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Should epap = titrated cpap pressure on Bilevel machine?
#1
Should epap = titrated cpap pressure on Bilevel machine?
I was wondering everyone's thoughts on this topic. When titrating for a bi-level device, a lot of people say that the epap should equal your straight CPAP pressure. I personally feel like the ipap should equal or be closer to the straight CPAP pressure and the epap should be set a few cmh20 below the ipap for comfort during exhalation. Setting epap to equal your straight CPAP pressure doesn't really make that much sense to me if you get a bi-level device for Comfort during exhalation because if you couldn't tolerate the straight CPAP pressure then why would you set the epap on the bi-level device as the same CPAP pressure and on top of that have an even higher ipap pressure. Wouldn't that defeat the purpose of getting a bi-level device for comfort during exhalation if you set it this way?
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#2
RE: Should epap = titrated cpap pressure on Bilevel machine?
It depends on how you had your CPAP set up. If you were using EPR on your CPAP than you would reduce the EPAP by the amount of EPR you had been using on the CPAP.


Example Cpap pressure is set to 10cm with a EPR set to 3cm. Than you would set your EPAP on the Bilevel to 7cm. With 3cm pressure support (PS) and a maximum IPAP of 25cm.
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#3
RE: Should epap = titrated cpap pressure on Bilevel machine?
That makes sense Walla. I was speaking more in general with no EPR on. Sorry I should have been a little more specific.
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#4
RE: Should epap = titrated cpap pressure on Bilevel machine?
(12-05-2018, 07:14 AM)Michaely6 Wrote: That makes sense Walla. I was speaking more in general  with no EPR on. Sorry I should have been a little more specific.

In that case I'd set the EPAP 4 cm below the pressure you've been using on CPAP and set the pressure support for 4cm and the max IPAP for 25cm and see how it goes.
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#5
RE: Should epap = titrated cpap pressure on Bilevel machine?
(12-05-2018, 08:09 AM)Walla Walla Wrote:
(12-05-2018, 07:14 AM)Michaely6 Wrote: That makes sense Walla. I was speaking more in general  with no EPR on. Sorry I should have been a little more specific.

In that case I'd set the EPAP 4 cm below the pressure you've been using on CPAP and set the pressure support for 4cm and the max IPAP for 25cm and see how it goes.

I'm glad to see that we have a similar approach when it comes to your Epap settings on a bilevel device.
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#6
RE: Should epap = titrated cpap pressure on Bilevel machine?
(12-05-2018, 06:49 AM)Michaely6 Wrote: I was wondering everyone's thoughts on this topic. When titrating for a bi-level device, a lot of people say that the epap should equal your straight CPAP pressure. I personally feel like the ipap should equal or be closer to the straight CPAP pressure and the epap should be set a few cmh20 below the ipap for comfort during exhalation. Setting epap to equal your straight CPAP pressure doesn't really make that much sense to me if you get a bi-level device for Comfort during exhalation because if you couldn't tolerate the straight CPAP pressure then why would you set the epap on the bi-level device as the same CPAP pressure and on top of that have an even higher ipap pressure. Wouldn't that defeat the purpose of getting a bi-level device for comfort during exhalation if you set it this way?

CPAP pressure is usually the 90th percentile pressure needed to stop OA, but some titrations may go on to titrate out hypopnea as well.  Hypopnea, flow limits and snores are better treated with pressure support in BPAP, so it is unlikely the CPAP titration will be an accurate starting point for bilevel EPAP.  Many people on CPAP have much higher pressure than they will need for bilevel EPAP.  I often encourage people trying bilevel to back off on EPAP to where OA events appear, then increase from there.  It really amounts to self titration.  due to the variability in titration quality, I don't think you can make a general rule that applies when changing to bilevel.
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#7
RE: Should epap = titrated cpap pressure on Bilevel machine?
(12-05-2018, 09:37 AM)Sleeprider Wrote:
(12-05-2018, 06:49 AM)Michaely6 Wrote: I was wondering everyone's thoughts on this topic. When titrating for a bi-level device, a lot of people say that the epap should equal your straight CPAP pressure. I personally feel like the ipap should equal or be closer to the straight CPAP pressure and the epap should be set a few cmh20 below the ipap for comfort during exhalation. Setting epap to equal your straight CPAP pressure doesn't really make that much sense to me if you get a bi-level device for Comfort during exhalation because if you couldn't tolerate the straight CPAP pressure then why would you set the epap on the bi-level device as the same CPAP pressure and on top of that have an even higher ipap pressure. Wouldn't that defeat the purpose of getting a bi-level device for comfort during exhalation if you set it this way?

CPAP pressure is usually the 90th percentile pressure needed to stop OA, but some titrations may go on to titrate out hypopnea as well.  Hypopnea, flow limits and snores are better treated with pressure support in BPAP, so it is unlikely the CPAP titration will be an accurate starting point for bilevel EPAP.  Many people on CPAP have much higher pressure than they will need for bilevel EPAP.  I often encourage people trying bilevel to back off on EPAP to where OA events appear, then increase from there.  It really amounts to self titration.  due to the variability in titration quality, I don't think you can make a general rule that applies when changing to bilevel.

Thanks sleeprider!! The ipap is used to eliminate flow limitations,  hypopneas and snores correct? So pretty much when there are hypopneas and flow limitations the pressure support should be increased in order to increase the ipap to get rid of the hypopneas and flow limitation?
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#8
RE: Should epap = titrated cpap pressure on Bilevel machine?
[Image: attachment.php?aid=4203]
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#9
RE: Should epap = titrated cpap pressure on Bilevel machine?
(12-05-2018, 10:32 AM)Sleeprider Wrote: [Image: attachment.php?aid=4203]

On the aircurve Vauto, what will the initial settings look like if following that diagram that you posted since the auto mode has to have a range? Or are you supposed to titrate in S Mode?
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#10
RE: Should epap = titrated cpap pressure on Bilevel machine?
I would set min at 2 cmw under your CPAP pressure and the max at 25 CMW and PS at 4 with the expectation to alter the settings after one night.  If no or low obstructive events I would consider another lowering of the EPAP.

Ask your self How do I feel?  This should always be asked if you are either in or near a therapeutic pressure.

Fred
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