Is Expiratory Pressure Relief (EPR) an option with Bilevel Positive Airway Pressure (BiPAP)?

Expiratory Pressure Relief (EPR) with BiPAP

Yes, Expiratory Pressure Relief (EPR) is available as an option with BiPAP devices in the spontaneous mode of selected devices, and can improve patient comfort and adherence when patients have difficulty exhaling against pressure. 1

Understanding EPR in BiPAP Therapy

EPR (also called flexible PAP or pressure waveform modification technology) is a comfort feature that reduces pressure during exhalation to make breathing more comfortable for patients. This feature works differently depending on the device and manufacturer:

• Available only in the spontaneous mode of selected BiPAP devices 1
• Designed to address patient complaints about difficulty exhaling against pressure 1
• Different manufacturers may call this feature by different names (C-Flex, EPR, SoftPAP, etc.) 2

Clinical Benefits of EPR with BiPAP

Improved Patient Comfort and Adherence

• Approximately 20% of PAP patients report difficulty exhaling against high pressure 1
• EPR can make therapy more comfortable for patients requiring higher pressure settings 1
• May improve patient acceptance and utilization of PAP therapy 1

When to Consider Using EPR

• When patients complain of difficulty exhaling against pressure 1
• When patients are struggling with BiPAP adherence due to pressure intolerance 1
• As part of a strategy to improve comfort when high EPAP is required 1

Implementation of EPR in BiPAP Therapy

Adjustment Protocol

1. If patient complains that EPAP is too high or difficult to tolerate, consider activating EPR 1
2. Monitor for mask leaks, as EPR may affect the pressure dynamics and potentially increase leak 1
3. Ensure that respiratory events remain controlled after implementing EPR 2

Important Considerations and Potential Pitfalls

• Efficacy concerns: Some pressure-relief features may compromise treatment efficacy if pressure reduction is too great 2
• Pressure adjustment: When activating EPR, you may need to increase the set EPAP to maintain effective therapy 2
• Device reporting: Some devices may report higher pressures than what is actually delivered when pressure relief features are active 2
• Mask leaks: Monitor for increased mask leaks after implementing EPR 1

Alternative Approaches for Improving BiPAP Tolerance

If EPR is not available or insufficient to improve comfort:

1. Adjust rise time: Customize the transition time from EPAP to IPAP based on patient condition:

   • Shorter rise times (100-400ms) for obstructive airway disease
   • Longer rise times (300-600ms) for restrictive disease 1

2. Adjust IPAP/EPAP duration:

   • Increase minimum IPAP duration if the device cycles to EPAP prematurely
   • Decrease maximum IPAP duration if the device cycles to EPAP too late 1

3. Consider head elevation: Elevating the head of the bed may allow down-titration of EPAP if pressure is difficult to tolerate 1

By implementing EPR appropriately in BiPAP therapy, clinicians can improve patient comfort while maintaining effective treatment of sleep-disordered breathing.