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Started on CPAP and was Switched to BIPAP
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me50 Offline

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Post: #1
Started on CPAP and was Switched to BIPAP
I have a question for those that started on a CPAP machine and was switched to a BIPAP machine.

As an example: Is there a difference in the pressure 12 on a CPAP vs. the pressure 12 on a BIPAP (for inhale)? I ask because I was told that there was a difference.

I am aware that with BIPAP, the inhale pressure is higher than the exhale pressure.

I just wanted to ask this question from those that have been through this rather than what someone told me that doesn't have apnea of any kind.

Thanks
11-20-2013 04:34 PM
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zonk Offline

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Post: #2
RE: Started on CPAP and was Switched to BIPAP
There is no difference in inhale pressure as both set at 12 but the main difference is the exhale pressure

CPAP EPR lower exhale pressure at 3 levels (1,2,3), 3 being the maximum
BIPAP pressure support can be set higher than CPAP EPR maximum level which some find more comfortable but as I understand BIPAP exhale pressure cannot be lower than CPAP inhale pressure
11-20-2013 05:17 PM
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me50 Offline

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Post: #3
RE: Started on CPAP and was Switched to BIPAP
(11-20-2013 05:17 PM)zonk Wrote:  as I understand BIPAP exhale pressure cannot be lower than CPAP inhale pressure

I am a little confused by BIPAP exhale pressure cannot be lower than CPAP inhale pressure.

For example: If my set CPAP inhale pressure is 15, are you saying that if I were on BIPAP or having a BIPAP titration that my BIPAP exhale pressure cannot be lower than 15? Sorry if I misunderstood what you are saying.
11-20-2013 06:05 PM
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zonk Offline

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Post: #4
RE: Started on CPAP and was Switched to BIPAP
This what Dr David Rapoport (NYU Sleep Center New York City) saying in his videos presentation ... Enjoy
http://www.youtube.com/watch?v=IP3IgvE36GA&feature=related

Edit: The reason being ... EPAP for obstructive apnea and IPAP for Hypopnea

Central apnea ... different machine and different topic altogether
(This post was last modified: 11-20-2013 06:21 PM by zonk.)
11-20-2013 06:13 PM
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me50 Offline

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Post: #5
RE: Started on CPAP and was Switched to BIPAP
(11-20-2013 06:13 PM)zonk Wrote:  This what Dr David Rapoport (NYU Sleep Center New York City) saying in his videos presentation ... Enjoy
http://www.youtube.com/watch?v=IP3IgvE36GA&feature=related

Edit: The reason being ... EPAP for obstructive apnea and IPAP for Hypopnea

Central apnea ... different machine and different topic altogether

I have watched 5 of them so far and I like this presentation and thanks for posting the link. It made me think 2 thoughts based on what I have heard so far.

1. With BIPAP (BI-LEVEL) or APAP for that matter, how much wear and tear and subsequent problems with the airway from the continuous expansion and deflation of the airway?

2. According to what I understood him to say, BI-LEVEL, in most cases, is really no more beneficial (and certainly no less beneficial) than CPAP, then wouldn't it make sense to build CPAPs that has a higher pressure than 20?

Just my thought process here. Interested in seeing what others have to say about this.
(This post was last modified: 11-20-2013 08:21 PM by me50.)
11-20-2013 07:17 PM
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robysue Offline
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Post: #6
RE: Started on CPAP and was Switched to BIPAP
me50,

You're original post asked for input from someone who had been through the switch from CPAP to BiPAP to explain something about how the differences between the two feel in use. I started PAP therapy using an S9 AutoSet set first in CPAP mode with EPR = 3 and then APAP mode with EPR = 3. I was switched to bi-level after three months due to severe problems with tolerating CPAP/APAP therapy. My problems were severe aerophagia and growing insomnia caused in part by the fact that the sensory stimuli from the S9 was driving me crazy and waking me up when I would go to bed while feeling like I was falling asleep on my feet.

My comments concern the differences between the Resmed S9 AutoSet with EPR compared to a bi-level machine---either the PR System One BiPAP (which I now use) or the Resmed VPAP.

Let me start with the most obvious difference between therapy using a CPAP/APAP machine and therapy using a bi-level machine (BiPAP or VPAP): On a bi-level, the difference between EPAP and IPAP is not limited to 3cm. This affects how the therapy actually feel in many ways. Two of the most important are:
  • For some people a larger difference between the two pressures is simply much more comfortable to breathe with. At low pressures, this not (usually) enough to medically justify the use of a bi-level machine, but it's also not something to be completely ignored when someone is having serious adjustment problems. But many people have very serious problems exhaling against pressure once their titrated pressure reaches 15cm or more of pressure. And so for people with very high pressure, a switch to bi-level can make a difference in the ability to tolerate the machine.
  • The overall average pressure needed to properly manage the OSA may be reduced, and that can increase comfort, and hence compliance in a subset of sensitive patients. Patients with minor problems with pressure indued centrals may find that the switch to bi-level is just enough to keep the pressure induced centrals from becoming a serious problem and hence prevent the need to move the patient to an even more expensive and possibly more difficult machine to adjust to. Another group of patients who may do better with a reduced average pressure are patients dealing with serious problems with aerophagia.

You specifically asked in your original post:
Quote:As an example: Is there a difference in the pressure 12 on a CPAP vs. the pressure 12 on a BIPAP (for inhale)? I ask because I was told that there was a difference.
I'm going to assume that you mean "Is there a difference between using a BiPAP with IPAP = 12 and an S9 AutoSet with pressure = 12 and the Resmed EPR system since that's the machine you have in your profile.

There is a more subtle, but very real difference between the S9 CPAP/APAPs and bi-levels: The transition between the EPAP pressure and the IPAP pressure is subtly different. Although most people like to think of EPR as a "poor man's bi-level", it's just not quite true.


The S9 CPAP/APAP with EPR starts to subtly raise the pressure earlier in the breath cycle than the S9 VPAP (or the PR BiPAP) does. The S9 AutoSet pressure transition is supposedly much smoother (with the so-called "easy breath" pattern and the default "medium" transition pattern, but the fact remains, the pressure starts to go up during the flat part of the wave flow---a part of the breathing cycle that is a brief pause between the exhalation and the inhalation; for some people(like me) this pause psychologically feels like the end of the "exhalation", and that subtle pressure increase can make it feel as though the S9 is trying to rush you to inhale before you are ready to. This figure illustrates what I'm talking about:

[Image: 54fc2138d9da9965b54969381f68354b.jpg]

The pressure curve is on top and the patient's airflow is on the bottom. The part of the wave flow under the red slanted line is the part of the pressure curve that corresponds to the brief pause between the exhalation and the inhalation. The period between the red vertical line and the green vertical line represents a period where the pressure is distinctly going up, but the wave flow is still in that pause between the exhalation and the inhalation.

(NOTE: The Flex system on the PR CPAPs and APAPs increases the pressure even earlier than EPR does and the increase during this pause between the exhalation and the inhalation is even more pronounced than the increase in the Resmed EPR system)


The S9 VPAP waits until the inhalation has clearly begun to raise the pressure. The following figure shows the pressure curve for the S9 VPAP Auto. Note how the transition to IPAP (the tops of the waves) is much sharper and and has a V-shaped notch rather than a smooth u-shaped bottom at the beginning of the pressure increase. The red slanted lines indicate where that pause between the active exhalation and the active inhalation occurs in the pressure curve. Unlike the S9 AutoSet's Easy Breathe with EPR curve, there is no pressure increase during that time period indicated by the red slanted line until the "sharp" jump upwards right at the end of the time period, which is when the inhalation actually starts:

[Image: a8468855a610e70fdf0763bca7358570.jpg]

It's a subtle difference in feel and most people probably would not be able to pick up on it if they were comparing an S9 APAP/CPAP with EPR set to 3 to an S9 VPAP with the PS set to 3. (On the S9 VPAP, the PS setting controls the difference between IPAP and EPAP: At all times, IPAP = EPAP + PS.)


The differences between the PR System One BiPAP and the S9 APAP/CPAP with EPR are even greater than the differences between the S9 APAP/CPAP with EPR and the S9 VPAP. The System One BiPAP has a more square shaped pressure transition curve than either the S9 VPAP or the S9 CPAP/APAP with EPR. And if you turn on Bi-Flex, then there's also the fact that you get a bit of additional pressure relief right at the start of the exhalation with the PR System One BiPAP. When Bi-Flex is turned on, the pressure curve and the patient's wave flow look like this:

[Image: 732976896c4b25d279984b3ca9f9575e.jpg]

The blue vertical line indicates the end of the "active" part of the exhalation and the beginning of the brief pause between the exhalation and the inhalation (that to me feels like it's part of my exhalation). Note how the dip in pressure triggered by the start of the exhalation has been increased back to the full EPAP setting by the time the active part of the exhalation is over. The red vertical line has been added to indicate where the Resmed EPR system kicks in its subtle pressure increase. Also note how the PR System One basically increases the pressure from EPAP to IPAP more or less in one giant leap with only the smallest bit of rounding based on the Flex setting.

If you compare the pressure increase on the System One BiPAP to the S9 VPAP, you'll see that both increase the pressure from EPAP to IPAP pretty quickly and pretty steeply at the beginning of the active stage of the inhalation. The S9 starts to drop the pressure as the inhalation starts to slow down (that's the characteristic "peak" in the pressure wave), while the System One maintains the pressure at full IPAP until the end of the exhalation.

Bi-Flex is an option on the PR System One BiPAP and not everybody likes it. (I really dislike it---it makes me feel like the machine is rushing me to inhale.) When you turn Bi-Flex off, you get a different option called Rise time. There is no additional decrease in pressure at the start of the exhalation, and the Rise Time setting controls how long it takes for the pressure to increase:
  • Rise time = 1 means it takes the System One 0.2 seconds to increase the pressure from EPAP to IPAP.
  • Rise time = 2 means it takes the System One 0.3 seconds to increase the pressure from EPAP to IPAP.
  • Rise time = 3 means it takes the System One 0.4 seconds to increase the pressure from EPAP to IPAP.

At this point I've probably overwhelmed you with technical information. So now I'll give you my subjective opinion.

I started out with the S9 AutoSet in CPAP mode at a pressure setting of 9 cm with EPR set to 3. I found it difficult to exhale and I felt like the machine was constantly rushing me to inhale before I was ready to take my next inhalation. But if I turned EPR down to 2 (or 1 or or off), I found it even harder to exhale against the pressure. In short, I felt like I was running a marathon in my sleep every night trying to keep up with all the air the S9 was "forcing" me to breath. And it triggered really severe aerophagia.

After a mere two weeks I could not stand the aerophagia any more and I looked like the walking dead. The PA in the sleep doc's office kindly switched me to APAP for a week or two of autotitriation which showed that 8cm was probably enough to manage my OSA. The aerophagia was more tolerable on APAP and I begged to not be switched back to full time CPAP. Hence she left me running in APAP with a tight range of 4-8 cm. Aerophagia continued to plague me and my AHI started to bounce around a bit and snoring became an intermittent problem. And the insomnia continued to grow worse. Two months later, after yet another meeting with me talking about how much worse I still felt, how hard it was for me to fall asleep and stay asleep, and how often I was still waking up in the middle of the night with a seriously bad stomach ache and a visibly bloated, rock hard abdomen, the PA said she and the doc had talked and all they could come up with was to swtich me to bi-level.

Back to the lab for a bilevel titration. The test showed rampant insomnia---far worse than I thought. I self reported that I thought I'd slept for about 3 1/2 or 4 hours during the test; the EEG data said I slept for 110 minutes. But at least my stomach was much more comfortable with the bilevel---no rock hard, bloated tummy that night. And a titration level of IPAP = 8; EPAP = 6. The S9 VPAP was not yet on the market and after a month of agonizing over whether to the the S8 VPAP or the PR System One BiPAP, I finally opted for the System One BiPAP.

I turned Bi-Flex off the first night: It made me feel like the machine was trying to make me inhale before I was ready to. I'm really, really sensitive to pressure increases when I am not actively inhaling. But when I switched the machine to Rise Time, for the first time in three long months, I actually felt sort of semi comfortable breathing with the damn machine. I still had trouble exhaling against the pressure when I was awake and hence I used the ramp alot while I was awake. And I still was waking up with aerophagia alot, but at least it no longer looked or felt like I'd swallowed a basketball. After six weeks of being on BiPAP, the PA sent me back to the lab for another titration study and my pressure was reduced to 7/4, which felt like heaven. I could finally breathe with the machine in comfort. Unfortunately, that was not enough pressure to really control the apnea on a nightly basis. And hence I was finally changed to the tight Auto BiPAP range I now use.

I occasionally self titrate to see if an increase in pressure would make me sleep any better. So far, the answer seems to be either,and empahtic "NO!" or "nor really." It sort of depends on how high the EPAP pressure goes during the autotitration period. If the EPAP spends any appreciable time above 6cm, my stomach objects. If the IPAP spends any appreciable time above 10 cm, my stomach may object. I sort of wish I had one of he newer Series 60 BiPAP Autos that allow you to set a minimum PS setting since that would allow me to let the IPAP go up to 9 or 10 cm while still restricting the max EPAP to 6 cm.

I personally find the fact that my BiPAP keeps the pressure at EPAP all the way through the entire exhalation and that pause between the active exhalation and the active inhalation very important. That's what makes it possible for me to be able to breathe in a fashion that feels mostly normal to me when I'm trying to get to sleep at the beginning of the night or when I'm trying to get back to sleep after one of my many wakes.
11-21-2013 02:40 AM
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zonk Offline

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Post: #7
RE: Started on CPAP and was Switched to BIPAP
Titration protocol reference guide
CPAP - BiPAP S - BiPAP autoSV Advanced
http://www.sleepapnea.com/downloads/1002...fGuide.pdf
11-21-2013 03:16 AM
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robysue Offline
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Post: #8
RE: Started on CPAP and was Switched to BIPAP
(11-20-2013 07:17 PM)me50 Wrote:  1. With BIPAP (BI-LEVEL) or APAP for that matter, how much wear and tear and subsequent problems with the airway from the continuous expansion and deflation of the airway?
Not sure what you mean here. The expansion of our airway and lungs is much more due to the air we breath in than the (relatively) tiny bit of extra pressure that it takes to keep our airway from collapsing. All the decrease to EPAP does is allow for a more natural sensation in exhalation---after all, in exhalation we typicallly have a lower relative air pressure in the upper airway compared to ambient airpressure. Breathing out against CPAP is what's "abnormal" if you will.

Quote:2. According to what I understood him to say, BI-LEVEL, in most cases, is really no more beneficial (and certainly no less beneficial) than CPAP, then wouldn't it make sense to build CPAPs that has a higher pressure than 20?
There are some sleep docs who have thought (and some who continue to think) that more widespread use of bi-level would increase compliance. The data coming from random control studies, however, does not seem to back that up. But then data coming from random control studies also indicate that APAPs are no better than CPAPs, that the exhalation relief systems don't seem to increase compliance, and that heated humidification is unneeded in many cases.

Bu anecdotal evidence indicates that for individual PAPers one or more of these "unnecessary interventions" is the key (or one of the key) ingredients in getting that person to comply with therapy. And statistics are not particularly good at predicting what a particular individual will need to make a difficult therapy work in their own bedroom for yearsto come.

And then there's also another thing the studies don't measure, and that's comfort. A lot of folks are capable of sucking it up and making PAP work no matter how horrible the experience. They'll stick out out because they do know the consequences of not doing so. But they really are more comfortable if they're using a BiPAP (or an APAP) instead of a straight CPAP. So it's not technically medically necessary a lot of the time, but the patient's quality of life goes up because the quality of their sleep experience goes up.

And finally one short coming of all the studies is that none of them are truly long term in the sense of following a group of OSA patients over the course of five or more years instead of a few weeks or a few months. There's a lot of focus on what will get people compliant for the first three months with the assumption that if someone uses the machine for three months, they'll be a PAPer for life. But I'm pretty sure that's a very rosy picture of what long term compliance really looks like. I do think that if a PAPer makes to to their first anniversary of PAPing in one piece there's a good chance they'll continue. But I bet a large number of folks drop out after that first set of compliance checks and followup appointments with the doc. They'll try for a while, but if nothing's getting any better by the end of four or five months? They'll toss the machine in the closet ....

Quote:Just my thought process here. Interested in seeing what others have to say about this.
In my case there's a whole lot of "process" that I will have to be dealing with once I reach Medicare age:

My initial sleep test used the Alternative Standard to score the hypopneas. And all my hyoponeas were "hypopneas with arousal"---they would NOT have been scored under the Medicare approved Recommended standard. And without the hypopneas? I go from having an AHI = 23.3 to having an AHI = 3.3. And not qualifying for a machine at all.

Is my BiPAP really medically necessary? Probably not. But---I really don't know how long I could have tolerated the severe aerophagia before just giving up and throwing the S9 into the closet. And I don't think it would have gotten any better with more time. Because the thing that finally "fixed" the aerophagia was getting a machine that did not tickle the back of my throat in a way that made me feel like it was rushing me to inhale before I was ready AND getting a machine that allows my EPAP to stay at 4cm for long stretches of the night while my IPAP is sitting at 8cm for long stretches of the night. (8/4 to 8/5 seems to be my "true" pressure needs.)

My DME messed up the paperwork when the doc sent the letter of medical necessity for the switch to BiPAP. The DME never filed the letter of medical necessity NOR the bill for the BiPAP with the insurance company. (They charged me my full copay, but not insurance company.) When I caught the error, the DME ate the cost of the difference between what they had gotten from the insurance company for the APAP and what they should have gotten from the insurance company for the BiPAP. It will be loads of fun for me when it's time to replace Kaa ...

So all I can say is it doesn't surprise me that there are docs out there saying BiPAPs don't need to be prescribed to hardly anybody. Or even to anybody at all except perhaps to that handful of people with central sleep apnea (and the sad thing is---a plain BiPAP really does NOT treat a serious, persistent case of central or complex sleep apnea).
11-21-2013 03:19 AM
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me50 Offline

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Post: #9
RE: Started on CPAP and was Switched to BIPAP
1. With BIPAP (BI-LEVEL) or APAP for that matter, how much wear and tear and subsequent problems with the airway from the continuous expansion and deflation of the airway?

What I mean by this is that with straight CPAP, the airway always receives the same pressure during inhale and exhale. With Bi-Level, the pressure on inhale and exhale is different and I am not sure I completely understand what happens during any events with the Bi-Level (I am still searching and reading info), but I wonder if the continuous higher pressure of breathing in and out (as opposed to what it is like during the day when we breath in and out, presuming the natural airflow is at a much less pressure than at night when those with apnea sleep and the airway collapses), it it causes stress or weaking in the airway walls (kind of like when a bulimia patient purges and over time, it weakens the esophagus to where it could and has in some patients, ruptured). At 2AM, I hope this makes sense

When I first started CPAP therapy, I was on a set pressure of 12. I tried that for almost for over 2 years and there was no improvement in how many times I woke up.

Then I was switched to APAP and I still continued to wake up a lot. Had a titration study where they determined that 16 was the optimal pressure although it was only used for 29 minutes. So, I have my settings currently from 15 to 20 with the majority of the pressure being 19.9. During this sleep study, I was started out at 12 and the pressure increased throughout the night to 16. I was told that if I got to 15 they were to try me on bi-level but the doctor wrote the instructions or the order that if I got over 16 to try bi-level. Well, time ran out so that never happened. See below the 2013 titration study.

[attachment=555]

Here is the 2011 titration study

[attachment=556]

So, I will be having a Bi-Level titration study in early Dec and the doctor is starting me out at 14/7. He was going to start me at 12/6 but since they asked me to be there at 9 PM (as opposed to 8 PM in my other 2 studies) and then with the attachment of all the wires, etc., he (and myself) were concerned that there wouldn't be enough time to find out if Bi-Level would work for me and, if so, to find the optimal pressure (they end the test at 5 rather than 6:30 AM in the other 2 tests that I had).

Thank you for a post with so much information. I will look at the charts that you included when I can think better.
11-21-2013 04:17 AM
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me50 Offline

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Post: #10
RE: Started on CPAP and was Switched to BIPAP
ANY of the members have any thoughts on this? See Below:

1. With BIPAP (BI-LEVEL) or APAP for that matter, how much wear and tear and subsequent problems with the airway from the continuous expansion and deflation of the airway?

What I mean by this is that with straight CPAP, the airway always receives the same pressure during inhale and exhale. With Bi-Level, the pressure on inhale and exhale is different and I am not sure I completely understand what happens during any events with the Bi-Level (I am still searching and reading info), but I wonder if the continuous higher pressure of breathing in and out (as opposed to what it is like during the day when we breath in and out, presuming the natural airflow is at a much less pressure than at night when those with apnea sleep and the airway collapses), it it causes stress or weakening in the airway walls (kind of like when a bulimia patient purges and over time, it weakens the esophagus to where it could and has in some patients, ruptured).

Just something to think about.

Thank you and have a great day.
(This post was last modified: 11-22-2013 08:43 AM by me50.)
11-22-2013 08:39 AM
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