If AirSense10 EPR 3 feels good, might BIPAP be even better?

[Carbon]

I am sleeping noticeably better since taking my EPR to 3 (after first taking minimum pressure to about my 90%), with no increase in centrals. AHI's average 1. I can't help but feel greedy for even better sleep, and am wondering if EPR (pressure support) of 4 or 5 might be even better, but would obviously need to switch to a bi-level machine.

My average and 90% pressures interestingly have drifted up by about 1.2 to 9.6 and 10.6 since raising the minimum, but at these relatively low pressures, is more EPR/ pressure support likely to make much difference?

The AutoCurve 10VAuto also spruiks an "Easy-Breathe waveform" that apparently gives a nice smooth breathing cycle vs the AutoSet. My flow rates still looks pretty notchy and flattened. Is a smoother waveform a real thing as far as comfort goes?
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And finally, if I take the leap, is the DreamStation BiPAP auto a better choice since it can auto-adjust both the IPAP and EPAP vs the AirCurves fixed difference between the autoadjusted IPAP and EPAP?

[DariaVader]

you need an EPAP that will keep your airway unobstructed. Higher pressure support can result in higher IPAP to acheive the necessary EPAP. My understanding is that if your flow restrictions and RERA events are greater than your OSA events, then greater pressure support can ease the required IPAP and still prevent OSA.

IOW: IPAP high enough to clear flow restrictions and RERA events - PS needs to be high enough to clear OSA

[justMongo]

I think you'd be wasting your money. Your waveforms look much like mine; and I have an S9 VPAP Auto with easybreathe.
I'd like to see the pressure waveform that goes with that flow waveform.
You are flat topping a bit -- so I bet your scoring some Flow Limitation at that time.

With EPR=3 and min pressure set to 9, you may be dropping as low as 6 cm-water on exhale.
If you had a bilevel, and set the PS=4, you'd likley have to raise EPAPmin.
You'd just be trading off parameters.

For your pressure range; and in the absence of any medical factors that might call for bilevel...
I'd say stick with what you have.

[robysue]

Carbon,

If you are sleeping well at night and feeling good in the daytime, it's a waste of time, money, and effort to try to switch to a bilevel just to see if a PS of 4 would somehow feel better to you.

Bilevel machines, like the Aircurve VPAPs, require a script that specifies "bilevel" if you want to buy one from a reputable DME (whether on-line or not.) A script that reads "CPAP" or "APAP" is not enough to allow a DME to sell you a bilevel machine.

Bilevel machines are also roughly twice as expensive as a top-of-the-line APAP. And your insurance won't pay for it unless the doc provides documentation of why a bilevel is required instead of a CPAP/APAP.

Yes, there's always the grey market of Craig's list out there where you could buy a used bilevel without a script. But personally I would be reluctant to do that with an important piece of medical equipment.

[palerider]

The AutoCurve 10VAuto also spruiks an "Easy-Breathe waveform" that apparently gives a nice smooth breathing cycle vs the AutoSet. My flow rates still looks pretty notchy and flattened. Is a smoother waveform a real thing as far as comfort goes?

you need to look at the mask pressure chart to see easy breath, instead of square blocky pressure changes, they look more like sharkfins. EPR has easybreath by default.

your waveform indicates you're having modest flow restrictions and probably need a little more pressure.

And finally, if I take the leap, is the DreamStation BiPAP auto a better choice since it can auto-adjust both the IPAP and EPAP vs the AirCurves fixed difference between the autoadjusted IPAP and EPAP?

so, I'm lost on the logic of wanting to go to a bilevel for MORE epap/ipap separation, then considering a machine that'd give you less most of the time.

[Carbon]

IOW: IPAP high enough to clear flow restrictions and RERA events - PS needs to be high enough to clear OSA

I should have been more specific – I was wondering whether I might do better pushing my IPAP up to a minimum of 10 or 11 with “EPR” Bipap equivalent of 4 or 5 to keep my epap minimum around 6 or so. I wasn't planning to drop absolute EPAP minimum.

I think you'd be wasting your money. Your waveforms look much like mine; and I have an S9 VPAP Auto with easybreathe.
I'd like to see the pressure waveform that goes with that flow waveform.
You are flat topping a bit -- so I bet your scoring some Flow Limitation at that time.

I was at APAP min 7,EPR 2 then gradually went to minimum 10 (roughly my 95%), EPR 2 but it didn’t feel so great, and I dropped back to 9 /2 which seemed a bit better. Tried 9 /3 and slept a bit better again with less awakenings, however noticed I do get more flat-tops and flow limits at 9/3 (albeit small) than at 10 /2. This observation, combined with knowing my machine won't record RERA's led to the thought that minimum 10 or even 11 IPAP while keeping min EPAP 4 or 5 points lower (i.e. at current absolute levels) might do even better.

If you had a bilevel, and set the PS=4, you'd likley have to raise EPAPmin.
You'd just be trading off parameters.

Not sure I follow that - did you mean "raise IPAPmin"?

Carbon,
If you are sleeping well at night and feeling good in the daytime, it's a waste of time, money, and effort to try to switch to a bilevel just to see if a PS of 4 would somehow feel better to you.

I'm back to 90% productive and self-employed in a high-pressure job. I can live with that, but it'd be nice to get back to full steam.

Bilevel machines, like the Aircurve VPAPs, require a script that specifies "bilevel" if you want to buy one from a reputable DME (whether on-line or not.)

I’m self-funded, and a new AutoCurve from USA costs about the same as what my AutoSet cost me in Australia, so it’s all relative I guess. My physician would have no problem in giving me a script for a machine with “bells and whistles” – he is quite happy with my progress and setting-fiddling to date.

And finally, if I take the leap, is the DreamStation BiPAP auto a better choice since it can auto-adjust both the IPAP and EPAP vs the AirCurves fixed difference between the autoadjusted IPAP and EPAP?

so, I'm lost on the logic of wanting to go to a bilevel for MORE epap/ipap separation, then considering a machine that'd give you less most of the time.

I had just assumed the DreamStation should sort all this out automatically to some sort of ideal. I wasn't aware that it would likely give less separation. Thanks for that tip.


With the extra information that I am wondering whether to get a BIPAP (maybe a loaner?) to push IPAP higher and maintain current EPAP min at 6, rather than to lower EPAP absolute minimum, are your collective recommendations unchanged i.e. that it is not likely to help?

[robysue]

And finally, if I take the leap, is the DreamStation BiPAP auto a better choice since it can auto-adjust both the IPAP and EPAP vs the AirCurves fixed difference between the autoadjusted IPAP and EPAP?

so, I'm lost on the logic of wanting to go to a bilevel for MORE epap/ipap separation, then considering a machine that'd give you less most of the time.

I had just assumed the DreamStation should sort all this out automatically to some sort of ideal. I wasn't aware that it would likely give less separation. Thanks for that tip.

Carbon,

palerider is simply wrong when he says that a DreamStation Auto BiPAP will give you less pressure relief "most of the time."

The PR Series 60 System One Auto BiPAPs and the PR DreamStation Auto BiPAPs have both a min PS and max PS setting.

If min PS = 3, the drop from IPAP to EPAP will always equal 3cm (or more) on the DreamStation. If BiFlex is turned on, there's an additional 1-2cm drop at the beginning of each exhalation, where the actual amount depends on the force of the exhalation and the flex setting.

If min PS = 4, the drop from IPAP to EPAP will always equal 4cm (or more) on the DreamStation. Again, if BiFlex is turned on, there's an additional 1-2 drop at the beginning of each exhalation, where the actual amount depends on the force of the exhalation and the flex setting.

Finally, I'll offer this: If aerophagia is an issue, it is really nice to have a machine that can independently raise the IPAP and EPAP.

The DreamStation will raise the IPAP in response to FL, RERAs, and clusters of Hs as well as the PR Search algorithm which proactively tests whether the shape of the inhalations improves with a modest pressure increase even before the machine can detect official FLs. The DreamStation will raise the EPAP in response to snoring and clusters OAs or OAs combined with Hs. The Resmed AirCurve VPAP raises the IPAP and EPAP together.

With the extra information that I am wondering whether to get a BIPAP (maybe a loaner?) to push IPAP higher and maintain current EPAP min at 6, rather than to lower EPAP absolute minimum, are your collective recommendations unchanged i.e. that it is not likely to help?

One advantage of a properly set up PR BiPAP is that you may need a bit less EPAP than you do using a CPAP with EPR. I'll use myself as an example:

I was originally started out on a Resmed S9 AutoSet with fixed pressure = 9 and EPR = 6. So the pressure was dropping to 6 at the beginning of the inhalations. My current settings on a PR Series 50 System One Auto BiPAP are min pressure = 4, max IPAP = 8, max PS = 4. On the older Series 50 machines like mine, the default min PS = 2 and cannot be changed. My EPAP hangs out at 4-5 almost all the time (the 95% EPAP is usually a bit over 5). My IPAP hangs out at 8 most of then night (sometimes my median IPAP = 8). Fact is 4-5cm is enough to keep most of my OAs from happening, but I need more like 8 to really keep the Hs and RERAs under control. FLs aren't bad at IPAP = 8, but if I increase the IPAP pressure to even as much at 10-12 cm, the FLs don't improve (and in fact can get worse) and I'm dealing with more aerophagia than I can handle.

[justMongo]

If you had a bilevel, and set the PS=4, you'd likley have to raise EPAPmin.
You'd just be trading off parameters.

Not sure I follow that - did you mean "raise IPAPmin"?

No such parameter as IPAPmin. On bilevel, there are 3 pressure parameters: 1) PS (Pressure support) which you wish to set to 4.
2) IPAPmax which limits the inhalation pressure. And, 3) EPAPmin which puts floor on how low expiratory pressure can go.

The machine always holds EPAP = IPAP + PS as it auto adjusts. It is constrained by IPAPmin and EPAPmax.

What you are attempting to do with a bilevel is set PS=4, but then you'd have to raise IPAPmin. You'll gain nothing over what your APAP can already do for you.

And, as RobySue pointed out, you'll pay a premium price for a bilevel; and it requires a prescription specific to bilevel.

Going to gray market sources is a violation of federal law. I've not heard of anyone being prosecuted; but you don't want to become a test case for the prosecution.

[PoolQ]

I think the OP lives in the land down under, so not sure what their "federal law" is.

Carbon, I am pretty sure you are looking for the same thing I was. My Doctor changed me from APAP to VPAP so I could have "an EPR of 4" and set up the settings to provide the BiLevel equivalent. Yes it help me sleep better, and I also discovered that there are several additional settings that have made a dramatic impact on my sleeping: Timin, Timax, trigger and cycle sensitivities.

If you get the VPAP you can still do what you are doing now, with the addition of several more and less restrictive settings.

[palerider]

so, I'm lost on the logic of wanting to go to a bilevel for MORE epap/ipap separation, then considering a machine that'd give you less most of the time.

I had just assumed the DreamStation should sort all this out automatically to some sort of ideal. I wasn't aware that it would likely give less separation. Thanks for that tip.

Carbon,

palerider is simply wrong when he says that a DreamStation Auto BiPAP will give you less pressure relief "most of the time."

The PR Series 60 System One Auto BiPAPs and the PR DreamStation Auto BiPAPs have both a min PS and max PS setting.

Unless Carbon wants to set his minps to 6 (which only gives him 2 cm for the machine to "sort it all out automatically", since the maxps is 8) then the presumption was that he'd have the minps set lower than he might have the fixed ps of the resmed, and absent of any need from breathing anomalies, his ps wouldn't increase, thus, giving him a lower ps, while the machine .... sorted it out.

perhaps not simply wrong, but complicatedly wrong.