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dsm
 
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Using a Bipap Auto SV and using a Vpap Adapt SV

Postby dsm on Wed Apr 16, 2008 6:09 am

Am using a new Bipap AutoSV for the 1st time tonight & plan to make this thread a running commentary on aspects of it.

#2 (added 13th Jun 08) From this date on in this thread, there are also reports on using a Vpap Adapt SV. - DSM ###

My very 1st deed was to open it up & confirm that internally it was pretty much identical to the Bipap S/T Grey Model - it was :)

Then I looked through the SV settings & decided on ...

EPAP=9 IpapMin=13 IpapMax=17 BPM=Auto LPM=10

Now it was a nice surprise to see that the real SV adjustment is for how many Litres of Air / min the machine will work to maintain. That really appeals to me because I have long believed my nightly Minute Ventilation could be a bit higher than it mostly is so I went for 10 Litres/min which is just a little bit higher than my typical average.

I set BPM to Auto as the MV volume will be the driver of therapy not my rate of breathing.

The machine seems to cycle very nicely (something I always had difficulty with on BipapAuto BipapST & BipapPro2) that was a big plus for this machine.

I don't have the software required to read the datacard so until I can get a copy, the feedback will be subjective based on how I end up feeling. (I will add my SpO2 reader tomorrow night). Also because I can't find my power lead that splits power to the Resp H/H I will be using my F&P HC150.

The machine is as quiet as the other Bipaps - no surprises there. This is good.

So - am now off to join the SV club.

DSM

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Last edited by dsm on Sat Jun 14, 2008 4:36 pm, edited 2 times in total.
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Postby dsm on Wed Apr 16, 2008 3:51 pm

1st Night: Result - washout :(

This machine is so full of promise ! - it felt very good - the pressure transitions were very comfortable

BUT

As soon as I would drift off to sleep -
BEEP-BEEP-BEEP ---- BEEP-BEEP-BEEP ---- BEEP-BEEP-BEEP ---- BEEP-BEEP-BEEP etc:

The alarm showing was 'MinVent' ???

So I pressed the rest button & tried again, just as about to fall asleep same penetrating sound & 'MinVent' alarm.

after 3 such alarms & wife getting irritated, I dropped the LPM (Liters per Min) setting to 8 LPM.

I got a bit further into the sleep cycle but yet again alarm.

I tried to find a menu setting for silencing alarms but no luck (clearly not the right moment for clear headed thinking re such fine detail). So I dropped LPM to 5 lpm

This time I got further into sleep (am sure I was asleep as it was in the faint distance I heard the alarm going off again - this was only 20 mins since going to bed so for the sake of marital harmony I reverted to the PB330.

Wife asked me "If that machine is supposed to ventilate you when your breathing slows why does it wake you up to tell you to breathe" :)

I tried to defend it by saying that my PB330 did the same until I found a way to stop the alarms on it. Also that these machines are for both home and clinical use & thus the high-end models all have alarms.

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

I realize there aren't many users of the Bipap AutoSV but this 1st night has raised the below questions & I will try to resolve them with some reading of the manuals that I have (I don't appear to hae the clinical manual), unless some other readers recognise the issues & have answers.

Q1. Is the LPM parameter merely an alarm setting (i.e. go beep if the sleeper drops below this minute ventilation value) or is it the level of minute ventilation that the machine seeks to sustain. ?

My belief & hope is that it is the latter else we get back to "why wake up the sleeper to tell them to breathe deeper" :) Reason I believe it has to be the target Minute Ventilation is how else does the machine know when to go over to servo ventilation.

Q2. Where in the menu system can alarms be turned off or on ?

Q3. Does anyone have a pdf of the clinical manual they can email ?

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

Impressions thus far ...

I am actually excited at the prospect of getting this working as this is the 1st Bipap I have used that seems to cycle epap to ipap to epap smoothly allowing that I often get nasal constriction - I am using a FF mask & have no hesitation in mouth breathing if that is what is needed to get air in.

DSM

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Postby Banned on Wed Apr 16, 2008 4:12 pm

The wife is onto a great concept about waking you up to tell you to breath. If there is an alarm on/off it should be somewhere in the Clinical menu. if you can't find it, maybe an alarm on/off doesn't exist. With the Adapt SV you can turn the the alarm off all you like, but it will still alarm. Have you thought about a Quatrro? Also, where is the hose laying when you sleep, hopefully not hanging from your headboard, ceiling, or some other weird spot? The Adapt alarmed the first night until I laid the hose next to me in the correct orientation, (i.e. down my front). No problems.

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Postby dsm on Wed Apr 16, 2008 4:20 pm

Banned,

The hose is coming from the headboard but with the Bipap AutoSV that should be ok (no proximal sensor to worry about).

I looked at the titration manual I have a copy of (pdf) and there is no mention of the LPM parameter which sort of implies it is an alarm value.

If the LPM doesn't set a target for MV then I am wondering how this machine decides when to SV vs work to spontaneous breathing.

We know that the Adapt SV targets 90% of a moving 3 min window of MV & rate. The Bipap AutoSV is said to target volume but no one has actually ever explained how it calculates the target.

If I can't get hold of a Clinical pdf, tonight I'll set the LPM parameter down to 1 (which was what it was at when I got the machine), & work on the assumption it is an alarm threshold.

SAG SWS - do you have any input re the LPM parameter & the way the Bipap AutoSV targets volume ?

Thanks

DSM

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Postby Snoredog on Wed Apr 16, 2008 4:30 pm

sounds to me like you are breathing shallow, to the machine a lower minute volume, the machine having a LPM value is expecting to see xx amount of volume, when you drop below that value it sounds the alarm, it certainly wouldn't sound the alarm if you were going above it or I wouldn't think it would.

For the alarm you should input what it should be (maybe from your other machine reports), then tweak other parameters to keep it from ever getting there.

it would seem to me, that you don't want to disable the alarm by lowering the LPM but by changing other parameters which reduce the shallow breathing by using parameters which force you to breathe more deeply.

That machine works by stabilizing your breathing pattern and allowing the events to subside on their own. It is not like a conventional xpap that uses pressure to splint an obstructed airway so you have to think the way the machine thinks.

This is a question for SAG, what parameters would cause you to breathe more deeply as opposed to shallow, shorter rise time? greater PS support? personally, I have no idea.

But dllo has that machine and I think the manual.
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Postby dsm on Wed Apr 16, 2008 5:29 pm

Snoredog wrote:sounds to me like you are breathing shallow, to the machine a lower minute volume, the machine having a LPM value is expecting to see xx amount of volume, when you drop below that value it sounds the alarm, it certainly wouldn't sound the alarm if you were going above it or I wouldn't think it would.

For the alarm you should input what it should be (maybe from your other machine reports), then tweak other parameters to keep it from ever getting there.

it would seem to me, that you don't want to disable the alarm by lowering the LPM but by changing other parameters which reduce the shallow breathing by using parameters which force you to breathe more deeply.

That machine works by stabilizing your breathing pattern and allowing the events to subside on their own. It is not like a conventional xpap that uses pressure to splint an obstructed airway so you have to think the way the machine thinks.

This is a question for SAG, what parameters would cause you to breathe more deeply as opposed to shallow, shorter rise time? greater PS support? personally, I have no idea.

But dllo has that machine and I think the manual.


Snoredog,

Good points - my thinking is that this was typical sleep onset issues as I always score very high HI vs AI

The LPM does look like an optional alarm as there is no mention of setting LPM when doing an SV titration.

What appeals to me about the BipapSV is if it can push me to maintain a good MV volume.

Am keen to better understand how it does the decision to push the ventilation. I am sure I need some pushing & have been wondering if straight bilevel is ok part of the time but falls short at others.

Re other parameters, there really aren't any others to change. The epap is for OSA resolution - they say set ipapMin to either the same as epap or add 2 or 3 CMS for comfort (which is very good advice based on my own experience - hence 9 + 4 (1 more than they suggest). Then set ipapMax to do the SV driving - the issue I am hoping to better understand is what is the trigger for that extra driving - I had hoped the LPM told the machine that but it does seem LPM is merely an alarm for clinical use.

Tks

DSM

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Postby Snoredog on Wed Apr 16, 2008 6:24 pm

I agree the alarm is just that, an alarm to indicate your breathing rate has ceased and/or is at levels lower than expected (amount expected input as LPM into the alarm value). My guess is if you put it down at its lowest allowed LPM value that pretty much disables it.

But do you want to do that?

Doing so wouldn't seem to help what caused the alarm to sound in the first place. Those sleep onset events would also be my guess as to what was causing the alarm to sound and most likely from shallow breathing as that to the machine resembles or is central apnea.

So the parameter you want to change restores stabil breathing and as a result of that your LPM should remain high where the alarm no longer sounds.

Setting EPAP to what it takes to clear your AI makes sense to me and would be what I would do.

But keep in mind that machine is also for CSDB where mixed events are seen. My theory on how that functions is it does a better job at avoiding the centrals and manipulates your breathing via other parameters to stablize it.

So the question becomes what parameters on the machine can you change to manipulate your breathing? A wider pressure change? A wider PS setting? If I want you to breathe I allow CO2 to build up in the blood towards Permissive Hypercapnia.

We know that CPAP alone won't do that so my guess is decreasing tidal volume on the machine? is there a setting for that? Hypoxemia is dangerous, Hypercapnia is not.

Man I had the settings and values for that machine somewhere, can't find it on this computer must be on one of my others.

if in AutoSV mode and central events are seen (same as those onset) you would:

-set EPAP to value to eliminate obstructive events.
-set IPAP same as EPAP
-set IPAP Max +10 cm above EPAP
-set Rise time to 2 or 3

You need page 3 of 4 of the titration manual, single page chart,

if you observe for periodic breathing increase IPAP by 2cm, if it does not eliminate events, set fixed BPM rate to 2 less than spontaneous BPM rate. Start I time at a minimum of 1.2 sec.

if periodic is no and central present,

Set fixed rate to a minimum of 10 BPM or 2 below spontaneous respiratory rate.
Start I time 1.2 sec.



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Last edited by Snoredog on Wed Apr 16, 2008 6:56 pm, edited 3 times in total.
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Postby rested gal on Wed Apr 16, 2008 6:26 pm

I've emailed Doug the Provider Manual.
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Postby dsm on Wed Apr 16, 2008 6:40 pm

Snoredog,

There are no other settings than the ones mentioned but RG very kindly sent the clinical pdf so I will be able to post details of how it does its volume matching.

I am running the machine in BPM = Auto mode & it is the best setting for me (AFAIKT) - the machine computes the current rate from spontaneous breaths & calls this the 'av breath period' & also calculates 'insp period' If tidal vol is less than 100ml it considers no breath has occurred.

Timed breaths when required are delivered in groups of 5 breaths - the 1st has different timing criteria as compared to the subsequent 4.

The machine will work differently if BPM= (4 to 30 BPM) as this sets the breathing rate to a fixed value.

I can't see any other data re what is considered the required or ideal volume.

Also the manual shows this machine in an older synchrony box so this machine must have been around before it was formally announced as the Bipap AutoSV. My guess is they had these in 2005 or thereabouts.


Rested Gal

Many thanks for the Clin data :wink:

Cheers

DSM

Also it seems the alarms can be active or not active - I am interpreting the below part of the manual as meaning they can be deactivated but am still looking for the absolute turn-it-on turn-it-off info - an alternate interpretation could be that an alarm has been triggered & the indicator doesn't relate to activation deactivation.

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Postby dsm on Wed Apr 16, 2008 6:50 pm

I believe I have the answer to the alarm.

Set the LPM param to the lowest it will go to.

The manual more or less says that this alarm will always operate based on the LPM setting & if it goes off 'contact your provider'

It seems that it is really there for when someone has a serious SDB condition (Cheynes Stokes Breathing) and the situation requires medical attention.

Perhaps even at 5 LPM I am setting this too high (but my av is 8 to 9 LPM). Perhaps dropping down to 3 LPM is ok in a small burst ?

I am still somewhat puzzled at what the machine targets that causes the ipapMax to get raised.

DSM
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Postby Snoredog on Wed Apr 16, 2008 6:59 pm

dsm wrote:I believe I have the answer to the alarm.

Set the LPM param to the lowest it will go to.

The manual more or less says that this alarm will always operate based on the LPM setting & if it goes off 'contact your provider'

It seems that it is really there for when someone has a serious SDB condition (Cheynes Stokes Breathing) and the situation requires medical attention.

Perhaps even at 5 LPM I am setting this too high (but my av is 8 to 9 LPM). Perhaps dropping down to 3 LPM is ok in a small burst ?

I am still somewhat puzzled at what the machine targets that causes the ipapMax to get raised.

DSM


if partial obstruction seen or periodic breathing, you increase IPAP by 2 cm until that goes away. BPM is 2 less than spontaneous BPM. Start I time remains at 1.2 sec. in either case.
someday science will catch up to what I'm saying...

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Postby dsm on Wed Apr 16, 2008 7:32 pm

Snoredog wrote:
dsm wrote:I believe I have the answer to the alarm.

Set the LPM param to the lowest it will go to.

The manual more or less says that this alarm will always operate based on the LPM setting & if it goes off 'contact your provider'

It seems that it is really there for when someone has a serious SDB condition (Cheynes Stokes Breathing) and the situation requires medical attention.

Perhaps even at 5 LPM I am setting this too high (but my av is 8 to 9 LPM). Perhaps dropping down to 3 LPM is ok in a small burst ?

I am still somewhat puzzled at what the machine targets that causes the ipapMax to get raised.

DSM


if partial obstruction seen or periodic breathing, you increase IPAP by 2 cm until that goes away. BPM is 2 less than spontaneous BPM. Start I time remains at 1.2 sec. in either case.


Snoredog,

That sounds like the titration steps rather than what the machines SV algorithm does.

As mentioned I had hoped that I could dial up a target MV and the LPM param looked such a good param to be that.

Because the LPM is an alarm only I'll set it to its lowest setting. I have been looking at DLFOs reports from his BipapSV & that in turn raises questions in my mind about what causes ipapMax to rise. But, DLFO's case is special & not really to be compared with my own.

DSM

More thoughts ...
#2 - I know what is going through my mind is why did the alarm go off ? - esp when I set LPM to 5 lpm as that seems a low figure to me. But maybe I should try 3 lpm as an alarm & see what happens - I would hope the machines SV function would not let it ever get that low.

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Postby akcpapguy on Wed Apr 16, 2008 8:19 pm

dsm,

Sorry it's been a busy day or i would have replied to this thread earlier.

You are correct setting the Low Minute Ventilation to 0 will disable the alarm. You have to keep in mind, this machine is classified as a Ventilator and as such by law must have certain alarms built into it for patient safety. Ofcourse there are also clinical settings and applications where having the LMV alarm on would be advantageous, however in your case it MAY not be, ofcourse I don't know your complete health picture, so take that for what it's worth.

So on to the Algorithm and how it decides when to assist your breath and when it doesn't. The Respironics ASV measures your Peak Flow on a breath by breath basis on a sliding 2 or 3 minute (can't recall off the top of my head if Respironics is 2 minutes or Resmed is 2 minutes or visa versa) average scale. When your Peak Flow for the current breath drops below that average by a certain % (can't pull that number off the top of my head either sorry), the machine assist your breath until the peak flow meets the average. This is done on a breath by breath basis and the peak flow average is changing with each breath as well.

That's the short version of it, one of the major differences between the Resmed and Respironics SV's is the measurement the algorithm uses to increase the pressure. Respironics uses Peak Flow and Resmed uses Minute Ventilation I believe, maybe someone who is more familiar with Resmed products and verify or debunk that.


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Postby ozij on Wed Apr 16, 2008 8:30 pm

User's Manual

This has a chapter about alarms and their meanings.

O.

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Postby dsm on Wed Apr 16, 2008 10:20 pm

Many thanks to everyone posting help re this. It is very much appreciated. Am sure many will be interested in how this experience goes.

My real interest was piqued by my constant recordings of high hypopneas while scoring typically 0.5 or less for AI.

As mentioned many times before none of the PSG studies indicated any centrals - my wife certainly believes that slowing breathing is an issue that was there from way before day 1. The other contradicting data though is that any SpO2 readings done while on cpap nearly always show 92% to 96% and that seems to say that no matter what the breathing volume is, the SpO2 is acceptable.

AKCPAPGUY,

The Resmed monitoring is a 3 min window and it tracks MV and breathing rate & seeks to keep the sleeper within 90% of this trailing 3 min window.

So until anyone else provides any contrasting time I'll accept that the Bipap AutoSV is tracking average peak flow in a 2 min window and will up ipap to push the sleeper within x% (a yet to be established) of the prior 2 min av peak flow.

Banned has kindly agreed for me to try out his soon to be stand-by Adapt SV & I am interested to see how that too works. I am not yet sure which is the best match for what I believe is excessive hypopneas in my own breathing. A deep discussion with a Resmed doctor suggested it might not be the best choice but trialling both should provide a good sense of what they each address. It is hard not to be somewhat infected with banned's enthusiasm for how well it works for him.

DSM

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