Doing worse on Bi-PAP than on Auto-PAP

[Bluebonnet_Gal]

I've posted results from my first two on the ResMed VPAP Auto 25 here:

http://www.box.net/shared/gtpdcb5gg1

I'm doing worse on Bi-PAP than I was on Auto-PAP. Can anyone tell me why? Do adjustments need to be made?

[Slinky]

Okay. Are you using it in VPAP mode or Spontaneous mode? What was your CPAP pressure? What are your VPAP pressures? What seems to be bothering you w/the bi-level therapy itself? (Stick it out for the two weeks so that this VPAP is YOURS, then switch it to straight CPAP mode if you prefer and are more comfortable w/that).

[Bluebonnet_Gal]

Okay. Are you using it in VPAP mode or Spontaneous mode? What was your CPAP pressure? What are your VPAP pressures? What seems to be bothering you w/the bi-level therapy itself? (Stick it out for the two weeks so that this VPAP is YOURS, then switch it to straight CPAP mode if you prefer and are more comfortable w/that).

My DME set it all up and I don't really understand it yet, but I just looked at the Clinical Menu and it says it's in VAuto Mode.

My IPAP is 20
EPAP is 8
Pressure Support is 4.0
Ti Max is 3.0
Ti Min is .5
Exhalation is Med
Trigger is Med
Cycle is Med

When I was on a standard Auto PAP, the DME started me with a range of 6 - 20. I gradually increased the min pressure until I was at 13. Most nights on the A-PAP, I had between 2 ant 5 apnea events per night. My last night on A-PAP I had 7 Apnea event. My first night on VPAP, it looks like 9 Apnea events (hard to count because some are piled on top of each other). My second night on VPVP (last night), I had 17 Apnea Events during the night! What is going on???

[GumbyCT]

My DME set it all up and I don't really understand it yet, but I just looked at the Clinical Menu and it says it's in VAuto Mode.

My IPAP is 20
EPAP is 8
Pressure Support is 4.0
Ti Max is 3.0
Ti Min is .5
Exhalation is Med
Trigger is Med
Cycle is Med

When I was on a standard Auto PAP, the DME started me with a range of 6 - 20. I gradually increased the min pressure until I was at 13. Most nights on the A-PAP, I had between 2 ant 5 apnea events per night. My last night on A-PAP I had 7 Apnea event. My first night on VPAP, it looks like 9 Apnea events (hard to count because some are piled on top of each other). My second night on VPVP (last night), I had 17 Apnea Events during the night! What is going on???

I don't pretend to know anything about Resmeds but is it were me I would bump up EPAP to 11 or 12 to see how that does for me

You're not that far off.

[Slinky]

Doggone! Your URL won't load for me today! It loaded about 3/4 of the way and then ..... zilch. 1/2 hour later it hadn't loaded one bit more. Will try again in a bit.

That pressure support of 4 is the Default. *sigh* It keeps the pressure range constant as I understand it so there can never be more than a 4 cms spread between EPAP and IPAP. And I "think" it depends on how high your EPAP climbs as to how high your IPAP can climb.

On the other hand, whilst your Ti Min is the Default, your Ti Max has been set by your DME (I think) as the Default Ti Max is 4.0s.

These doggone "comfort options" are so dag blamed complicated. I haven't found anyone yet who understands them or who REALLY or HONESTLY knows how to set what why. Maybe you will be blessed and your DME's RT will know.

[Bluebonnet_Gal]

Maybe you will be blessed and your DME's RT will know.

I don't know if my DME HAS a RT. The person I always talk to about xPAP is the owner of the business (this is in a very small town). I'm hoping my ENT will know what to do when he gets the reports, but that's 2 wees away!

[jnk]

I'm doing worse on Bi-PAP than I was on Auto-PAP.

Like Slinky said, don't judge by one or two nights. Give your body a few weeks to get used to autobilevel treatment. That being said, I agree with GumbyCT--if I had your charts, I would definitely raise the minimum EPAP a cm or two from where it is now, and I would do that tonight.

That pressure support of 4 is the Default. *sigh* It keeps the pressure range constant as I understand it so there can never be more than a 4 cms spread between EPAP and IPAP. And I "think" it depends on how high your EPAP climbs as to how high your IPAP can climb.

That's a good default, though. (Although I still think Slinky should have hers at 5 in order to harmonize her machine with her prescriptions. ) And as Slinky said, with ResMed autobilevels, the pressure support keeps the gap between experienced ipap and experienced epap constant. The gap never varies on that ResMed overnight. (A Respironics autobipap machine works differently. Those machies have a hardcoded minimum pressure support and a programmed maximum, so the gap varies overnight.) Anyway, I would not change the pressure support number.

"Exhalation," "Trigger," and "Cycle" are pure comfort adjustments. There is no harm in playing with those, since they do not significantly affect therapy. "Exhalation" adjusts how the drop in exhale pressure occurs--whether it is closer to an even/constant drop or closer to a quick initial dip that then slows. (Supposedly most prefer it at medium.) "Trigger" adjusts how sensitive the machine is in recognizing that you have started to breathe in. "Cycle" adjusts how sensitive the machine is in recognizing that you have started to breathe out. But again, those are not treatment adjustments, merely comfort adjustments. And the default settings yours are at should be fine if you find the machine to be comfortable to use.

I wouldn't mess with TiMax or TiMin at all. If you find the machine wakes you up by going out of sync with your breathing, you should mention that to the RT at your DME. (Every DME has to have one.) Looking at your charts, it is possible your sleep doc prescribed the "3" for TiMax, I don't know. Decisions on that number may be based on reports that give your tidal volume, minute respiration, and respiration rate. Those numbers can be medically significant.

Hope that isn't TMI. Hang in there. You've got a great machine that is going to make you feel better!

[Bluebonnet_Gal]

If you find the machine wakes you up by going out of sync with your breathing, you should mention that to the RT at your DME. (Every DME has to have one.)

If he has one, I'm guessing it's the owner himself as I have to make an appointment with him for mask fittings or anything to do with xPAP.

Hope that isn't TMI. Hang in there. You've got a great machine that is going to make you feel better!

I know I have a great machine. I just home my ENT give the DME good directives on future settings.

The ENT wanted me to use the VPAP for 2 weeks, then have the DME fax him a report. He would then let the DME know what settings he wants it on. Today I'm feeling awful - like I've been run over by a truck (very similar to how I felt before I started on xPAP). I'm thinking that if my results continue as lousy as they were the last 2 nights and I continue to feel crappy, I might see if I can get the DME to send the reports SOONER than 2 weeks (based on me feeling worse, not better) and see if we can get the "ball rolling" sooner.

[jnk]

I might see if I can get the DME to send the reports SOONER

I see your point. Good idea. No need feeling like a train wreck for two weeks!

Alternatively, just as a thought, and depending on how cool your ENT is, he/she may give you permission to move the min EPAP up to 13 on your own for the remainder of the experiment, if you give him/her a link to the pdf you posted.

They can't expect all their patients to be as smart and proactive as you, so they have been going about things the way they normally would. They are acting logically with the best of motives, but it may be once the ENT sees how helpful you can be in the process, he/she may be willing to work slightly outside the box with you if you come off both smart and cooperative.

[Slinky]

Ha, BlueBonnet, just in case you subscribe to the theory that misery loves company. I switched back to Spontaneous mode last night as my scripted settings - and lasted all of 30 minutes AT MOST!

I then re-set Pressure Support to 5, and because I was tired and cranky by that time, reset the Trigger and Cycle Sensitivities to Low.

Sure wasn't the comfort of Auto mode!!! But, for me, better! And my data sucks big time too! I was able to finally get your link downloaded to view. I see the VPAP 25 reports Spontaneous triggered and Spontaneous cycled breaths. The VPAP Auto doesn't. At least not to my knowledge. But I was surprised to not see it report the Calculated 95th precentile IPAP and EPAP. My VPAP Auto includes that in the ResScan report. Unless .... I'm using ResScan 3.4. I'll be switching to 3.7 w/in the week. Which version are you using??

[Bluebonnet_Gal]

Ha, BlueBonnet, just in case you subscribe to the theory that misery loves company. I switched back to Spontaneous mode last night as my scripted settings - and lasted all of 30 minutes AT MOST!

Thanks for the company Slinky, but I don't want anyone else to be miserable!

I see the VPAP 25 reports Spontaneous triggered and Spontaneous cycled breaths. The VPAP Auto doesn't. At least not to my knowledge.

Where do you see Spontaneous Triggered and Spontaneous cycled breaths? I don't see that.

But I was surprised to not see it report the Calculated 95th precentile IPAP and EPAP. My VPAP Auto includes that in the ResScan report. Unless .... I'm using ResScan 3.4. I'll be switching to 3.7 w/in the week. Which version are you using??

I'm using ResScan 3.7. I'd like to see the 95th percentile IPAP and EPAP. Perhaps I just need to change something in the options. There are so many - may take me a while to find it!

[papdad]

Hi BlueBonnet. With the Auto 25, if you experience a leak the machine will stay in IPAP mode until it hits the Ti max setting. Ti Max = ( 60 divided by patient's respiratory rate ) divided by 2. Ti Max for 15 BPM = 2.0 My machine is still set at default for Ti Max and Min which are Ti Max = 2.0, Ti Min = .3 If you are experiencing leaks, which your leak graph indicated, then your machine in staying in IPAP too long ( Ti Max = 3.0 ) and your pressure just keeps going up and up because your IPAP max is set at 20. If you will look at your leak graph compared to your pressure graph then you can get an indication of this happening. To get a true test you will need to get the leaks under control and this is going to be very difficult to do with the pressure going so high due to the Ti Max setting.
Just my thoughts, Norm

[jnk]

Hi BlueBonnet. With the Auto 25, if you experience a leak the machine will stay in IPAP mode until it hits the Ti max setting. Ti Max = ( 60 divided by patient's respiratory rate ) divided by 2. Ti Max for 15 BPM = 2.0 My machine is still set at default for Ti Max and Min which are Ti Max = 2.0, Ti Min = .3 If you are experiencing leaks, which your leak graph indicated, then your machine in staying in IPAP too long ( Ti Max = 3.0 ) and your pressure just keeps going up and up because your IPAP max is set at 20. If you will look at your leak graph compared to your pressure graph then you can get an indication of this happening. To get a true test you will need to get the leaks under control and this is going to be very difficult to do with the pressure going so high due to the Ti Max setting.
Just my thoughts, Norm

It's always good to keep leak low, within reason. But I would NOT mess with TiMax.

I'd like to see the 95th percentile IPAP and EPAP.

You can calculate those numbers easily enough. Add 2 to your reported pressure to get your IPAP numbers. Subtract 2 from your reported pressure to get your EPAP numbers. That will work for you to get you close enough, because your pressure support is set at 4, and the pressure numbers reported to you are based on the autoset pressure, the number midway between experienced IPAP and experienced EPAP, as used by the machine's internal algorithm. That would make your median, 95-centile, and maximum numbers the following: IPAP: 17.9, 21.1, 21.8; EPAP: 13.9, 17.1, 17.8.

As a reminder, though, don't listen to me, or anyone else, as closely as you listen to Slinky about this stuff. I believe that she is the most experienced user of the VPAP Auto in this forum, and that is the machine closest to your 25.

[papdad]

JNK I didn't say that she should reset Ti Max on her machine. I was merely trying to restate what is says in the manual about Ti Max and what it does and how it can affect the machine's operation. A Ti Max setting of 3.0 is, according to the manual, for a person with an average BPM of 10 breaths per minute. BlueBonnet's numbers were above that. I was just trying to shed a little light on her orginally posted question. I tried to copy the information from the manual but the tables in the manual would not copy. The following is what did copy from the manual.
Norm




Setting Ti Max
The majority of patients on bilevel therapy experience mouth leaks, especially
during sleep. During mouth leak there may be poor synchronization between
patient and machine breaths, which reduces both the comfort and effectiveness
of therapy.
The VPAP Auto allows clinicians to specify a maximum IPAP time (ie the time the
device spends delivering the inspiratory pressure during a spontaneous breath).
Thus, if a patient develops mouth leak, the VPAP Auto automatically cycles to
EPAP after reaching the maximum time set by the clinician.
In the following graph, Panel A demonstrates poor synchrony between the
diaphragm EMG (EMGdi—which is indicative of inspiratory effort) and
inspiration, resulting in poor chest wall movement and ineffective therapy.
Panel B demonstrates improved synchrony when Ti Max is set to profile the
patient’s intrinsic inspiratory time, as demonstrated by EMGdi, chest wall
movement, and pressure profile synchronization.
TiControl
Patient Flow
Ti
Min
Ti
Max
Cycle
Window
Operating Information 7
Use the equation or table below to calculate a value for Ti Max. This will generally
ensure that Ti Max is set slightly longer that the patient’s inspiratory time.
Ti Max = (60 ÷ patient’s respiratory rate) ÷ 2
Setting Ti Min
The Ti Min parameter allows the clinician to set a minimum time the patient
spends in IPAP. It allows adjustment of the minimum inspiratory time parameter
ranging from 0.1secs to Ti Max. Ti Min is usually set to its default setting of 0.1
second.

[jnk]

. . . JNK I didn't say that she should reset Ti Max on her machine. . .

Thanks for the claification. I didn't mean to imply that you had. Sorry. My bad. Thanks for the further info you posted, too. Good stuff.

I haven't been able to sleep with my TiMax down at where my sleep doc/pulmo wants me to. My very first night on PAP I had to change that adjustment to be able to sleep at all. But my sleep doc wants me to slowly get it back to where it was set. So far, I haven't been able to, though.