During a titration study a patients apneas are eliminated at 10cmH2O by hypopneas and snoring continue at 16cmH2O. According to recommended guidelines, the appropriate pressures to begin a bilevel titration is:

During a titration study a patients apneas are eliminated at 10cmH2O by hypopneas and snoring continue at 16cmH2O. According to recommended guidelines, the appropriate pressures to begin a bilevel titration is:

• A. IPAP 4 EPAP 8
• B. IPAP 10 EPAP 6
• C. IPAP 14 EPAP 10
• D. IPAP 10 EPAP 14

Answer: (C)

When titrating bilevel therapy, set EPAP high enough to prevent airway collapse on expiration (eliminate obstructive events seen at that phase), then add inspiratory pressure (IPAP) above EPAP to address residual events during inspiration. In this scenario, apneas were resolved at 10 cmH2O (EPAP around 10 works for expiration), but hypopneas and snoring persisted up to a higher pressure (16 cmH2O) during CPAP. That means you want to keep EPAP at about 10 to maintain airway patency on exhalation, and increase IPAP to help during inspiration. A modest differential of about 4 cmH2O is a typical starting point, giving IPAP around 14 cmH2O while EPAP remains at 10 cmH2O. This level addresses the residual hypopneas and snoring without making the pressures uncomfortable or causing aerophagia. Starting with IPAP lower than EPAP or with EPAP set higher than IPAP would not adequately support inspiration or would be impractical for bilevel therapy, and would likely fail to resolve the residual events. If residual events persist after this starting point, the IPAP can be titrated upward gradually.

When titrating bilevel therapy, set EPAP high enough to prevent airway collapse on expiration (eliminate obstructive events seen at that phase), then add inspiratory pressure (IPAP) above EPAP to address residual events during inspiration. In this scenario, apneas were resolved at 10 cmH2O (EPAP around 10 works for expiration), but hypopneas and snoring persisted up to a higher pressure (16 cmH2O) during CPAP. That means you want to keep EPAP at about 10 to maintain airway patency on exhalation, and increase IPAP to help during inspiration. A modest differential of about 4 cmH2O is a typical starting point, giving IPAP around 14 cmH2O while EPAP remains at 10 cmH2O. This level addresses the residual hypopneas and snoring without making the pressures uncomfortable or causing aerophagia.

Starting with IPAP lower than EPAP or with EPAP set higher than IPAP would not adequately support inspiration or would be impractical for bilevel therapy, and would likely fail to resolve the residual events. If residual events persist after this starting point, the IPAP can be titrated upward gradually.