Resmed VPAP Adapt SV - for Central Sleep Apnea

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
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dsm
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Post by dsm » Sat Jul 29, 2006 5:06 pm

Chriton wrote:I ran across this in another thread and it seems apropos here as well. It is part of this post viewtopic.php?p=97023#97023
-SWS wrote: you cannot take any one person's response to an APAP algorithm and conclusively generalize that single person's response across an entire apneic patient population. The laws of probability across an extremely physiologically diverse human population simply don't work that way. That statement is true of BiLevel algorithms as well, IMO.

What one person describes as "clearly a problem" with a particular machine or algorithm is their opinion based upon their experience and cannot be assumed to be a problem for everyone else.

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I read SWS's post there and thus will answer it here for both.

In circumstances like this, If I have an machine that I purchased to do a job using a *normal* configuration & it doesn't behave as it should, there are many possibilities - these are the common ones

1) This *one* machine may have a defect
2) I bought the wrong machine for the job
3) The machine can't do what it claims in can
4) I am not using the machine correctly

(*normal* config = 15 cms Ipap, 8 cms Epap, UMFF mask, 6ft hose, + 12in hose on the mask).

In my case and in regard to the 1st machine I bought, I concluded 1) above (that this one unit was defective). I posted comments to this effect 6 months back when I 1st asked for opinions on why it was behaving oddly).

I later paid a large amount (the most I have ever paid for any machine) for a 2nd one brand new. I was completely taken aback when it behaved exactly as the 1st.

Now if in the end, I obtain 3 machines that all behave in a similar fashion in the example situation & all 3 fail to produce the desired result and *in a clearly obvious manner*, then there is a high probability that the 3 machines either ...

1) Just aren't suited for the job at hand
2) Have a design limitation that shows up for the current job

The to go further. If I am in a situation where I can test any of the 3 machines against 5-6 other machines designed for the same job *and* they *all* do the job as expected, then I believe it is simply basic logic to then conclude there is probably a design limitation (by any other sane words, a 'flaw') in the 3 same brand/type machines that can't do the job.

The bottom line for me as a diagnostician, is that other brands & models both new and old, don't exhibit this questioned behaviour. This behaviour renders these machines unuseable for me. Also, unlike the runaway conditions discussed. The problem I have spoken of is predicatable and repeatable. As I said, I am *not* going to buy a 4th one to prove what I already can see, repeatedly and predictably.

Now, it seems that some people can't seem to accept or won't accept (for whatever their reasons), that someone among us here, may have the background and expertise & diagnostic skills to come to any such conclusion about a brand of xPAP.

A point-of-view that argues that *no* xpap machines have any design 'limitations' (flaws) is absurd. To imply that someone with reasonable intelligence & who has taken the time & the effort to *thoroughly* investigate the problem, can't be right about an apparent 'flaw', is frustrating.


Cheers

DSM

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Post by dsm » Sat Jul 29, 2006 5:29 pm

I have decided to go look for the very early discussion on this issue as it serves to show how long my investigation has been going on.

I will be writing to Respironics re this - not sure what it will achieve but I will be writing to them since being able to compare against all those other machines. An event that only happened in the past few weeks.

*****************************************

This was when I got the 1st Bipap Pro 2 - hadn't formed any firm conclusions
as I was still trying to replace the motor bearings ...
viewtopic.php?t=6111&highlight=bipap+pro

************

This was where I 1st asked for advice re the early flipping I was experiencing.
It the 3rd post I concluded the machine was defective possibly due to water damage
...
viewtopic.php?t=6789&highlight=bipap+pro

************

Here was a post by someone who experienced 100% the issue I am writing of, by this time I had begun to believe the model had a design limitation ...

viewtopic.php?t=8452&postdays=0&postord ... ng&start=0


***********

This thread was summarizing the issues with the Bipaps but the Bipap S/T in particular.

viewtopic.php?t=8494&start=0

***************

Since then anytime I seem to raise the possibility that there is a 'flaw' the inevitable 'can't be right' - 'must only be you', posts appear.

DSM

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xPAP and Quattro std mask (plus a pad-a-cheek anti-leak strap)

Chriton

Post by Chriton » Sun Jul 30, 2006 12:22 am

Thank you DSM, for taking the time to respond and for providing background on this issue.

You wrote
In circumstances like this, If I have an machine that I purchased to do a job using a *normal* configuration & it doesn't behave as it should, there are many possibilities - these are the common ones

1) This *one* machine may have a defect
2) I bought the wrong machine for the job
3) The machine can't do what it claims in can
4) I am not using the machine correctly
I would suggest one other possible scenario.
5) The algorithms are not well-suited to your particular breathing patterns

If I am in a situation where I can test any of the 3 machines against 5-6 other machines designed for the same job *and* they *all* do the job as expected, then I believe it is simply basic logic to then conclude there is probably a design limitation (by any other sane words, a 'flaw') in the 3 same brand/type machines that can't do the job.
You have obviously investigated this problem thoroughly in an effort to understand the poor results you obtained with this machine. However, I believe your conclusion as to the cause of these results is debatable. You attribute the inadequate treatment you experienced to a design limitation or flaw. I wonder if the cause might more accurately be described as insufficient technology. No machine is capable of treating every individual equally effectively, as is evidenced by the fact not all users of this particular machine experience the same results you did. Likewise, the machines you found to be the most effective in doing the job as expected may be ineffective for someone else.

I appreciate your expertise and diagnostic skills and this may be a simple matter of semantics, but I would suggest 'technological limitation' is a more appropriate term than 'design limitation' or 'flaw'. Would you agree?

Guest

Post by Guest » Sun Jul 30, 2006 1:39 am

Chriton wrote:Thank you DSM, for taking the time to respond and for providing background on this issue. You wrote
In circumstances like this, If I have an machine that I purchased to do a job using a *normal* configuration & it doesn't behave as it should, there are many possibilities - these are the common ones

1) This *one* machine may have a defect
2) I bought the wrong machine for the job
3) The machine can't do what it claims in can
4) I am not using the machine correctly
I would suggest one other possible scenario.
5) The algorithms are not well-suited to your particular breathing patterns

If I am in a situation where I can test any of the 3 machines against 5-6 other machines designed for the same job *and* they *all* do the job as expected, then I believe it is simply basic logic to then conclude there is probably a design limitation (by any other sane words, a 'flaw') in the 3 same brand/type machines that can't do the job.
You have obviously investigated this problem thoroughly in an effort to understand the poor results you obtained with this machine. However, I believe your conclusion as to the cause of these results is debatable. You attribute the inadequate treatment you experienced to a design limitation or flaw. I wonder if the cause might more accurately be described as insufficient technology.

No machine is capable of treating every individual equally effectively, as is evidenced by the fact not all users of this particular machine experience the same results you did.

### Others did state they had exactly this issue and in almost identical terms? - did you read all of the referenced posts ?. And yes I know there are people using different masks at different cms who are able to use these machines. That fact alone does not prove they are not without design limitations. My tests were very generous. I would love to be using the Bipap S/T, It was not purchased as a museum piece

Likewise, the machines you found to be the most effective in doing the job as expected may be ineffective for someone else.

### I think it is obvious that machines will vary, but not repeatedly fail at a fairly straight forward test using a reasonably standard mask/cms config. Of course not everyone is going to have the same config as me. I did state in my earlier posts that at lower cms the problem diminishes and with nasal pillows, the problem also diminishes. It seems to me you are ignoring all the effort I put into trying different masks & different cms settings yet still kept getting this early flip problem.

I appreciate your expertise and diagnostic skills and this may be a simple matter of semantics, but I would suggest 'technological limitation' is a more appropriate term than 'design limitation' or 'flaw'. Would you agree?
### If I were not able to achieve good Ipap/Epap control with the other old and new machines, I might agree. But my tests tell me very clearly that these machines are deficient at managing airflow in a fairly normal configuration.

If Respironics published a bulleting that stated that these machines may exhibit instability with certain masks (i.e. UMFF) then I would have *no* grounds for complaint, but to the best of my knowledge they never have.

I can say that I have seen Resmed issue a bulletin that the 1st model of their Sullivan Autoset-T won't work with full face masks!

Resmed subsequently added a mask pressure sensor line on that machine then issued a new bulleting that it would now work with their UMFF. Those bulletins are proof that machines do have 'flaws' just like the early Autoset-T had. I am sure we both would agree on that. It seems I am the one who is doing all the leg work to identify this 'flaw' in the Bipap


Chriton

**************************************************

I believe that my testing with other old & brand new Bilevels, which work exactly as one would expect & hope, prove more than that it is merely the design algorithm differences of the Bipaps in question.

To be fair here, you have not come into this discussion with any proofs, no tests that you have posted, no photos of machines you are testing, why should anyone consider your argument ? - on what merits ?.

I feel that it is a case where you personally don't agree with me calling a spade a spade. You are merely saying (not proving) that my conclusions are 'not fair'.

If I restate your position, it comes across to me as exactly this ....

'No matter what testing you do (dsm that is) & no matter what you can prove or what conclusions you come to, it is only fair to say that a particular brand of Bilevel doesn't suit you ! . It is not fair to conclude it has a flaw!'.

Maybe it is semantics, but I am the one doing all the research & tests.

Cheers DSM


Chriton

Post by Chriton » Sun Jul 30, 2006 7:50 am

I see my suggestion this might be a simple matter of semantics was incorrect and you would not consider the term 'technological limitation' to be a more accurate description than 'design flaw'.

To that end, it would be crucial to know if each and every user experiences the same phenomenon, thus lending credence to your hypothesis the machine itself is inherently flawed and incapable of performing correctly. In your research, have you come across anyone who has not experienced the same results?
I think it is obvious that machines will vary, but not repeatedly fail at a fairly straight forward test using a reasonably standard mask/cms config.
This is where I take exception to your conclusion. I contend some machines will repeatedly fail a fairly straight-forward test using a reasonably standard mask/pressure for some portion of the population as a result of individual breathing patterns and algorithmic incompatibility. You contend the failure must be the result of a design flaw.

I have no illusions of changing your mind on this subject, but only wish to reiterate some individuals receive poor treatment with some machines even when using a standard mask at a standard pressure. The Healthdyne xPAP will fail for a percentage of the population, the Respironics xPAP will fail for another percentage, the Resmed xPAP another percentage, the Puritan Bennett xPAP another percentage, etc. I will continue to attribute that failure to technological limitation due to physiologic idiosyncracies until proven otherwise. I understand you will continue to attribute that failure to design flaw.


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Post by frequenseeker » Sun Jul 30, 2006 12:24 pm

DSM -
Did you do a download of data from your VPAP III trial (in which your wife heard the whine)?

Thanks to -SWS, I have just become aware of this machine and this thread. I had just successfully asked my Beth Israel provider for a prescription so I could get a quieter machine than the VPAP III and to have relief from aerophagia, now that she has me on cpap with the deadspace mask. I was thinking about the S8 Vantage I had briefly in the past and the EPR was a plus for helping the aerophagia according to my provider.

Now I am going to ask to have this new machine reviewed for my needs and hope to get at least a trial. I need the medical necessity certification so my insurance will pay. They replace machines every 5 years and it has been not quite 3 on the VPAP.

For those who need my history, I went through cpap and Bipap Pro 2 feeling very badly and ended up with the VPAP III at 14/11 working well enough to survive physically, once I got the settings optimized (meaning very prolonged). After finding out about the role of CO2 problems, I went to Beth Israel in Boston for their sleep study and received a deadspace titration. I was given an extra 2" of tube at the end of the Swift tubing, and a vent there with the Swift vents plugged up entirely, and a cpap pressure of 12. This fixed my eduring problem of feeling mental difficulties, a computational dyslexia, as I described it. But now I still do not feel right with my physical energy, can't get above 11.8, and the aerophagia and noise of the vent interfere with my sleep as well. I have gained yet another 5lb (gained 15 over the first few months of PAP) and while still not obese (having started out slim) I am not happy about this. I am theorizing about aerophagia distending the stomach and signaling weight gain somehow therefore, but that is another topic..

For those of you who know more of my details, the update is that my hormone supplementation was able to be reduced through my own system kicking in more, my proteinuria appears reduced/eliminated through taking milk thistle for my liver (my kidney specialist found no reason short of biopsy for my high protein levels previously), and my edema from venous reasons improved alot with the low sulfite diet but I still have a persistent global edema despite negative echocardiagram. I now theorize possible nocturnal CHF type activity producing the edema and wonder if this new machine would reduce that?! It will be good to get the chance to see.

Great to see old friends here and I look forward to learning and sharing more.

frequenseeker


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Post by rested gal » Sun Jul 30, 2006 1:17 pm

frequen, it's good to see you! Thanks for the update.

For those who have not met frequenseeker before, she was responsible for starting two of the longest threads ever on the TAS message board:

Topic started by frequenseeker Dec 01 2004 subject: mouth leak solution, cheap DIY oral appliance

Nov 06 2005 subject: Sleep Disordered Breathing - a New Category. Excellent artic
ResMed S9 VPAP Auto (ASV)
Humidifier: Integrated + Climate Control hose
Mask: Aeiomed Headrest (deconstructed, with homemade straps
3M painters tape over mouth
ALL LINKS by rested gal:
viewtopic.php?t=17435

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dsm
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Post by dsm » Sun Jul 30, 2006 4:01 pm

frequenseeker wrote:DSM -
Did you do a download of data from your VPAP III trial (in which your wife heard the whine)?
<snip>


Yes I have 3 nights data from the machine. Am happy to post the data on my web site.

Also, I did further forensic investigations of why the machine seemed so much noisier the night my wife heard it (3rd night's use). This came about because the next night my wife pointed out that something was still noisier even though I had reverted to the PB330. It also seemed the same to me.

On very close inspection, I discovered that the top vent in the UMFF mask had come out in 1 corner & was venting more air than usual.

As a side note, this particular top vent leak problem happened with me once before when a friend on cpap therapy came to me asking what was wrong with her brand new UMFF mask, (only 1 week old). I compared it to mine and it made a distinct hissing noise. I could not see a thing wrong with her mask. Neither her nor my wife nor I could explain why her mask hissed and was keeping her awake. I could only suggest she take it back to the DME she bought it from. They pointed to the top air vent being dislodged at one corner - pushed it home & it went quiet. My friend had dislodged this little vent during cleaning.

Back to my own mask - it turned out to be the same issue. The top vent had become slightly dislodged & thus was venting a lot more air than it should. I realised then why I never pinpointed this problem in my friends mask & that is because the extra air was escaping right where air is normally vented naturally so I failed to realise that the problem was with the seating of that little vent plug (these have about 5 holes in them for venting air & are removable from the UMFF).

So I then got the VPAP III out again & did a further trial and the machine was noticably quieter. I had obviously dislodged the upper vent the day of the night my wife had returned, bad luck, because this caused the machine to try to compensate & that unfortunately raised the noise level of the motor & thus a louder than normal hum combined with a nightlong extra hissing from my mask. No wonder she was not happy that night.

Re the S8. I have only tried an S8 cpap. Not the autoset. The S8 is a lovely machine & is now the one I use for travel. I also had a 420S and that too was great for travel but I sold it to a friend (the one I mentioned above who had the new mask problem) who went on a trip to Japan and wanted the lightest cpap she could get.

I have mentioned in other posts that my wife had previously (last year) asked me not to use an S7 autoset spirit because of the noise of the motor. And that I had previously been using an S7 Elite (cpap) and that she had no issues with it. Interestingly The Elite & Spirit are identical machines apart from the software. & Even though I swaped the entire sealed blower assembly between them the noise in the spirit was the same. What that told me was that Resmed had a problem with hum/whine in their blowers when the speed is varied - now I have a VPAP III I am seeing the same issue.

I have negotiated with my wife to let me try the VPAP III again now that we both could see that the mask was a likely cause of the the higher noise level from the machine the night she had to listen to it. The reason I am so keen to use the VPAP III is because it does record detailed nightly data whereas my PB330 A/C & Bipap S/T do not. The PB330 records nothing, the Bipap S/T only record a nights average AHI & details + a running tally of BPM. Useless data to me.

The Bipap Pro 2 of course does record nightly data, but as I have detailed here I have to use a Breeze mask to use it & then the mouth leaks slowly return.

Getting back to the Resmed CS2 - because this machine uses an entirely new blower, one can but hope they have learned to contain the hum/whine their other Bilevels & Autos have become noted for.

A twin impeller blower mightv be guilty of twice the hum. Two impellers operating independantly might be guilty of hum plus harmonic resonance (the problem pilots had to deal with on propeller driven aeroplanes when one engine starts to run at a different speed to the other)

Cheers

DSM

xPAP and Quattro std mask (plus a pad-a-cheek anti-leak strap)

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Post by -SWS » Sun Jul 30, 2006 4:20 pm

dsm wrote:A twin impeller blower mightv be guilty of twice the hum. Smile Two impellers operating independantly might be guilty of hum plus harmonic resonance (the problem pilots had to deal with on propeller driven aeroplanes when one engine starts to run at a different speed to the other)


I suspect the opposite to be the case. That second impeller sits on the opposite end of the shaft to achieve the sole objective of tuned inertia (not CO2 facilitation as I had originally assumed at the beginning of this thread before seeing the diagrams DSM kindly provided). And tuned inertia strives to achieve less wobble on that rotational axis. Less wobble, in turn (pun intended ), amounts to less mechanical harmonic resonance and much greater rotational control. That is what adaptive servo in the non-AutoSet CS2 world is all about as well: tuned inertia toward greater rotational control and energy efficiency.

With that said, I'm kind of reading between the lines regarding the evolutionary history of this adaptive-servo machine. Here is what I think Resmed just may have done with this machine over recent years regarding the three model names and gradual firmware augmentation (that firmware augmentation regarding additional mathematical modeling of various central apnea sub-phenotypes and corresponding designed responses):

1) "AutoSet CS" which exclusively addressed CHF/CSR

2) "AutoSet CS2" which not only updated the physical form factor, but likely also included some more central-apnea sub-phenotypes along with designed responses (perhaps some even on a preliminary developmental basis)

3) "VPAP Adapt SV" which now supposedly treats **all** central
apnea sub-phenotypes as well as mixed apnea, periodic breathing,
CHF/CSR, etc.

Note that VPAP adaptive-servo relies on a radical albeit subtly different treatment approach than all previous Resmed non-adaptive-servo VPAP machines. Comparing this machine to the previous VPAP models is like comparing apples to oranges in my opinion. This machine is all about preventing ventilatory overshoot as it achieves respiratory synchronization. It will be very interesting to see what this machine can do for Christinequilts, Frequenseeker, and other likely candidates for adaptive servo ventilation.

It's so good to have Frequenseeker here!


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dsm
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Post by dsm » Sun Jul 30, 2006 4:38 pm

-SWS wrote: <snip>

3) "VPAP Adapt SV" which now supposedly treats **all** central
apnea sub-phenotypes as well as mixed apnea, periodic breathing,
CHF/CSR, etc.
SWS,
This was a new one on me - I missed discovering this when researching the CS2

Thanks for the info

DSM

#1 Here are Resmed's claims ...

SR: Last November you told “Inside Track” about a new product ResMed was launching early in 2006: VPAP Adapt SV™, an adaptive servo-ventilator for central sleep apnea and periodic breathing. How has the initial market release gone, and how have the first patients responded to Adapt SV therapy?

Farrell: The first patients went on the Adapt SV after its market release during February 2006: the results have been extraordinarily successful. Sleep physicians intently watching their first patients at their sleep centers have been amazed as they observed elimination of Cheyne-Stokes respiration and normalization of PSG montage readings live. One of the initial sleep center case studies showed a patient with an apnea-hypopnea index (AHI) of around 120, with a spectrum of central, mixed, and obstructive events. Standard positive airway pressure treatment was able to lower the AHI by approximately 10% to 15%. However, the Adapt SV was able to eliminate all central and mixed apneas and lower the AHI by more than 95%, including normalization of periodic breathing patterns. We look forward to working with clinicians who utilize unique features of our VPAP III ST bilevel devices (V-synch triggering, 50 ms rise-time adjustment increments, Tmin and Tmax inspiratory time settings). Together, we will take US home care ventilation to the next level.

#2
Aha!!! - so this VPAP Adap SV is an AUTO Bilevel Device - with S/T ! Now the significance of the Respironics Bipap AUTO launch becomes clearer - Resmed appear to have a market killer product.

Product Spotlight: VPAP Adapt SV

ResMed's VPAP™ Adapt SV is FDA-cleared to treat central sleep apnea (CSA), mixed apnea and periodic breathing. As noted in peer-reviewed literature, the VPAP Adapt SV can normalize CSA in minutes and maintain a normal breathing pattern throughout the night. VPAP Adapt SV improves treatment outcomes for a whole new class of patients. "We just released an auto bi-level … It is a RAD device with a backup rate specifically addressing central apneas and complex breathing patterns that are typically associated with patients who have cardiovascular disease. We did a number of trials with this product in Europe on thousands of patients and then recently had FDA approval of that product and have started selling it under a controlled marketing release." —Ron Richard, senior vice president of strategic marketing initiatives, ResMed, Poway, Calif.

"(To treat complex sleep apnea,) you can try to create a CPAP machine that is so smart that it knows where you are, it knows whether the power (nerves impulses) is on or off. And when the power is starting to go off, it kicks in and it provides … the respiratory drive that otherwise would be missing. And that in essence is what the Adapt machine is. What it does is it keeps track of what for you ought to be normal breathing. And it says, 'If this person's breathing starts to drop below about 90 percent of that amount, we're going to kick in. And we'll begin to apply essentially a pumping action and pressure, so that we'll effectively put the patient on what amounts to a ventilator for that short period of time that the power is off. And we'll wait for the power to come back on again, and when the power comes back on again, then we can kind of chill out for a while.' At the same time that machine can be set to deal with any plumbing problems (obstructive events), in other words it can be applying pressure at all times. But … it's meant to be smart enough to know and track what's going on with the power and to effectively pinch it for you when your nervous system is not doing the job." —Robert Daly, chairman of Total Sleep Holdings Inc., Wesley, Mass.
ResMed Corp.

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Last edited by dsm on Sun Jul 30, 2006 4:49 pm, edited 2 times in total.
xPAP and Quattro std mask (plus a pad-a-cheek anti-leak strap)

frequenseeker
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Post by frequenseeker » Sun Jul 30, 2006 4:43 pm

Thanks for the welcome!

dsm - could you tell me where I can see your data? If you don't want to advertise your site location, let me know and I will post an email address for you to send it.

If you need any VPAP III suggestions let me know, I have been the queen of this machine...but I may be switching loyalties soon!!

It's reassuring to know the real source of the noise is not the VPAP BTW. I wonder if your results will be different with the leak fixed... Your data printout would show. At the least, the machine won't be compensating for the leak. At the most, you may have been blowing off CO2 with the compensatory flow!

frequenseeker

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Post by frequenseeker » Sun Jul 30, 2006 4:48 pm

I was interested in the ResMed mention of reduction of Vocal Cord Dysfunction as well. VCD is a fascinating related syndrome which may complicate some people's apneas and response to PAP (along with GERD and other autonomic based disorders).


StillAnotherGuest

They're All Over The Place

Post by StillAnotherGuest » Sun Jul 30, 2006 5:38 pm

Course, we could always wait to see what Respironics does:

HeartPAP
SAG


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Post by frequenseeker » Sun Jul 30, 2006 5:48 pm

IPAP of 21.8???
Did they intend to beat the apnea into submission to get numbers that look right?? Or am I misinterpreting something?

Guest

Post by Guest » Sun Jul 30, 2006 5:55 pm

Is the Respironics BiPAP autoSV (aka HeartPAP) available only in Germany?