[Treatment] Clownbell PAP Journey

[Dormeo]

I'm so glad this question came up. I know that hypopneas can be both central and obstructive in nature, but I assume we're talking about obstructive Hs here.

In the past, I had the idea that raising EPAP was the way to resolve Hs, same as OAs. But I could swear I've recently seen Sleeprider comment that introducing or increasing pressure support (aka EPR) can help with Hs as well as with flow limitations. So I'm really curious what the collective wisdom about this is.

[Gideon]

One of the BiPap titration guides says
EPAP for OA then
PS for hypopnea, RERAs, and Flow Limits.

and (I hope) obviously this is for obstructive events

[Dormeo]

Oh, many thanks, Gideon! And yes, central events would be something else again.

[clownbell]

This is interesting. I did not realize that hypopneas could be central and/or obstructive in nature Attached is a typical OSCAP page showing hypopneas but zero obstructive events. Should I assume the Hs are not obstructive in nature?

Also, I am confused by Gideon's statement saying
"EPAP for OA then
PS for hypopnea, RERAs, and Flow Limits."

What does Gideon mean by saying "PS for hypopnea?" As I understand it, PS is the difference between inhale and exhale pressure; PS is not a setting by itself. Not to be criticizing Gideon, I am simply uneducated.

Final item: Crimson Nape has previously replied that EPAP has to be increased in order to treat Hs, as opposed to Gideon's advice above "EPAP for OA." These twio pieces of advice seem (to me) to be contradictory.

Any guidance is much appreciated. I do not intend to be nit-picking, just confused.

Thanks

Craig

[Crimson Nape]

I based my answer on, what I feel is the most common, OA hypopnea.   Your airway will start to collapse while you exhale if you don't have enough back pressure.   Also, OAs usually occur during the exhale phase.  That is why I was making the statement that you usually increase the EPAP to increase the back pressure.

PS pertains only to AirCurve bi-level machines. The AirSense10 only has EPR. Both EPR and PS refer to the pressure delta between the IPAP and the EPAP. The difference is how they are applied to achieve the pressure difference.

I hope this clears it up for you.  If not, just ask.

- Red

[clownbell]

@ Crimson Nape - I think I do understand now. Thank you for the clarification.

[Dormeo]

Crimson Nape is right that the terminology of "pressure support" isn't used for the Airsense 10 Autoset. He's also right that EPR is correctly understood as pressure support, with the caveats that it can go no higher than 3 and comes only in increments of 1.

Yes, Gideon's statement, which is about obstructive hypopneas, is in conflict with the other statement about how to treat obstructive hypopneas. I don't think you can tell the difference between obstructive and central Hs via Oscar, though I might be wrong about that.

Craig, I'll be so interested to hear how things go for you with the changes you're going to try!

[staceyburke]

Craig - ps is the same as EPR. PS is used on bipap (aircurve and Phillips) and EPS is used on ResMed cpap(airsense ). 

Airsense:
The min is where the machine starts on inhale and exhale. It will rise to the max you have set to stop all apnea events (not centrals). 

The EPR (in ResMed airsense ) subtracts from the min for exhale pressure. So mim=10 EPR=3 your exhale pressure would be 7. Making it easier to exhale.

On beginning the inhale it would return to a pressure of 10 and go up only if there is an obstruction and will raise to the amount needed to open the airway (up to the max you have set).

[Gideon]

PS is a term that is associated with BiLevels. Depending on BiLevel mode it can be a setting, though in "S" (Spontaneous) mode it is not a setting, whereas in VAuto mode it is a setting.
For therapeutic purposes I consider PS and EPR to be equivalent with EPR limited to the values of 1,2, or 3.
There I was paraphrasing a BiPAP titration guide, I believe from Respironics for an S mode (fixed pressure) BiPAP machine

Step 1 (paraphrasing again) start low, see if OA events are managed. If not increase EPAP by 1 and repeat. If managed go to step 2.

Step 2 (Note, all the guides I've seen actually start with a PS of 4) see if hypopneas, RERAs, Flow Limits are managed, If not increase PS by one, otherwise repeat.

[clownbell]

I am not the only one having trouble with the N30 (not the "i" version) headgear. I get lots of leaks and can't seem to resolve with tweaking the headgear. Are there any hacks or tricks?

For example, I believe some P10 users use a headgear different than original. I'm wondering if there is something similar to apply to the N30 (again, not the "i" version).

Thanks to all.