I have my BiPap now what

CarrieS · Post by **CarrieS** » Wed Dec 05, 2007 1:07 pm

Well sometimes I wonder how much some DMEs know. I think I taught her more then she taught me. SHe asked if I wanted 300 or 500 so I dont know about that I think she jsut picked 300, I told her I didnt know what it was so she just picked one. Also she had no idea I could see daily data with my Vantage...I could go on and on but she basically didnt know very much at all about the thing. I dont know anything about BiLevels yet so any info on it would be great so I can tweak it to the best treatment. Keep in mind Im trying to minimize my aerophagia. TIA

Guest · Post by **Guest** » Wed Dec 05, 2007 3:09 pm

I think all DME owners should come on here and read about the level of service and detail their customers expect from them (you're customers to them, patients to your doctor).

When you really break it all down, you guys really aren't asking for that much, right? Just a good grip of how the thing works, how to operate it, try on a few masks, have the ability to come back and exchange a mask for another one, etc.

What else is there?

Guest · Post by **Guest** » Wed Dec 05, 2007 3:19 pm

Exactly if they get give ideas and pointers to improve treatment thats great but all that is expected is how to use the thing and have it explained how it works. I think every DME should have to sit down and play with every single machine and monthly before they can start showing patients, versus learning on the run when a patient suddenly needs it - she was essentially figuring it out herself as she was showing me. There were many things I had to show and suggest to her, even how to go through her clinical menu lol. Sigh I dont know what people do who arent proactive they must be so lost when they rely on some of the DMEs (or some docs for that matter) alone for their needs.

Guest · Post by **Guest** » Wed Dec 05, 2007 3:23 pm

I noticed that I trigger the exhale not the machine picking the exhale - is that they way it should be? She seemed unsure - I inhaled longer to see how it works and then when I did an intenitonal long inhale it suddenly dropped by itself but when I breathed normally I lead and kicked in the lower pressure automaticaly when I exhaled. I assume this is the way it should be but she just seemd so puzzled so I wasnt very confident in any info I got.

Guest · Post by **Guest** » Wed Dec 05, 2007 3:25 pm

oh also another question is the lower number at 5 about right - or should I lower it more - Im trying to minimze aerophagia. Thanks again for any help.

rested gal · Post by **rested gal** » Wed Dec 05, 2007 4:40 pm

CarrieS accidentally guested wrote:I noticed that I trigger the exhale not the machine picking the exhale - is that they way it should be?

Yes, that's exactly the way it should be, unless the person inhales an unusually long time.

She seemed unsure - I inhaled longer to see how it works and then when I did an intenitonal long inhale it suddenly dropped by itself

That's what it's supposed to do...drops down to the lower EPAP if the person inhales an unusually long time. There is a setting in the clinical menu that you can adjust to make the amount of time the IPAP pressure would be delivered, from a short time to a long time, but I think about 4 seconds is as long as you can set that for.

I loaned my S7 VPAP III (bi-level) to a friend, so don't have it handy to look at what that setting is called, but as best I remember it's called something like "Max IPAP." I always set it for as long as it would let me, which (from faulty memory) I think was 4.00 (4 seconds.)

That doesn't mean the inhale pressure will keep blowing for four full seconds if you start to exhale during that time. You exhaling will switch it down to the EPAP pressure just like you've already noticed. It just means that IF you drew in an extra long inhale for 4 seconds, the machine would keep giving the IPAP pressure for that amount of time, as long as YOU were inhaling and hadn't started to exhale.

That's one of those settings on a resmed bi-level that many DMEs are not even aware of. Can make a big difference. Lengthening that time can help keep a person who normally takes long slow breaths from feeling like their inhalation is cut off. I think the default setting is about 2 seconds. -- again, if I remember correctly.

but when I breathed normally I lead and kicked in the lower pressure automaticaly when I exhaled. I assume this is the way it should be but she just seemd so puzzled so I wasnt very confident in any info I got.

Right. The machine should follow your lead absolutely when you exhale. The only time it will not follow you is if you take a VERY long slow inhale... longer than the duration the IPAP timer (Max IPAP?) can be set for. If that happens, the machine will drop down to the exhale pressure before you start to exhale.

The exhale pressure, on the other hand, will stay down at EPAP indefinitely...until YOU start to inhale again. You can try this little experiment. After you exhale partially or completely, hold your breath -- delay inhaling for as long as you can stand it. The machine will sit there delivering the lower EPAP pressure for as long as you are not breathing in. That's the way it's supposed to be. It's supposed to wait for you to inhale again before it switches up to IPAP. It will wait down at the EPAP pressure until the cows come home.

There's another setting that the DME might not have known about... called Rise Time. Setting the Rise Time for as long or almost as long (the higher numbers -- they are in milliseconds) as it would allow felt more comfortable to me than the default, which I think was fairly fast. Rise Time governs how fast the machine will switch to the higher IPAP pressure when you start to breathe in.

A low number for the Rise Time will make it jump fast up to the inhale pressure when you start to inhale. A high number (longer time) will make the transition more gradual. It won't be "slow" no matter how long you set the Rise Time for. Since Rise Time is set in milliseconds, it's going to definitely give you more pressure the instant you start to inhale...it can simply feel smoother as it moves quickly on up to the full inhale pressure if you set a fairly long Rise Time.

You can play with that setting while you're awake, to see which length of Rise Time feels smoothest and most natural to you. A very short (low number) Rise Time can feel bumpy...like the pressure change up to full IPAP is too abrupt.

oh also another question is the lower number at 5 about right - or should I lower it more - Im trying to minimze aerophagia.

Well, that's going to be up to you. Do bear in mind though, that when using a bi-level machine the EPAP pressure is the most important one to "get right" -- in my opinion, anyway. The EPAP pressure in a bi-level machine is the pressure that is supposed to be set high enough to PREVENT all obstructive APNEAS. Just the apneas. Then the IPAP pressure is set higher to take care of other things like hypopneas and residual snores and flow limitations.

I know it sounds odd, but the lesser EPAP pressure is what prevents apneas. The higher IPAP pressure is for partial closures. I remember thinking, "Apneas are the worst, so surely it would take MORE pressure to handle them." But that's not the way it goes. And when you really think about it this way, it makes sense:

If "some" pressure (the lower EPAP) can keep the throat at least partially open, there is no apnea. At least some air can be breathed through. But to get the throat well and truly fully open when we start to inhale, it takes more pressure (the higher IPAP.)

So....you want to set the EPAP up high enough to prevent total closure of the throat. Prevent obstructive apneas with EPAP.

Since you're dealing with aerophagia, I guess you'll just have to experiment with what works for you. But if you set the EPAP toooooo low, it might not be able to ward off obstructive apneas.

Of course, if aerophagia is too painful to let you use the most effective EPAP pressure ...is so painful that it could cause a person to have to stop treatment completely....then it does become a trade-off situation. A balancing act. Trading off optimum EPAP pressure for less pressure that's ok, just not the best.... in order to be able to use the machine at all.

Good luck!

CarrieS · Post by **CarrieS** » Wed Dec 05, 2007 10:10 pm

THANK YOU SO MUCH! Thank you for explaining so thoroughly - I was so clueless and you made it all very clear. Ive searched all over the internet for this type of easy to understand explanation of how the BiPap works and its full purpose. This really needs to bbe put into Collective Wisdom. I truly appreciate you taking the time to answer my questions and help make sure its clear to me. Ive been searching and theorizing all day on how this thing works. Your my new official best friend....you and RiverDave ...I better stop Im going to leave some one out LOL THANK YOU! & Blessings!

wabmorgan · Post by **wabmorgan** » Wed Dec 05, 2007 10:18 pm

Anonymous wrote:I think all DME owners should come on here and read about the level of service and detail their customers expect from them (you're customers to them, patients to your doctor).

I HATE to make the compairison on this.... but how often do you walk in to BB, CC, WM, and YOU know MORE then the clerk does.

!!!!!!!!!!!!!NEARLY ALL THE TIME!!!!!!!!!!

CarrieS · Post by **CarrieS** » Wed Dec 05, 2007 10:41 pm

note :My VPAP average each morning was always between 8 and 11

Sorry one more thing Im not understanding...on my data from my Vantage APAP whenever I had an Apnea, a full one, usually lasting 15-20 seconds quite a few time s a night some nights - the pressure kicked up to 10 or so. This makes me wonder whats going to happen now when I stop breathing will it just sit at that 5 (the lower pressure) inevitably? Sorry I just am not sure how this will prevent apneas I see what your saying and how it will defintely decrease hypoapneas since Im still breathing some I will kick it into the high pressure on inhale but how will I make it through an apnea floating on a pressure of 5 when usually it takes a 10 to make me breath. Thanks again I do appreciate it!

goose · Post by **goose** » Thu Dec 06, 2007 12:08 am

That's a great question Carrie -- I had the same one, but I'm still trying to digest RG's long post to make sure I understand it......
I don't have a Bi-PAP and may not need one, but apparently I'm having centrals as well as obstructives, so it makes me wonder how, if I'm not breathing in, it is going to pump up to the IPAP to open the airway if I'm not breathing in.....

Laura is such a GREAT resource for us!!! (thanks RG for the explain!!!)

cheers
goose

rested gal · Post by **rested gal** » Thu Dec 06, 2007 1:18 am

CarrieS wrote:on my data from my Vantage APAP whenever I had an Apnea, a full one, usually lasting 15-20 seconds quite a few time s a night some nights - the pressure kicked up to 10 or so. This makes me wonder whats going to happen now when I stop breathing will it just sit at that 5 (the lower pressure) inevitably?

Carrie, great question! I'm sorry...my fault for not thinking that through better. I was thinking about what just a plain bipap does -- sits at the EPAP pressure forever until you start to inhale. And I was thinking about the times I've experimentally held my breath as long as I could at the end of an exhale with the BiPAP Auto to see if the IPAP pressure came in...which it didn't. I wasn't even thinking about the fact that EPAP itself could move if needed. Duh, Laura!!

I forgot about this: The BiPAP Auto in auto bilevel mode is a completely different animal from just a plain bipap. If the machine senses no airflow from a person for a certain amount of time (longer than I can hold my breath) during EPAP, the autotitrating design in the machine will either (I'm not techie so I'm guessing here...):

1. finally start raising the EPAP. If that's what it does, I guess that action is designed to wait longer than most people could voluntarily hold their breath.

or (I'm not sure which way it goes about it)

2. raise the EPAP after that apnea clears, in order to try to ward off the possibility of additional apneas. After the breathing seems "normal" for awhile, the EPAP pressure would work its way down gradually. Just like an autopap does.

One way or another, that does happen (EPAP going up) because I see it occasionally on my detailed graph the next day....I see that the EPAP went up completely independently of the IPAP. I know that it was EPAP going up on its own (and not IPAP dragging it up) because of the amount of difference I have set between them (the most difference I can give them) in the "Max Press Sup" setting...letting them operate as independently of each other as possible.

That sounds confusing, I know. The software graphs of that happening would make it clearer.

So... the BiPAP Auto will do what any autopap would do when it senses sustained lack of airflow from you. It would start raising the EPAP pressure. Just like an autopap would raise whatever pressure it's using at the time if there were no airflow from you for a certain amount of time.

I do still think it's important to set the EPAP up high enough to try to prevent apneas in the first place, if that pressure doesn't unduly aggravate your aerophagia. But it's not as crucial to set EPAP up that much with the BiPAP Auto as it would be if using just a BiPAP, since turning on "auto bilevel" mode will let EPAP go up as needed.

How much the EPAP is allowed to go up while in auto bilevel mode will, of course, depend on how high you set the IPAP. Because EPAP can never get closer up under IPAP than within 2 cms.

For example, if you needed 10 cm to ward off any/all pure obstructive apneas, and you had the IPAP set at 10 and EPAP set at 5, the highest EPAP can go up to deal with an apnea would be going up to 8 cm. Two cms below what you had IPAP set for.

You'd have to decide whether you needed to use lower pressures because of the aerophagia, or use higher pressures to get optimum treatment. The EncoreViewer software could help you see what was going on treatment-wise. You'd have to weigh that against how you felt aerophagia-wise, and tweak accordingly.

Guest · Post by **Guest** » Thu Dec 06, 2007 6:59 am

I have Resmeds Bi Level VPAP III so Im not sure if it differs from the Auto. Last night though my AHI was 5.6 thougj YIKES! not delighted about that hopefully theres a logical reason - is it learning me still? do I have it set wrond? I have the EPAP at 5 maybe I need to raise it? Hopefully I ccan get help here since my alternative is to call my less knowledable DME.

CarrieS · Post by **CarrieS** » Thu Dec 06, 2007 7:07 am

PS
I do have software but I havent seen if my Vantage cord and software are compatible yet I imagine they are my onboard data says?
O LEAK VT 200-400 RESP RATE 5-20 MV 2.0-7.2 AHI 5.6 AI 2.9

_________________

CPAPopedia Keywords Contained In This Post (Click For Definition): AHI

CarrieS · Post by **CarrieS** » Thu Dec 06, 2007 7:49 am

Well I called am Im going to see a sleep doc tomorrow - today Im go back to get my APAP back and asked for one with EPR or Cflex but they said they dont think they have any respironics just resmed at the store and would have to order. Either way its better then what my BiPap is making me feel like. Tomorrow the Sleep doc can decide what I should do for now I work with the lesser of the evils.

self-solving + DME + Family Doc just isnt cutting it anymore
Between us 3 I just dont think we can put it all together when I say 3 I mean 1 = me really lol since they just seem to do what I tell them. So they got me in tomorrow already its with their nurse practioner but it a start - pray I get someone good to help solve all this nonense IM SOOO TIRED. Honestly I already am having sep anxiety from my APAP (not from the aerophagia though) but I knew my APAP and felt like it knew me

_________________

CPAPopedia Keywords Contained In This Post (Click For Definition): DME, APAP, aerophagia

rested gal · Post by **rested gal** » Thu Dec 06, 2007 10:33 am

CarrieS wrote:I have Resmeds Bi Level VPAP III so Im not sure if it differs from the Auto.

The two machines are very different from each other.

Your resmed VPAP III is a bi-level machine with no ability to autotitrate.

The BiPAP Auto is a bi-level machine with the ability to operate as a bi-level AND autotitrate (vary the EPAP/IPAP independently of each other as needed) at the same time.

The auto-titrating can be turned off, of course, so that it can operate simply as a bi-level just like yours.