Taming a new Respironics BiPap S/T

[dsm]

This thread was started as a result of some discussion in another thread where the topic of adjusting the 'rise time' came up & I believe that some of the posters may have misunderstood what the purpose of the rise time adjustment is.

The below link will take you to 20 photos of my new latest model Respironics BiPap S/T machine. Inside, the machine is mechanically the same as the BiPap Pro 2 model but the electronics are more sophisticated and the motherboard has more components on it. There are more buttons on the front and side and also at last, Respironics have made it possible to change clinical settings with us having to remove & re-apply power.

http://www.internetage.com/cpapinfo/bipap-st-1/

I had intended switching to this new machine from my PB330 because the Respironics machine has the datacard facility and I was wanting to get detailed feedback from the machine, something I can't do with my PB330.

But as soon as I tried using the machine I found it kept flipping from IPAP to EPAP far too quickly. Anyway, after lots of experimenting I may have worked out how to partially tame this machine even though to do so has meant using some apparently non-standard settings. I have been disappointed in the way the machine worked when normal settings were applied. Hopefully today's experiments have nailed the beast but a test run just now still has the machine occasionally flipping at the wrong time. This early flipping is exactly how my BiPap Pro 2 behaves and I had concluded that it was faulty.

The interesting thing about this annoying behavior is that it *is* affected by what type of mask I use and this to me is a strong clue as to where part of the algorithm may have a weakness. This being the machine's ability to work with masks that have a high fixed-leak rate such as my ResMed Ultra Mirage F/F mask (the designed fixed leak is approx 45 lpm at 15 CMS).
The ResMed VPAP II/III & PB 320/325/330 machines both allow the user to set a rate of fixed-leak based on the data supplied with the mask. The BiPap models don't.

If I use a mask with a low fixed leak rate, the annoying IPAP/EPAP flipping starts to go away and the machine behaves exactly as expected and needed. This applies to both my BiPap Pro 2 and this BiPap S/T. I have a 3rd BiPap Pro 2 coming so can yet again compare it for this issue.

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

Photos 1 - 8 show the buttons and set up of the machine.

It uses an external powerpack that delivers DC 26 volts. Obviously requires an inverter to run of 12vdc.

Photo 8 in particular shows my + & - Manometer that I use for assessing pressures (purchased from cpap.com)

Photos 9 & 10 show that the Bipap S/T delivers very accurate CMS.

Photos 11 & 12 show me with the machine in use.

Photo 13 shows how to enter clinical mode (this can only be done when the air flow is stopped. That is stopped and started by a button on the side of the unit).

Photo 14 shows S/T mode selected NOTE: BiFlex gets deactivated when in S/T mode

Photo 15 was included to show the range of display fields on the LCD. This is much more than are on the BiPap Pro 2.

The remaining pics show what I have set the machine to to try and tame it.

Photo 18 shows that I had to go as low as 6 Breaths/Min - this is way lower than what is recommended. 12 is normal. If I go above 6 the annoying IPAP to EPAP flipping becomes increasingly intolerable.

Photo 19 shows another important adjustment that supposedly helps to control the flipping between IPAP & EPAP, here I have set the machine to the max of 3 seconds as once again, if I go any lower, the flipping between IPAP and EPAP becomes increasingly annoying.

Photo 20 shows that I have set the rise time to 2. The rise time is a personal comfort setting designed to adjust the speed with which the machine flips between pressures. When set too fast (1) it can seem like the machine is 'jumping' from one pressure to the other, when set to slow (6) it seems that the machine is 'floating' from one pressure to the other.
The jump effect can be annoying and the floating can seem too soft so there are 6 settings in between used to improve the comfort for the user.

RG, in your other post on this topic (IIRC) you commented that you believe 'rise time' was the adjustment that would impact when the machine flips - you also provided a link to ChristineQuilts who also said she sets her machines rise time to max (6) in order to overcome some of the effects of the IPAP EPAP flipping problem. I believe that adjusting 'rise time' doesn't affect when the flip occurs but would help mask the effect of the flipping.

The two parameters that affect when the machine flips are the BPM (Breaths per minute) and the 'insp time' (see photo 19). Again, rise time adjusts the speed of the flip. and remember that BiFlex is deactivated when the machine is in S/T mode.

BiFlex only gets activated in S mode and CPAP mode.

Hope this helps clarify these matters

Cheers

DSM

_________________

CPAPopedia Keywords Contained In This Post (Click For Definition): respironics, resmed, bipap, mirage, cpap.com, manometer, CPAP, Power

[rested gal]

Photo 18 shows that I had to go as low as 6 Breaths/Min - this is way lower than what is recommended. 12 is normal. If I go above 6 the annoying IPAP to EPAP flipping becomes increasingly intolerable.

This was interesting, dsm. When I used a ResMed VPAP III ST for a couple of weeks, I played around quite a bit with the timed back-up breaths setting. I found that a bi-level ST machine delivering an extra breath (actually just kicking in IPAP sometimes when I was not ready to take a breath) was extremely annoying.

I first used several "normal" number of breaths settings, then tried more (worse, of course), and tried less.

I noticed that the percentage of spontaneous breaths it registered in the software data got better and better, the lower I set the timed rate. I did best percentage wise for spontaneous breaths when I finally dropped the timing down as low as it would go -- 4 breaths per minute, if I recall correctly. That made it "tolerable", as you so aptly put it.

So, for me, as for you, setting the timed breaths per minute rate down so low as to almost not be using "timed" at all was the most comfortable. No surprise, really, as I do not have central apnea and rarely have an occasional random Ca or NR (possible central) show up in the software data of the PB and Respironics autopaps I've used.

Since I don't have central apnea and don't really need a machine to deliver timed backup breaths, it's no wonder the feeling of a normal number of breaths/minute being delivered would be annoying to me. If a person is already breathing well enough spontaneously, the feeling of the machine delivering "breaths" (the IPAP pressure) when you don't need them is an annoyance.

The two weeks I spent with a very sophisticated bi-level ST were fun for playing around with the multitude of settings and for trying various timed backup rates. Finally switching it to just "spontaneous" near the end of the two weeks worked much more comfortably for me.

I can see how a machine with timed capability would be necessary for some people, especially people with true Central Sleep Apnea. Not for me.

[dsm]

RG,

The main point for me is that the Healthdyne BiLevel works so smoothly at the IPAP EPAP switch and yet it is an older less sophisticated model than the Bipap S/T or the Bipap Pro (& Pro 2). It works just like a good BiLevel should. I now regard the Healthdyne as vastly superior to the Respironics Bipap Pro / Pro 2. The Healthdyne BiLevel is so sensitive to the change in tidal flow that it almost seems like a T Bilevel. The slightest change in breath on full exhalation, will flip it into IPAP mode whereas the Respironics models *all* seem to make that flip far too soon and repeatedly. Other posters seem to confirm this shortcoming.

This afternoon I did further testing with all four & used an Adams Circuit nasal pillows mask. The Healthdyne and PB330 were consistent and very good to use. The Bipap S/T and Bipap Pro 2 were *both* inconsistent despite my earlier efforts (with the Bipap S/T) to tune it.

The PB330 works very well in S mode and A/C mode (same as T mode) and is excellent at switching between IPAP & EPAP. It has been a great investment for me, pity it is not capable of delivering the detailed data I am wanting.

The Respironics Bipap range, just seem to struggle in that IPAP / EPAP sensitivity yet they have excellent electronics and the mechanics are also good. They just seem to have inferior algorithms at handling the finer aspects of tidal flow and mask leak rates.

Cheers DSM

PS
What CMS were you running the machines you use at ?

I am wondering if that is a factor that may make a difference with the Respironics machines even though it seems to mean little to the Healthdyne and PB33o machines.

D

PPS
I may get my hands on a VPAP S/T machine soon. I am particularly keen to try one of them as the reports I read rate them as perhaps the absolute best (i rate the PB330 as that just at this time) but my experience with a Resmed Spirit fan noise and my my growing cynicism at claims of how great some machines really are, has me wanting to try a couple for myself then judging if the stories I read are fact or marketing fiction.

D

[dsm]

<snip>
Since I don't have central apnea and don't really need a machine to deliver timed backup breaths, it's no wonder the feeling of a normal number of breaths/minute being delivered would be annoying to me. If a person is already breathing well enough spontaneously, the feeling of the machine delivering "breaths" (the IPAP pressure) when you don't need them is an annoyance.
<snip>

RG,

Just did some thinking about your comments re BPM. Are you saying you believe the machine actually delivers that number of BPM to the user ?, if so then that may be a mistaken assumption.

The BPM setting does not force the machine to make the user breath at a particular rate, what it does is use that rate as the minimum before it steps in and exerts its 'flipping' action (flipping from EPAP to IPAP).

So any comment about BiLevels being uncomfortable because they control ones breathing seems to me to be a mistaken perception. All the BiLevels I have & have tried feel very comfortable because the dominant control is the spontaneous control. In fact all home BiLevels that I have looked at only activate T mode in combination with S mode.

Hospital Ventilators *do* usually have settings for manipulating the breathing rate of a user (T mode only settings).

Cheers

DSM

[rested gal]

RG,

Just did some thinking about your comments re BPM. Are you saying you believe the machine actually delivers that number of BPM to the user ?, if so then that is a mistaken assumption.

The BPM setting does not force the machine to make the user breath at a particular rate, what it does is use that rate as the minimum before it steps in and excerts its 'flipping' action (flipping from EPAP to IPAP).

If I gave the impression I thought that, then I was conveying my thoughts very poorly. No, I've never thought any bi-level ST machines were making the user breathe, much less at any particular rate.

My apologies...I should have been more precise. Instead of saying "delivers a breath", I should have said "occasionally switches from EPAP to IPAP without the user initiating the inspiration." The "flip" as you aptly refer to it. A kick that hopefully encourages a person who is having a central apnea to start spontaneously breathing in again sooner than they would have otherwise. I fully understand that the machine is not delivering a "breath". That was not a good choice of word on my part.

As you're aware, that can happen with a bi-level ST machine if operated in timed mode...that occasional "flip" to IPAP without the user having initiated inhaling. I think that was the very sensation that you found to be "intolerable" until you dropped the BPM down (as I did, too) to a rate where the machine was following our spontaneous breathing most of the time, rarely kicking in the IPAP without being invited to do so. The invitation being the user starting to inhale.

The lower the BPM rate is set (as you found by setting yours down at 6, and I found by setting mine down at 4) the less likely it is that the machine will deliver a non-user-initiated switch from EPAP to IPAP.

Having a bi-level machine following one's spontaneous breathing is very comfortable. But when a bi-level ST machine in timed mode occasionally switches from EPAP to IPAP when you did not intend to draw a breath at that moment, it can be disconcerting or annoying. Or even intolerable, if it happens very often, which it certainly can do if the BPM rate is set high.

I found (as you did) that setting the BPM rate quite low makes it more comfortable. I don't need a machine with a "timed" mode. But, each of us have our own preferences about machines. If you feel that using timed mode with the BPM rate set so low as to almost not be using "timed" at all is giving you better treatment than spontaneous mode only, then that's what you're happiest using.

So any comment about BiLevels being uncomfortable because they control ones breathing seems to me to be a mistaken perception.

I don't think I've ever said a bi-level controls one's breathing, but if I gave that impression I really must apologize for not being clearer.

Since I don't think that, I would never say bi-level machines are "uncomfortable because they control ones breathing." As we both know, they don't "control" breathing at all. I agree, dsm...that would be a mistaken perception.

I've never thought a bi-level or bi-level ST machine was breathing for the user, or forcing the user to breathe at a certain rate, or making a person take a breath. Nor have I ever thought that a bi-level ST in "timed mode" operates like a true hospital invasive ventilator.

All the BiLevels I have & have tried feel very comfortable because the dominant control is the spontaneous control. In fact all home BiLevels that I have looked at only activate T mode in combination with S mode.

We're in agreement again -- all the bi-level machines I've tried were very comfortable, too...at least when operating in Spontaneous mode only. I did not like the feeling of a machine occasionally switching from EPAP to IPAP when I was not initiating the inspiration myself at that moment.

The lower the timed backup rate for BPM was set, the more the machine responded only to my spontaneous breathing and the less often the annoying "flip" happened. If I can be more comfortable and get efficacious treatment with an extremely low setting for BPM, obviously I don't really need a machine with Timed capability.

At any rate (no pun intended! ) it was interesting trying out an ST machine.

[Bella]

I'm the one who confused things on the other thread, and I really appreciate you straightening things out. I use the Synchrony in the S/T mode because I have severe Central Sleep Apnea. (I never formally introduced myself here, regrettably. I have an AHI of 128, and my settings are 14/4, with a backup rate of .

I don't have much time right now to comment, but I do have the Provider Manual with me and I just noted that the Synchrony has a build in "safety mechanism" that limits "time spent at the IPAP level during spontaneous breathing in the S, S/T, and PC modes". The maximum time is 3.0 seconds. Once that limit is reached it automatically cycles to EPAP. Would that cause some of the undesired "flipping"

Bella, the minimally informed

PS - I don't have the most recent Synchrony as you do dsm, I have the one just before it.

[rested gal]

You didn't confuse things at all, Bella...not to worry.

Good point about the maximum time spent at the IPAP level. I think (not sure) that all bi-level machines, whether they are "regular" bi-levels or are bi-levels with ST capability have a built-in maximum IPAP time. Some bi-levels do allow the user to adjust the time the machine can spend at IPAP, up to a built in limit, like you mentioned.

I recall the ResMed VPAP III ST A that I was able to try out for a couple of weeks had settings ranges for IPAP Max and Min -- how long the machine could spend delivering the IPAP pressure. Those were in addition to the "rise" time setting which (as dsm kindly pointed out) can be adjusted to smooth the transition.

Laura, the even less than minimally informed.

P.S. It's maddening, isn't it, when you type an 8 (for your backup rate) and it turns into just because of a bit of punctuation immediately after the number.

[BNLfan]

Hello everybody! I'm new to the forum and found that this topic describes my problems to a "T". Thank you dsm and rested gal for your valuable information, thoughts, photos, experience, and willingness to share your info and to educate us.

Last week I switched to a BiPAP pro with Bi-Flex. I had been using a CPAP prior to that, since 2000. My pulmonologist thought that a BiPAP might resolve some issues that I was having: chest/rib pain, and aerophagia.

I had a sleep study and all was well until I received my BiPAP at home.

I have a terrible time with the "early flip". I called the DME and told them about the problem. They told me that they couldn't do anything about it unless I had a Rx from the doctor.

I contacted my doctor and his nurse said that he told her that there weren't any changes that could be made to the machine to help me, except for the IPAP and EPAP, which were fine when compared with the study.

The doctor's advice? I should try it for longer than 1 week and that some folks cannot adjust to BiPAP or CPAP therapy. He said that if I happened to be one of those folks that I should just use the BiPAP as long as I can tolerate (per night) and hopefully, over time, I would adjust.

I mentioned to them that I did *fine* during my sleep study. I'm not 100% sure, but I believe that I was titrated on a VPAP III.

But, they assured me that all machines were the same and that the only changes that would make any difference were the IPAP and EPAP.

I know that they are wrong, thanks to dsm and rested gal.

My question is: Should I just go ahead and try to change the breaths per minute, insp time, and rise myself? I do not own this machine, nor do I have the setup manual, but I suppose that I could find a setup manual by searching here.

Or, should I just accept that I'm not going to get along with this machine and try to get a Rx so that I can purchase a PB300?

Thanks in advance for any suggestions that you can provide!

[rested gal]

My question is: Should I just go ahead and try to change the breaths per minute, insp time, and rise myself? I do not own this machine, nor do I have the setup manual, but I suppose that I could find a setup manual by searching here.

Hi BNLfan! The machine you have is a very good one. It would be nice if it were a Pro 2 instead of a Pro. The Pro 2 can use software to check AHI and some other things. But other than that, the BiPAP Pro and Pro 2 are the same machine.

Yes, you should look at the settings yourself and tweak the machine yourself. Doesn't sound like you're getting very good help with comfort issues from either the DME or the doctor's office.

P.S. Check your "Private Messages" - upper right of this message board page.

Not every bi-level machine has the kinds of settings that get talked about here. But yes, do look at the ones for your machine and learn all you can about it. Sometimes we have to take up the reins ourselves to make this kind of treatment work. Good luck.

[dsm]

Hi BNLFan,

AS I mentioned, I have yet a 3rd BiPap (a Pro 2) on the way and want to test it for its ability to flip in a normal way.

If it too has this problem then I will take it up with Respironics. I currently think it may be related to the type of mask one uses.

Are you able to try a nasal pillows mask ?

Also,
The PB330 and Tranquility Bilevels I have, both works absolutely happily in this IPAP to EPAP flip.

I believe that the VPAP II & II are also very good.

The problem with the Bipap Pro & Pro 2 is that there are so few parameters to change. I suspect Respironics may have a software upgrade to deal with such a problem assuming it is acknowledged by them.

I am interested in knowing if anyone has ever had a software upgrade applied to their BiLelel machine ?

Cheers & thanks

(& RG, many thanks as always for your replies and feedback - you are a gem )

Cheers

DSM

[dsm]

[quote="Bella"]I'm the one who confused things on the other thread, and I really appreciate you straightening things out. I use the Synchrony in the S/T mode because I have severe Central Sleep Apnea. (I never formally introduced myself here, regrettably. I have an AHI of 128, and my settings are 14/4, with a backup rate of .

I don't have much time right now to comment, but I do have the Provider Manual with me and I just noted that the Synchrony has a build in "safety mechanism" that limits "time spent at the IPAP level during spontaneous breathing in the S, S/T, and PC modes". The maximum time is 3.0 seconds. Once that limit is reached it automatically cycles to EPAP. Would that cause some of the undesired "flipping"

Bella, the minimally informed

PS - I don't have the most recent Synchrony as you do dsm, I have the one just before it.

[Bella]

You didn't confuse things at all, Bella...not to worry.


P.S. It's maddening, isn't it, when you type an 8 (for your backup rate) and it turns into just because of a bit of punctuation immediately after the number.

Oh rested gal, you truly made me laugh out loud when I read this! I thought that I had some understanding of the emoticons have some earlier posts about this. You are correct, my backup rate is 8!

PS - As you'll see below, I next have to try and master "quoting". Ok, maybe not master, but become semi-functional

[Bella]

[/quote]Bella,

One question I am very interested in is can you set your model to run in T mode only ?

Mine will run in either CPAP mode, S mode or S/T mode but has no way for me to set it to T only mode.

Seeing as my machine is the same machine but a later model, I was expecting them to be essentially the same.

Do you have a setting (that you know of) that allows you to run in T only mode ?

Cheers

DSM

_________________

CPAPopedia Keywords Contained In This Post (Click For Definition): CPAP, AHI[/quote]

DSM, my Synchrony can run in several modes:
CPAP mode
S mode(spontaneous bi-level pressure support with Bi-Flex
S/T spontaneous and timed
PC mode (Pressure Control) which is similar to the S/T mode, except that all breaths are machine-cycled. Inspiration can be patient or machine triggered, but IPAP will be pressure-limited with a set cycle determined by the Inspiratory Time control. It is a lot like S/T, but all breaths have a set cycle time.
Timed Mode

The reason that I have a Synchrony with all of the upgrades is because it was provided to me without charge from our Ventilation Pool here in Ontario. We have two xPAP programs. If you need any type of timed machine you get it from the Vent Pool. For non-timed you go to our Assistive Devices Program (ADP) and get 75% of a set rate covered. I guess with the Vent Pool all of their equipment has all of the bells and whistles to make distribution easier. And they give all of the manuals with them , so I don't have to hunt around for them.

[BNLfan]

dsm,

Thanks so much for your reply!

I will give the nasal pillows a try; unfortunately, I can only tolerate them for a couple of hours. I also have a ConfortLite 2 and was wondering if the leak rate for that is less than my FF mask...perhaps that would be worth trying as well.

I applaud your efforts to contact Respironics if your studies show that the early flip problem is consistent. If so, I would hope that they would acknowledge the problem and issue a software upgrade.

If I am unsuccessful with tweaking, I will seriously look into the PB330 or the Tranquility Bilevel.

Thanks!

[BNLfan]

I just wanted to follow-up with how things are going since I tweaked my BiPAP Pro.

I was able to adjust the "Bi-flex" and the "Comfort" settings. It appears that only one of those changes can be made at a time.

If the machine is set to run in bilevel mode, then the "Comfort" setting can be adjusted.

If the machine is set to run in biflex mode, then the "Bi-flex" setting can be adjusted.

I tried both modes and the lowest (1) and highest (3) settings for each setup.

I seem to be able to get to sleep and stay asleep by using the ramp feature in the bilevel mode with the "Comfort" setting as high as it will go (3).

It does not resolve the early flipping problem, but does make it more tolerable. It appears that this will be my choice setup unless/until I decide to buy a machine on my own.

Perhaps, as dsm suggested, Respironics will issue a software upgrade if this problem is indeed an algorithm problem.

Thanks to everyone for your willingness to help and listen. I've been reading this forum for a while and am glad that I joined...you folks are indeed *very* well educated.

I will formally introduce myself to the whole group and thanks again for your help.