. A hypopnea is, after all, just a less-severe obstruction than an obstructive apnea. Thus a person who turns on EPR and leaves the pressure alone will find no increase in hyponeas, and since the expiratory pressure is just a few centimeters lower, that reduction is not enough to result in an increase in obstructive apneas.

Regardless of how one tries to explain these things, the fact remains that many people can turn on EPR with no need to raise their pressure.
Sleepster

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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