Getting A BiPAP - Anything I should Know?

[OldLincoln]

i everybody, been quite a spell since I've been here. Hope all are well.

Hey I know, we should bust up the threads into multiple forums! JUST KIDDING!! That one's for you, Rooster, RIP. What's that, I think I hear him saying something nasty to me. Nah, must be that ringing in my ears.

I've been a good boy and now have over 10K hours on my Auto M, but after a re-titration the doc wants to put me on a Bi-PAP. I'm thinking of a System One Remstar BiPAP Auto with Bi-Flex and the matching humidifier. Is this the right thing to do? Are there any gotchas?

I see me doc for the Rx Monday so if you can share your thoughts soon.

Many Thanks!

Old Lincoln

[GumbyCT]

Resmed or Respironics you can't go wrong, well 'cept for software. There is a new 'open source' software called Sleepyhead. Right now I think it works only on System Ones but is still in development and there are plans for Resmed.

Search for Sleepyhead to read more.

o and wb

[deerslayer]

concur with the Gumb
only pisser is they changed to an SD card AKA software *&%#@#~!

[DaveMunson]

I like my S9. Best yet.

What should you know...
The product code of what you want so you could ask the doctor to specify that. Include heated humidifier, heated hose if optional, permanent humidifier, filters, etc. Rent / lease requirements of your insurance. money matters.

I printed out my (clinical) manual and brought in a copy when I picked it up. I had made a spreadsheet of each possible setting for auto bilevel and researched anything I did not understand - what each program option was before picking up the machine. I quickly went over each of the more important settings with the DME and asked them what they typically see for the other settings. I don't think they change from the default settings much.

Anyway, when I got to the dme's shop, I changed a few settings to what I wanted in their office (no ramp, a few other things). You should know the machines offer a lot of variables to change. Understanding what the machine can possible do will help. Having a customer who knew how to quickly get into the clinical menu, menu structure, what each option is and what I wanted it set to was a first for my dme. Especially since this was the second s9 bilevel they sold.

The bilevel thing where you breath in and out at a different pressures has options on breath timing. If it don't work right you can adjust the trigger level so the machine and you sync in breath. You may have to adjust that if it feels like you are fighting the machine. I also extended the maximum time limit cause it was changing modes while i was breathing slowly it tried to change from in to out. Anyway, when you get it and -if- it ain't syncing with your breathing already knowing what to tweak makes the adjustment process short.

If you are going to get the S9, I would recommend the permanent humidifier rather than the disposable one. The heated hose is a must. Get a backup cheap hose.

[cflame1]

definately go for an auto bipap... especially as you've been using an APAP.

try and make sure if you're going for the PR that you get one of the new one's... they have backlighting and are supposed to be quieter.

[Pugsy]

Software options for S1 explained here.
viewtopic/t64906/PR-S1-software-options ... Novel.html

SleepyHead developers working on ResMed version but it is not even near alpha version now.

PR S1 version kicks some serious butt.

I hear Onkor has a new release but have not had time to play with it.

Should you want Encore Pro or Viewer, if you have the DT 3500 Infineer card reader, the 2.xxxx versions of EP and EV will also work on your "old" machines.

[OldLincoln]

definately go for an auto bipap... especially as you've been using an APAP.

try and make sure if you're going for the PR that you get one of the new one's... they have backlighting and are supposed to be quieter.

I'm pretty sure I want the Respironics machines, but which is/are the new ones? Where does the https://www.cpap.com/cpap-machine/respi ... iflex.html fit in?

[cflame1]

2011 Manufacture date

Supposed to be some picture of the tops around here somewhere, though I can't find it right now. I probably should be sleeping!

[robysue]

The two main bi-level PAP machines that get talked about around here are the PR System One BiPAP Auto and the Resmed VPAP Auto. In April, Resmed released a VPAP Auto based on their state-of-the-art S9 platform to replace the VPAP Auto 25 that was based on the S8 platform. The PR System One BiPAP Auto is the up-to-date Resprionics BiPAP Auto. It was released about a year or so ago. On the PR side, PR System One BiPAP Pro which is fully featured except that it cannot run in Auto mode. The Resmed S9 VPAP has more settings that control exactly how the pressure is delivered, and that does make setting it up more complex.

Which should you get? Well that depends. Most folks will likely adjust to either machine. But they may not "feel" exactly the same to you. Since you are already using a Resprionics machine, you should find the System One quite comfortable.

Both machines are full data machines in the sense of recording full efficacy data:

• The S9 VPAP provides an easy user interface ON the machine's LCD that lets you check the numbers every day if you want to---as long as you look at the daily numbers before NOON your time. If you want more detailed data (such as when the events occur each night, you'll have to find and download the ResScan software, which is not supposed to be sold to patients. However, the ResScan software is readily available for downloads and you can find a link to it by searching for posts by a user named Uncle_Bob.
• The System One's LCD data is extremely limited---to the point of being almost useless. But you can buy Encore Viewer 2.0(from our host CPAP.com among other places) to download the data whenever you want to in order to see what's going on. Or go looking for Encore Pro 2.*. Two sets of forum members are working hard on alternatives to Encore Viewer and Pro. SleepyHead is in alpha testing and works remarkably well. Good support of the S1 BiPAP Auto has been added. Onkor is supposed to have a brand new beta-release, but I've not used it yet. Previous versions of Onkor showed my BiPAP's wave form data nicely, but have had real problems displaying the data in the Respriatory Flags table correctly for my data. Others have not had the same problem.

Because the S9 VPAP is so new (Resmed announced its release on April 11, 2011 I believe), there's a chance that the DME will try to convince you to just let them set you up with an S8 VPAP if you decide to switch to Resmed. While the S8 VPAP is a good machine, it's important to realize that it uses a proprietary data card and card reader and these cards and card readers a nearly impossible to locate here in the US and your DME will NOT help you find/order one. The System One and the S9 VPAP both use standard SD cards for recording the data and any SD card reader will work for downloading the data into the appropriate software package.

Exhalation relief: On a bi-level PAP, substantial exhalation relief is provided by instantaneous drop from IPAP to EPAP as soon as you start to exhale. (That is part of the point of a bi-level.)

• The PR S1 also has Bi-Flex available, which provides a bit additional exhale relief right at the beginning of each exhale, and the pressure will increase back to the full EPAP pressure about halfway through each exhalation. Bi-Flex is makes the transition between EPAP and IPAP smoother.
• I don't think the S9 VPAP has any additional relief beyond that provided by the "Easy Wave" breathing form and the IPAP to EPAP pressure drop. There are a variety of Ti settings on the S9 that control the transition from EPAP to IPAP pressure.

Both the S9 VPAP and the System One BiPAP will have a ramp feature. On the S9, the user menu allows you to control the length of time the ramp is on (and turn it off completely), but doesn't allow you to change the starting ramp pressure. On the System One, the user menu allows you to change the starting pressure, but doesn't let you change the length of time or turn the ramp off completely. A properly designed ramp feature would, of course, allow the user to do both things. So in either machine, it's worth downloading the clinical menu if for no other reason than to have full control over the ramp feature.

But of course, the heart of both the Resmed S9 VPAP Auto and the PR S1 BiPAP Auto are the algorithms that automatically adjust the IPAP and EPAP pressures in response to the various events detected by the machine. And the two companies have taken quite different approaches in their algorithms. Informally this difference can be described as follows:

• The Resmed S9 VPAP adjusts BOTH the EPAP and IPAP by the same amount in response to OAs, hypopneas, snoring, and flow limitations. Like the S9 AutoSet, the VPAP tends to respond quickly to clusters of events and then slowly reduces both pressures back down at the same rate until more events occur.
• The PR S1 BiPAP Auto adjusts EPAP and IPAP independently of each other: EPAP is increased in response to OAs and snoring, and IPAP Is increased in response to hypopneas, flow limitations, and RERAs. In addition to these things, the PR S1 also uses the same "hunt and peck" algorithm that the PR S1 Auto uses to test whether the shape of the wave flow data improves with a slight increase in pressure. The hunt and peck algorithm is only applied to the IPAP pressure for increasing pressure. After events that trigger an increase in IPAP or EPAP are resolved, the S1 does a reverse hunt and peck to find out how far it can lower the pressure: As long as the flow wave remains stable, the PR keeps lowering the appropriate pressure, but if the flow wave becomes more ragged, the S1 will raise that pressure back up to the last level where the flow wave was stable

To make the some of the differences between the two machines' auto algorithms clearer, we need to introduce a setting that only Auto Bi-level PAP machines have---the PS (pressure support setting). Loosely PS is the difference between IPAP and EPAP and the value of the PS setting affects the way the EPAP and IPAP pressures are adjusted. The way PS is implemented on the S1 and the VPAP is quite different however:

• On the S1 BiPAP Auto, the PS setting is the maximum allowable value for IPAP - EPAP. And the minimum value the S1 will allow for IPAP - EPAP is 2. The upshot of this is that whenever 2 < IPAP - EPAP < PS, the IPAP and the EPAP are allowed to vary independently of each other. But when IPAP - EPAP = 2 or IPAP - EPAP = PS, there are some constraints on how the pressures are increased or decreased.
  • When IPAP - EPAP = PS:
    • if the IPAP needs to be increased, then both IPAP and EPAP will increase at the same rate
    • if the EPAP needs to be decreased, then both IPAP and EPAP will decrease at the same rate
  • When IPAP - EPAP = 2:
    • if the IPAP needs to be decreased, then both IPAP and EPAP will decrease at the same rate
    • if the EPAP needs to be increased, then both IPAP and EPAP will increase at the same rate.
  • And at the start of the night, EPAP = min EPAP and IPAP =min EPAP + 2.
• On the VPAP, the PS setting is the fixed value for IPAP - EPAP. Hence IPAP and EPAP are always increased together on the VPAP. (And that's why the ResScan reports for VPAP mahcines can show the pressure info with only one curve.) At the start of the night EPAP = min EPAP and IPAP = min EPAP + PS.

Of course the big questions are: Which system is more effective? and Which system is more comfortable? As a mere patient, I haven't the foggiest if one of these systems is inherently better at treating apnea. And obviously both machines have been run through the full range of efficacy testing required by the government. As for comfort: That's obviously in the eyes of the individual user. My own guess is that most people will find both machines equally comfortable.

[ozze_dollar]

I just started to use a Resmed S9 VPAP and find everything is running well and no problems. It was expensive though.

[rested gal]

Hi everybody, been quite a spell since I've been here. Hope all are well.

Hi there, OL !! Yes, it sure has been quite a while -- great to see you posting again! Have missed you. Nice to see the familiar cool avatar pic again.

Hey I know, we should bust up the threads into multiple forums! JUST KIDDING!!

That thread was a long time ago, for sure!

I've been a good boy and now have over 10K hours on my Auto M, but after a re-titration the doc wants to put me on a Bi-PAP. I'm thinking of a System One Remstar BiPAP Auto with Bi-Flex and the matching humidifier. Is this the right thing to do? Are there any gotchas?

You probably recall that I used mostly Respironics machines for years, including the M series Auto you have. The past several years my primary machine was the Respironics BiPAP Auto. This year I began using ResMed's S8 VPAP Auto and like it very much. When I have an opportunity to get an S9 VPAP Auto, that's what I'll use.

Yeah, I've switched from Respironics to ResMed. I've always thought the ResMed machines are manufactured with better quality, but I used Respironics machines because I liked the way C-Flex (and A-Flex) worked, better than I liked "EPR."

I've always thought ResMed's way of showing overnight data in the little window was better than the way Respironics gave "weekly" averages with no data for just the previous night, but I've always had the software for either brand, so that didn't matter that much to me. You won't have a bit of problem getting software for whichever brand you end up with, btw.

Either brand is likely to suit you well. Either one does fine for me; however, I know a couple of people on this forum who are very experienced with quite a few machines and who were absolutely unable to use the Respironics BiPAP Auto (even though they could use Respironics Autopap fine.) The "digital tracking" used by Respironics did not suit their breathing at all -- kept switching prematurely to inhalation pressure (IPAP) before they were finished breathing out. I've not had that problem, but it's something to consider.

So...even if a person can (and has) used a Respironics autopap with no problem, that doesn't mean a Respironics (Philips Respironics) bilevel will suit at all, simply because it's the same brand as the autopap the person was using. That would be the main "gotcha" that could affect some people, OldLincoln. You'd know that pretty much right away...if premature switching to Inhale pressure started happening for you. There's no mistaking the feel of the higher IPAP pressure hitting you suddenly before you're finished breathing out.

If you do get a Philips Respironics System One BiPAP Auto, I'd make sure the DME agreed up front to let you swap for a ResMed VPAP Auto ... IF that premature switching happens for you. Having a bilevel machine get out of sync with one's breathing can run the gamut from annoying to "I just can't use this at all."

There is a considerable difference in the way ResMed and Respironics (Philips Respironics) handle the PS (Pressure Support) setting in their machines. That PS setting (along with the most important setting of all, imho..."EPAP") will have the most impact on the effectiveness of bilevel treatment.

jnk wrote a classic, easy to understand description of the very different way those two major brands handle the PS setting:

Jeff's (jnk) great explanation about the difference in how the ResMed VPAP Auto (and "25") and the Respironics BiPAP Auto handle the "PS" (Pressure Support) setting:
topic: ResMed VPAP Auto 25 Clinician's manual
viewtopic.php?p=376749#p376749

___________________

Jeff (jnk) answering IFLEW's questions:
topic: ResMed Pressure Support
viewtopic.php?p=428022#p428022

As you probably already know, OldLincoln, (so I'm sticking this in for new readers):

BiPAP is Respironics (Philips Respironics) trademark name for their bilevel machine.
VPAP is ResMed's trademark name for their bilevel machine.

The word "BiPAP" is often used to refer to any manufacturer's bilevel machine, much in the same way other trademark names have fallen into common "generic" use -- like "kleenex" and "chapstick" even when referring to other brands of facial tissue and lip balm.

[robysue]

Either brand is likely to suit you well. Either one does fine for me; however, I know a couple of people on this forum who are very experienced with quite a few machines and who were absolutely unable to use the Respironics BiPAP Auto (even though they could use Respironics Autopap fine.) The "digital tracking" used by Respironics did not suit their breathing at all -- kept switching prematurely to inhalation pressure (IPAP) before they were finished breathing out. I've not had that problem, but it's something to consider.

I may be an outlier and I am comparing apples and oranges here. But a significant reason that I was unable to adapt to the S9 AutoSet that I started out with was that when EPR=2 or EPR=3, the increase in pressure came "prematurely" on every single breath and I felt as though the machine was forcing me to start inhaling before I was done with my exhale, even though the conventional wisdom here says EPR on the S9 AutoSet does not increase pressure back up until you start to inhale. And with EPR = 0 or EPR = 1, I could not exhale properly against the pressure. For what it is worth, I don't like the feeling of B-Flex at all and have it turned OFF on my BiPAP.

For me, switching from the S9 AutoSet running in a tight Auto mode (7--8cm, with EPR =2) to the System One Bi-Flex running in fixed mode (8/6) made a world of difference, even though conventional wisdom here at cpaptalk is that my S9 AutoSet should have effectively felt like a bi-level running betwen 7/5 and 8/6. Further tweaking on my IPAP/EPAP pressures have been done to continue addressing my on-going aerophagia problems. But with the System one BiPAP, I don't feel like the machine is rushing my inhales.

I only point this out because there's the potential for both the bi-level machines to misinterpret a given indivdual's breathing patterns and hence mess up the transition from EPAP to IPAP.

There is a considerable difference in the way ResMed and Respironics (Philips Respironics) handle the PS (Pressure Support) setting in their machines. That PS setting (along with the most important setting of all, imho..."EPAP") will have the most impact on the effectiveness of bilevel treatment.

This is a major point of my post. Although I will admit that jnk's informal analogy is a great way to describe the difference without getting into all the numbers.

For me, I find the System One's ability to independently vary IPAP and EPAP a godsend. But I am also one of the people for whom the System One's digital tracking of the breathing pattern works.

[cflame1]

here's the pictures that I was remembering... page 1 has an old version and page 3 has a new version. It's all about where the lettering is on the machine top.

viewtopic.php?f=1&t=61099&st=0&sk=t&sd= ... 1&start=30

[rested gal]

I may be an outlier

Very likely so.

and I am comparing apples and oranges here.

Yes. When you try to compare how treatment felt to you when using a ResMed Autoset with EPR (an autotitrating CPAP) to a Philips Respironics System One BiPAP Auto (a bilevel auto), you're talking about different types of machines...not just different brands of same type of machine.

Even within the same brand.... to try to base how a ResMed VPAP Auto (bilevel auto) would interpret a person's respiratory cycle, on how EPR in a ResMed Autoset (autotitrating CPAP) interpreted it in the same person... that also is comparing apples to oranges, as you said. By now, the fruit basket is getting a little full.

Definitely there will be some people for whom one or the other brand of bilevel auto will suit better. I don't think EPR suiting or not suiting them in a different type (autopap) of ResMed machine would be any indication at all of how that might go.

[rested gal]

try and make sure if you're going for the PR that you get one of the new one's... they have backlighting and are supposed to be quieter.

Excellent point, cflame1.

And very helpful link!

here's the pictures that I was remembering... page 1 has an old version and page 3 has a new version. It's all about where the lettering is on the machine top.

viewtopic.php?f=1&t=61099&st=0&sk=t&sd= ... 1&start=30