distance between IPAP and EPAP

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Postby stars » Sat Nov 08, 2003 9:13 pm

To Ted "when your mean about unstable airway with Bipap???? When your try change Bipap : min EPAP requement set up when mostly OSA` remove,and this level Epap pressure usually keep airway open :?: how you set Bipap for patient with chest wall disorder or Neuromuscular disorder.Sincerely Stars
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Use of bipap

Postby Ted the Sleep Guy » Sun Nov 09, 2003 4:26 pm

We have Bipap but we only use CPAP where I am currently employed. In my last place of employment we used Bipap. It was nonsense. The protocol allowed for a pressure differential of not more than 2cm. There were no capnographic capabilities. All the techs were OJTs without credentials or licensure. This is the reason I prefer the modality not be used unless its in the hands of properly trained and educated people who are also equiped to properly monitor the modality.
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Re: Back to you SCVN

Postby SCNVsleep » Mon Nov 10, 2003 12:16 am

Ted the Sleep Guy wrote:Aren't we saying the same thing? Or am I not understanding? First, most bilevel vents have lesser flow capabilities and allow for rebreathing of CO2. This imposes an increased work of breathing. Second, if the IPAP-EPAP differential is 2-3 cm, gas exchange is not enhanced. Third, use of pressure differentials greater than 5cm does enhance gas exchange. It seems to me all of the above SCREAMS-----MONITOR CO2!!!!!!!!


We are saying the same thing...and you are saying more. I do not feel that if proper pressure differentials are maintained (i.e greater than 4-5 cm between IPAP and EPAP) CO2 monitoring is necessary. As far as bilevel flow capabilities go, I disagree that bilevel has a lesser cpaability than CPAP. Its the opposite, as most CPAP units go to 20-25 cwp, and most bilevels IPAP goes to 30-35 cwp.

Put it another way...I agree with you whole heartedly that if the pressure differential is only 2-3 cwp, you need to do CO2 monitoring. But you have to say the same thing to techs and labs who will actually titrate a patient to 3-4 cwp (I've seen it done, kids). The lack of washout is the same.

I feel that if a pressure differential is maintained at 4-5 cwp,(and CPAP studies never go below 5 cwp), CO2 monitoring is unecessary, in the absence of mitigating or concomitant issues with CO2 retention.
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Postby stars » Mon Nov 10, 2003 2:56 am

I think you 100 % right .Plus Cpap below 5 cm never work
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To SCVN

Postby Ted the Sleep Guy » Mon Nov 10, 2003 5:38 pm

You make a good point. How do you know there isn't CO2 retention or hyperventilation. You can only know with capnography. Especially in our buisiness. People come in all the time with Chronic Hypoventilation Syndrome. You can get an ABG during wake with normal values. When they sleep they are retaining CO2. The only way to know is through Capnography. By the way, if you are going to the Focus meeting in Baltimore this April, lets get together and have a couple of beers and talk it over.
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CO2 Monitoring During CPAP

Postby Rick » Mon Nov 10, 2003 10:53 pm

From the above statements, if the IPAP and EPAP pressures are within 3-4 cm H2O you should monitor CO2. So, if the IPAP and EPAP pressures are the same you should also monitor CO2? The point being that CPAP is equal IPAP and EPAP so the recommendation is to monitor CO2 whenever performing CPAP titrations?
Breathing higher levels of CO2 actually increases respiratory rate and depth (of non-COPD patients) and we are only speaking of rebreathing the quantities of exhaled air in the mask that has not been flushed by CPAP flow. I will admit to being a dinosaur and remembering tanks of Carbogen (5% CO2 95% O2 I believe) that were used to try and prevent postoperative pneumonias.
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Re: CO2 Monitoring During CPAP

Postby SCNVsleep » Mon Nov 10, 2003 11:20 pm

Rick wrote:From the above statements, if the IPAP and EPAP pressures are within 3-4 cm H2O you should monitor CO2. So, if the IPAP and EPAP pressures are the same you should also monitor CO2? The point being that CPAP is equal IPAP and EPAP so the recommendation is to monitor CO2 whenever performing CPAP titrations?
Breathing higher levels of CO2 actually increases respiratory rate and depth (of non-COPD patients) and we are only speaking of rebreathing the quantities of exhaled air in the mask that has not been flushed by CPAP flow. I will admit to being a dinosaur and remembering tanks of Carbogen (5% CO2 95% O2 I believe) that were used to try and prevent postoperative pneumonias.


If you are doing a CPAP titration at pressures below 4-5 cwp, then yes, as there is not enough flow to wash out the CO2. In all honesty, CPAP titrations shouldn't be performed below 5 cwp (except for pt comfort until they get to sleep) as most insurance companies will deny coverage for pressures that low.
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Reply to Rick and SCVN

Postby Ted the Sleep Guy » Tue Nov 11, 2003 5:05 am

Using capnography is always a good idea. It can't hurt and can be a valuable tool. This does not mean it is essential for every CPAP titration. In some places and situations it can be cost prohibitive. The point I have been trying to make is simply that when using dual pressures there is an enhanced degree of minute ventilation. This demands the monitoring of CO2. People can disagree. I don't understand why they would. Yet to each his own. Using 95% and 5%. Wow that takes me back more years than I care to remember. I can remember using that in a rebreathing mask to Tx Hiccups. Talk about a blast from the past!!!!!!!!!!!
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Postby stars » Tue Nov 11, 2003 8:45 am

When used in a hospital setting, the pressure support resulting from the difference between IPAP and EPAP is used to augment the volume of severely hypercapnic patients in an effort to stave off impending respiratory failure. In the sleep lab setting any pressure is primarily used to overcome the resistance of a closed airway. There is no more chance of hypocapnia with a pressure difference than there is with just CPAP. Bilevel in the sleep lab is primarily a patient tolerance issue. Perhaps you are confusing the danger of oxygen induced hypoventilation with the positive aspects of an open airway.
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Nope

Postby Ted the Sleep Guy » Tue Nov 11, 2003 12:51 pm

Sorry Stars. The greater the level of pressure difference, the greater the level of pressure support, the greater the minute ventilation.
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Postby sleepadmin » Mon Nov 24, 2003 11:31 pm

Here's a reference for those interested in reading more:

Sleep Medicine Pearls, Richard M. Berry, M.D., Sahn & Heffner eds. 1999
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Thanks Andrew

Postby Ted the Sleep Guy » Tue Nov 25, 2003 4:29 am

Thank you Andrew, that was a good read. My issue is not the value of Bipap over Cpap. My concern is the use of pressure support and its effect on an augmented ventilation. The greater the Ipap-Epap will result in promotion of augmented levels of ventilation. This must be monitored by capnography. We measure SpO2 to insure adequate levels of Cpap. (Actually, we would not do a titration without it). Doesn't it stand to reason we should measure CO2 when using pressure support? The greater the level of pressure support, the greater the need for capnographic monitoring. Even 3 cm of press support should be accompanied by CO2 analysis. It is simply good technique. On the other hand, I could be wrong. To be perfectly honest---Being wrong is something I have experienced more than afew times. :lol:
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bipap

Postby cdnolte » Fri Jan 20, 2012 11:41 am

does any know if the ipap and epap is more than 10 apart it can cause heart problems, i thought i read this somewhere but cannot remember where. please help thanks
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