Bipap and Apap comfort?

[tarheelalum]

Recently I did a titration study for OSA and I never could get comfortable, especially during expiration. Breathing against the air pressure was extremely troublesome for me. I have been reading that bipap and apap machines drop the pressure on expiration and are more comfortable than cpap in this regard. But is the reduction of pressure that much greater on bipap as opposed to apap machine? If so, are there any drawbacks to using a bipap machine for OSA? Are they more likely to cause central apneas for people who only have OSA? I've read that bipaps are more comfortable for people who have trouble with treatment but I don't know if that is a sales pitch or the truth. My insurance will pay for either one, (provided that I use it daily) so I'm just looking for the most comfortable solution that I can tolerate for my OSA.

[babydinosnoreless]

I have a bilevel (resmed machines are not bipap because phillips trademarked that name). Set with a ps of 4. This gives me a bigger drop in exhale than I would get with the flex settings of an autopap. I have tried ps3 which is similar to what a autoset would give you but it is not a big enough drop for me. I struggled for a couple of hours before I set it back to ps4.

[ragtopcircus]

Recently I did a titration study for OSA and I never could get comfortable, especially during expiration. Breathing against the air pressure was extremely troublesome for me. I have been reading that bipap and apap machines drop the pressure on expiration and are more comfortable than cpap in this regard. But is the reduction of pressure that much greater on bipap as opposed to apap machine? If so, are there any drawbacks to using a bipap machine for OSA? Are they more likely to cause central apneas for people who only have OSA? I've read that bipaps are more comfortable for people who have trouble with treatment but I don't know if that is a sales pitch or the truth. My insurance will pay for either one, (provided that I use it daily) so I'm just looking for the most comfortable solution that I can tolerate for my OSA.

If we focus on Resmed Airsense and Aircurve products for a moment, CPAP and APAP are just a limited version of BiLevel CPAP/APAP. The Airsense 10 Autoset is a BiLevel machine that is limited to a maximum pressure difference of 3 cmH2O. The controls are a little less sophisticated, and the parameters have different names, but it is doing the same thing. Yes, that pressure difference makes breathing more comfortable (if not excessive), and yes setting is too high can cause central apnea by removing too much CO2 from your bloodstream. The Aircurve products can be set to greater pressure differences, and provide more control, but they can also be turned down to the same levels as the Autoset machines. The Aircurve 10 Vauto is a fantastic machine if you can get it, but it is probably more than you need. But hey, if you can get one, no there are no drawbacks if set correctly for YOU. The Airsense 10 Autoset may be all that you need though. It's plenty for many people. Like @Babydinosnoreless though, I am more comfortable with a difference of 4, which the Vauto can do but the Autoset cannot.

Posting the results of your study will help people advise you.

The Dreamstation Pro (CPAP) or Auto machines have something called Flex instead. It provides some relief, but not as much as the Resmed Airsense, and it is oddly timed. To me, it feels like just a brief moment of relief.

I have never used a Dreamstation BiLevel machine, so I can't comment on that except to point out that BiPAP is Respironics' trade name for Bilevel.

[ragtopcircus]

To make it confusing, BiLevel machine setting are expressed in terms of Exhalation Pressure (EPAP) and Pressure Support (PS). EPAP + PS = Inhalation Pressure (IPAP). Regular Resmed machines settings are expressed as IPAP (but now called just Pressure) and Exhalation Pressure Relief (EPR). IPAP - EPR = EPAP. PS is added to the EPAP, or EPR is subtracted from IPAP, but it's still the same (except PS can be bigger).

[Pugsy]

If you can swing the ResMed AirCurve 10 bilevel...get it.
Not only does it offer the extra range in exhale relief but it has some additional features (not available on apap/cpap) that can further customize the inhale/exhale timing transition that can make things easier for a person.

As for bilevel sometimes causing centrals....very minimal risk of that happening. There is a very small percentage of people who do bilevel that it actually triggers centrals. Not common at all and when it does happen sometimes it's easily managed and people don't necessarily have to give up the exhale relief. Cross that bridge if/when you even come to it.

ResMed AirSense 10 AutoSet and EPR....it's good but real bilevel is better and yes...the difference between 3 cm and 4 cm relief can feel markedly different despite it being a small numerical difference.

[palerider]

If so, are there any drawbacks to using a bipap machine for OSA?

Other than cost, no.

Are they more likely to cause central apneas for people who only have OSA?

Depends on you, and how much pressure support you crank in.

[tarheelalum]

The Aircurve 10 Vauto is a fantastic machine if you can get it, but it is probably more than you need. But hey, if you can get one, no there are no drawbacks if set correctly for YOU. The Airsense 10 Autoset may be all that you need though. It's plenty for many people. Like @Babydinosnoreless though, I am more comfortable with a difference of 4, which the Vauto can do but the Autoset cannot.

Posting the results of your study will help people advise you.

Unfortunately I only got about 30 minutes of sleep the whole night so I don't have much data to go on. The clinic was using a phillips machine and the tech told me the exhalation support was set on 2 but that didn't feel like it helped at all. My doctor's office said since I was not able to sleep enough to get a correct pressure so they would prescribe an Resmed apap. ( I get the feeling my doctor is normally a cpap only doctor) But after reading about the bipap and hearing what you all have to say, I'm going to insist on a bipap. My insurance will only pay for one machine every so many years and I'm not getting stuck with the wrong one. I want maximum comfort and if they refuse I'm going to walk away and try to get my GP to prescribe it. I also made an appointment with a different sleep specialist for early December just incase my GP doesn't feel comfortable with it all.

One more quick question about the Resmed Aircurve Vauto machines. Can you basically self titrate them to find what pressure is best for you the way you can with a Resmed APAP? Like set the pressure from 6 to 16 and let the machine figure it all out all the while you have the exhalation support set at the max level? Also can a bipap machine be set at one pressure like a cpap? Or is it always going with a range of pressure?

And lets just say on the off chance that I fall into the category of people who bilevel pressure causes central apneas, would the oscar software be able to distinguish a OSA event from a central apnea to warn me about it?

Thank you all for the info and advice. I truly appreciate it.

[palerider]

I'm going to insist on a bipap.

Good luck with that.

One more quick question about the Resmed Aircurve Vauto machines. Can you basically self titrate them to find what pressure is best for you the way you can with a Resmed APAP?

The VAuto *IS*, for all intents and purposes, a Resmed "APAP", with more. The only thing it doesn't have is the RERA flagging (as far as I know).

Like set the pressure from 6 to 16 and let the machine figure it all out

That's not how you do an APAP if you want success.

all the while you have the exhalation support set at the max level?

Not sure what you think "exhalation support" is, but the 'max level' on a VAuto would be 22cm difference between inhalation and exhalation... which would be a recipe for sudden onset hyperventilation, and all the dizzying effects that would come with that.

So, ... not a good idea. Perhaps you should stick to a safer Autoset.

Also can a bipap machine be set at one pressure like a cpap?

"bipap" is a registered trademark of Philips Respironics, referring to their various and varied bilevel machines.

Or is it always going with a range of pressure?

Bilevel machines come in many different forms and models. Some of them are fixed pressure, some are auto, some are like nothing you've even ever imagined.

And lets just say on the off chance that I fall into the category of people who bilevel pressure causes central apneas, would the oscar software be able to distinguish a OSA event from a central apnea to warn me about it?

No, Oscar only reports what the machine flags.

Some bilevel machines differentiate between central and obstructive apneas, some don't. The VAuto does.

[ragtopcircus]

Yes, a Vauto can function as a regular CPAP.

As palerider hinted, you are unlikely to get insurance coverage for it. Your doctor can prescribe it and you can buy it, but insurance is not going to cover it as a first machine without a clear need from the sleep study.

The Autoset your doctor wants is a fine machine.

[ragtopcircus]

Btw, central apnea is not the only limitation for pressure relief/support. The exhalation pressure is what holds the airway open to treat obstructive apnea.

For example, I need a minimum pressure of 10 to prevent obstructive apnea events. With a pressure difference of 4, that means my inhalation pressure is 14, which works well for me most of the time. Increasing the pressure difference means increasing the inhalation pressure.

On an Autoset, it is expressed differently, but the effect is the same. If you have the pressure set to 8 and pressure relief set to 1, for example, your exhalation pressure is 7. To maintain the same control of obstructive apnea, increasing the pressure relief to 3 would often require increasing the pressure to 10 so the exhalation pressure remains at 7.

Of course, that’s a simplistic example, and not intended as therapy advice. The point is, there’s no free lunch. It’s not a more-is-better situation.

[tarheelalum]

Btw, central apnea is not the only limitation for pressure relief/support. The exhalation pressure is what holds the airway open to treat obstructive apnea.

For example, I need a minimum pressure of 10 to prevent obstructive apnea events. With a pressure difference of 4, that means my inhalation pressure is 14, which works well for me most of the time. Increasing the pressure difference means increasing the inhalation pressure.

On a Autoset, it is expressed differently, but the effect is the same. If you have the pressure set to 8 and pressure relief set to 1, for example, your exhalation pressure is 7. To maintain the same control of obstructive apnea, increasing the pressure relief to 3 would often require increasing the pressure to 10 so the exhalation pressure remains at 7.

Of course, that’s a simplistic example, and not intended as therapy advice. The point is, there’s no free lunch. It’s not a more-is-better situation.

Thank you very much for the advice. I hadn't thought of it in that manner. You are oh so correct in the no free lunch saying. I had such a difficult time with the titration study its caused me to try to come up with anyway around the problems I faced with it. I've considered the oral appliance but read about all sorts of problems that can lead to. I've started working out daily with the goal of getting as fit as I was at age 18 in hopes of that curing it. Even if it doesn't it cure my OSA, it will improve my health overall so its a win regardless. Thanks again for the advice.