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Why not having a bi-level machine instead of a single pressure CPAP/APAP?
#1
Why not having a bi-level machine instead of a single pressure CPAP/APAP?
Hi,

After sleeping for 4 nights with a borrowed (very old) ResMed VPAP III-ST, here are the findings:

Pressure settings: IPAP 12,  EPAP 2 (constant pressure).

Advantages:
1. Very comfortable breathing.
2. Mouth breathing disappeared!  (I have a severe mouth breathing issue with the PRISMA 20A).
3. Very low mask leak (2-4 L/Min).
Disadvantages:
Therapy was bad!

Question: Will a modern Bi-Level machine solve my severe mouth breathing issue? Further, if we disregard the cost issue, why not having a bi-level machine instead of a single pressure CPAP/APAP? It is much comfortable and can improve quality of sleep?
Thanks,
Arik 
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#2
RE: Why not having a bi-level machine instead of a single pressure CPAP/APAP?
Arik, you were using an extremly high pressure support of 10 cm (12/2) and this would normally cause a LOT of central apnea. If you were using the timed backup rate that might have been corrected somewhat. The bigger problems is the use of very low EPAP of 2-cm. EPAP is what holds the airway patent and prevents obstructive apnea, so assuming you have obstructive sleep apnea, the machine was set up very incorrectly. Normally, for bilevel therapy, we would set the EPAP at the pressure in CPAP that treats obstructive apnea, then use the pressure support to treat hypopnea snoring and flow limitation.

A bilevel machine is very nice and is capable of more directly targeting apnea and hypopnea. The machines most appropriate for you are the Resmed Aircurve 10 Vauto, Dreamstation BiPAP Auto. Lowenstien also makes a bilevel, but I'm unfamiliar with the series and as you know the data is not as complete. It's more important that you understand how to setup a machine for your needs using standards titration protocols. An auto bilevel lets the machine adjust pressures automatically, but we still would want to set it up for your needs. We know from your other thread that you want exhale pressure to be as near zero as possible, however you experience a great deal of obstruction at low pressures. An appropriate pressure range with a comfortable pressure support should be much better for comfort and efficacy, however if you objective remains an EPAP pressure in the ultra-low range, you will continue to have obstructive apnea.

For your current VPAP-ST, I would suggest that you set EPAP at 6.0 and IPAP at 10 to 12 and see if that helps a bit. If your airway collapses and obstructs during exhale, there is no IPAP pressure that will re-open it, however the contrast between inhale and exhale pressure is what makes respiration "feel" easier, and thus reduce mouth breathing and respiratory effort. In your titration work with Bonjour in the other thread, an EPAP pressure of 6.0 with PS 3 still left you with 7 obstructive apnea per hour. We can assume you will eventually need settings with an EPAP pressure of 8 or 9 and enough pressure support to make that comfortable. At least with a Vauto, you could start at EPAP minimum pressure of 6.0, set a pressure support at 6.0 and maximum pressure of 20 and let the machine titrate you.
Sleeprider
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#3
RE: Why not having a bi-level machine instead of a single pressure CPAP/APAP?
Thanks a lot, Sleeprider. Your answer provides priceless information for me. Will try these settings next night and let you know. 
Two questions:
1. How the machine knows to distinguish between obstructive and central Apneas? from looking at the graphs at high resolution they look the same to me.
2. Can humidifier reduce mouth breathing? apneas?

Thanks,
Arik
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#4
RE: Why not having a bi-level machine instead of a single pressure CPAP/APAP?
Newer machines can determine whether the airway is open or obstructed by using air pulses and detecting the "echo", kind of like sonar. Resmed machines use "Forced Oscillation Technique (FOT)" which is a high frequency oscillation of pressure. The Respironics products use pressure pulses (PP) to sound out the airway. There is a good explanation by Lanky Lefty on Youtube at https://www.youtube.com/watch?v=XuUVW5V_sEM   One correction to Lanky's narrative, the FOT or PP do not help to restart breathing, rather they are used by the machine logic to either increase pressure (OA) or decrease pressure (CA). Accuracy seems better for Resmed than Respironics.  Also see the Optimizing Therapy wiki http://www.apneaboard.com/wiki/index.php...ng_therapy

Humidity has more to do with comfort than how you breathe. The job of the upper airway is to pre-warm and humidify the air before it reaches the lungs. When using CPAP or bilevel pressure air delivery can feel dryer or colder, so a CPAP humidifier is used to increase the relative humidity of the air and reduce irritation on the upper airway.  This can avoid congestion caused by your natural reaction to try to increase airway moisture, or even nosebleeds if the airway it too dry or irritated.  Whether you breathe through your nose or mouth is affected to the extent that proper humidification can promote nasal breathing by keeping the nasal passages less irritated, congested and comfortable. Some people are going to breath through the mouth or equally the mouth and nose due to habit or obstruction from deviated septum and other sinus problems.  Nasal breathing is preferred, but if you're inclined to mix it up a bit, there is not much we can do about it, but an Ear, Nose Throat (ENT) specialist might have some ideas how to open up that possibility.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
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Organize your OSCAR Charts
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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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#5
RE: Why not having a bi-level machine instead of a single pressure CPAP/APAP?
Thanks!
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#6
RE: Why not having a bi-level machine instead of a single pressure CPAP/APAP?
Hi Guys,
 
Following my previous posts/treads, I managed to get the data out of the Resmed machine (this was challenging...crossed RS232 cables…). I was disappointed to realize that the machine does not differentiate between central and obstructive apnea, nor produces detailed graphs (or I missed something in the configuration?).
I’m attaching here two reports (14 and 16 Jan.) and ask for your opinion how I can improve my treatment. As I already reported, the main advantage of the this machine, as oppose to the PRISMA, is the minimum mouth breathing that drives me crazy. Nevertheless, the PRISMA AHI was much lower (unless each machine has a completely different way to calculate AHI…).
Thanks,
Arik
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#7
RE: Why not having a bi-level machine instead of a single pressure CPAP/APAP?
Without the detailed data and indication of central vs obstructive, we are at a significant disadvantage. I will assume both types of events may be present, and since the AHI is much greater with this machine than the Prisma, I will lean towards the most likely explanation being that the high pressure support is causing centrals. I will recommend EPAP at 7.0 which will help reduce OA, and I want to reduce the pressure support, so IPAP at 11.0 which is a PS of 4.0. Check for comfort and go with it if you find that tolerable.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
Organize your OSCAR Charts
Attaching Files

How To Deal With Equipment Supplier


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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