High Pressure Support / EPR

[r4robin]

I’ve been through a lot of threads talking about PS, and the one thing I’ve noticed in almost all these conversions is the recommendation of 4PS (and usually nothing higher). 

I’m just curious is there a reason why higher numbers like let’s say 7, are not popular / recommended? 

I am kind of new to bilevel and am trying to find a good PS, I’ve noticed a high IPAP works good for me, but I do have trouble with EPAP making it hard to breathe - so in cases like mine, is it worth trying a high PS like 6+?

Also, if anyone does use high PS (~6+), how did you end up at that point and what are the pros and cons you’ve noticed?

Interested to hear your thoughts…

[Crimson Nape]

Higher PS values are more prone to cause CAs. The object, at least for me, is to monitor your flow rate waveform, and increase the PS until the tops of the form are more rounded as opposed to being flat.

- Red

[Sleeprider]

Tolerance and efficacy with higher PS varies by individual, and my guidance in bilevel is to start at 4.0, then use increases to resolve flow limitation and comfort issues, and less if centrals emerge. Pulmonary restriction is a really good example of a case where higher PS may be needed to enable a full breath in a short time. I don't endorse very high pressure support in healthy individuals that replaces spontaneous respiratory effort with the mechanical assist of bilevel. I have no evidence that the very high PS settings, generally above 6.0, are directly harmful to long-term health, but intuitively it seems we should avoid it without a good reason. When coaching members here, I have seen users that have self-titrated above 9.0 PS and that replaces all muscular effort in inspiration. Typically over-titrated individuals have unusually high tidal volume, slow spontaneous respiration rates and feel they are not getting enough air at more normal pressure support levels. We want to resolve respiratory issues and strive for comfort and good sleep without over-titrating PS, so I do coach against excessive PS.

[SarcasticDave94]

As was mentioned, higher PS can make it more susceptible to have Central Apnea events. Very high PS, I'm thinking 9 and above, is likely reserved for ventilator, high assist breathing that's not spontaneous. This wouldn't be a scenario most CPAP/BPAP users be considered.