Respironics M Series Auto Bipap

Hello,
I was diagnosed with OSA with an untreated AHI of over 50. O2 Nadir of 70 and the struggle was just getting started. I was very fortunate to have good insurance and to have found this forum, without these resources I would have given up long ago. I found out in August 08 and only recently have I found any sucess.

Machine 1 Resmed Autopap: After hunting for weeks for a copy of Rescan I found that 3.5 did not like Vista at all. When I finally got it to work I discovered that the A10 firmware left my untreated OSA and I woke up feeling like I was suffocating night after night. After fighting with the DME for a month they issued me a M series APAP which worked much better due to the NRAH software but I found I was only able to sleep 4 hours; going into REM the machine couldn't handle it and I would again wake up each night.

Machine #3 Respironics BiPAP Auto, this machine has worked the best for me. I was told that part of my issue was weight, turbinates, deviated speptum. I saw 3-4 ENT who all offered surgery but were quick to point out that I would still need the BiPAP anyways, ultimately I decided what was the point then? The next issue I faced was the mask, again I am fortunate to have a very understanding Insurance company and have tried/purchased 5-6 masks in the last 5 months. Nasal Mask=Bridge problem, Nasal Pillow=Fall Off each night, The Comfortlite 2 seems to be the one that works the best(relatively). The Cpap/BiPaps have allowed me to going the gym and I now can run for 2 hours non stop in the treadmill(10-11 miles) and do so 4-5 days a week. I am slowly losing weight(I weighted 265 at 6 feet tall). I have lost 20 pounds and have noticed an improvement in my over health and an increase in the efficacy of the BiPap device as a result. So summary, it has take 4-5 months of trial and error, sweat and tears but triumph(99%) has arrived. My AHI has been trending <5 consistently.
There remains one thing I would like to change but I don't know eenoughabout the BiPAP/SV/VPAPs and I was hoping someone could point me in the right direction. I believe that not only have OSA and because of my weight also OHS. I have also recently read the BiPAP titration guidelines that were published this year and they specifically state that there should be at least a 4 CMS differential between the EPAP and IPAP min. Sadly, the BiPAP M Auto Ipap Min is hard coded at 2 CMS. The Respironics SV devise offers the ability to adjust the IPAP min feature, but I am concerned that the software driving the two machines may be too different and I don't want to back track. I tried the Resmed APAP and was frustrated by the Rescan issues and the A10 cutoff, so I reluctant to go down that road again. Ideally I would like to see a Respironics Auto BiPAP that has a feature to set the IPAP min which is currently set at 2 CMS(hardcoded). I am seeing the EPAP remain constant around 9 CMS but the EPAP wants to bounce around from 11-12.5. I think a 3 CMS spread would be much smoother but it cant be changed on this device. I could go straight BiPAP and forget the Auto Part? Does anyone have any suggestions as what to try next? Any suggestions would be greatly appreciated. Thanks to all for the vast wealth of knowledge I have learned here.

Thanks to All,

Jeff

what's your PS set to (on the Auto Bipap)? That's what controls the difference.

On my bipap I have -
Max IP =
Min EP = This is what you want to stay at 9?
Max Sup Press = this is what you will have to increase. I would go 1cm at a time to see where you end up.

Keep in mind that your situation may be that EP needs to go up a bit more - meaning no matter what you do it is trying to do its job.

Snoredog had a real good explananation of how these all interacted. Give it a search.

May help to add you equipment in your profile (in text) also.

Good Luck,
GumbyCT

Hello,
The Epap is set to 9.5 the IpapMax is 14.5, PS is set to the max at 5. What I am finding is that the EPAP floor is staying pretty close to the 9.5 although it seems to want to goto 10CMS and stay there all night. Where I am getting the activity is in the IPAP pressure. Since the PS min is hard coded and not changable at 2 CMS it starts out at 12 and then wants to jump to 13-14 CMS. I would ideally like to be able to set the PS min to 3 CMS but on this model that is not possible. Is there a BiPAP auto out there that allows the user to change the min PS? I am hesitant to change machines since this is my third one in 5 months and it is working relatively well compared to the other machines I have tried. I liked the RESMED APAP but it was too much trouble with the A10 software and then you couldnt get the RESCAN software and when I did get my hands on a copy it ran terribly on Vista. Any advice is greatly appreciate. I could post my graphs but I am not sure how to? The other alternative would be to manually set the BiPAP I have to EPAP 9.5 and IPAP to 13. I am not sure what that would do to the tidal voulme.
Thanks everyone,
Jeff

Jeff, I'm not a doctor, but I wonder if there really would be much effect on your treatment to have "one cm" more difference between EPAP and the starting IPAP.

Or, to put it another way, since in auto bilevel mode, your machine ends up using only one cm more of EPAP and one or two more cms of IPAP anyway than what you have it set for, I don't quite see why it would be particularly desirable to start off with an additional single cm more of "PS" difference between those two.

From what you've described, it sounds like the machine is doing what needs to be done, and isn't having to go up much at all from your EPAP/IPAP settings.

But if you do want at least a 3 cm gap between EPAP, then what you've already thought about doing (setting it for just bilevel mode, with IPAP set 3 cms above EPAP) is the way to go.

I guess I'm just puzzled why you seem to feel that "activity" in the IPAP pressure is an indication that the hardcoded minimum PS of 2 cm is a problem.

"Activity", in the form of EPAP and IPAP going up/down independently of each other, is exactly what an autotitrating bilevel machine is supposed to do. Does it really matter that it starts out with the default minimum PS of 2 cms difference, if both those pressures are going to adjust independently as needed?

Here are links to my understanding of the Maximum Pressure Support setting -- like two dogs on a leash.

That setting is called "Max Press Sup" in the M series BiPAP Auto.
It's called "PS" in the older non-M series BiPAP Auto.
Same thing.

viewtopic.php?t=22099
Jul 14, 2007 subject: What is 'Max Press Sup'

viewtopic.php?t=15666
Dec 08, 2006 subject: Question for BiPap users - UPDATED 12/14/2006

Hello,
My reasoning for wanting a EPAP/IPAP differential > than the hard coded 2 CMS is coming from two places. One is the titration guidelines that came out this year where they recommend a minimum EPAP/IPAP differential of 4 CMS. Why the panel made this determination I am not sure. I assume that it has something to due with tidal volume.

4.3.1.6 The recommended minimum IPAP-EPAP differential is 4 CM H20 and the recommended maximum is 10 CM H2O.

They reference a study done in 2003 in the foot note. I will have to look up this study to determine their reasoning. The other main reason I would prefer a greater minimum differential is that my 90% scores are EPAP 10 CMS and IPAP 13 CMS. A 3 CMS minimum differential would be perfect and would cause less activity. I am interested in reducing activity because I find that it the machine is making too many adjustments then I end up waking up and cant get back to sleep. There was also an Italian study done that showed too wide a range and too much adjusting can have a negative effect. I believe the reason is that the software will only make adjustments in increments and if you have 5 CMS to go and the machine is making the steps in 1 CMS increments for example(per minute say) then your going to have 5 minutes of problems and O2/heart strain. I suspect Respironics will allow for EPAP-IPAP minimum differntial adjustments in future iternations of this model, especially now that this guideline has been published. I could go to the SV version that allows this metric to be set but I am hesitant to do this since I have had so much trouble getting to this point. My AHI is looking great < 3, my O2 is looking good and I have gotten to that magic sweet spot that had been elusive until now. I only wish Repsironics would let me bump that hard coded 2CMS minimum to 3CMS. I could just manually set it. I will be seeing one of the authors of the guidelines next month and will ask them what they think is the way to go.

The other interesting piece that I have not figured out is that the machine wants to change the IPAP from 12 to 13 CMS but when I look at the section in Encore Viewer that tells what is going (events) there are not always OA/Flow limits/Hypos etc. Something else is causing that bump in the IPAP but the devise is not flagging the driver? I have to read over the reports and the patent more closely to try to figure out what the cause is. I suspect it could be variable breathing or something else that is not being flagged and reported but the machine is none the less reacting and increasing. If the SV machine runs on the same software but I can adjust the Minimum PS I would be tempted to go that route. I am not sure how to post images, if someone can let me know I will post my reports and show what I am talking about. At the end of the day, this is the best I have done since this journey began. My untreat AHI was 50 and not I am getting AHIs of 1-3 with apneas <20 seconds. SPO2 looking good and I am not waking up when I am hitting REM because the machine is not reacting fast enough or too fast. It has taken three machines, 5 masks, 5 doctor visits and hour upon hours of research to get here so maybe I am looking for prefection. I am a bit of a perfectionist, perhaps I need to quit while I am ahead. The Max PS is not really an issue because there doesnt seem to be a big spread anyways on my Auto. Tonight I bumped up the EPAP .5CMS to 10CMS to try to eliminate the 4-8 apneas I am still having. They are very short in duration usually < 20 seconds and are not waking me up. Hopefully I can elimiate the few blips that remain.

Thanks to All, I could not have made it without this forum. It has been a lifesaver(literally). I had such severe OSA that several docs told me if it were much worse I would be dead. I feel better now that I have in years and have been able to exercise with the extra energy I now have from sleeping better.

Thank you for your help,
Jeff

Hello Everyone,
Last night I bumped up my BiPAP Epap from 9.5 to 10. In theory raising the EPAP is the way to eliminate OSAs but instead it increased it? I read another poster that had this same problem and went to a SV which is the way I am leaning. I read the titration guidelines and I am read the foot noted study that was used to recommend the 4 CMS min EPAP IPAP differential. The study did not really give a reason as to why this minimum was chosen. They study was several years old and it was done with straight BiPAPs and not Auto BiPAPs. I have a complicated case because there are several factors that a creating a perfect storm. I have sinus resistance issues(deviated Septum), Allergies, and I have put on weight as I have gotten older. My BMI is 33. I did read one study tonight that stated people with higher BMIs tend to not due as well on CPAPs, as was my experience. The BiPAP has worked the best so far but I have to have the EPAP set to 9.5 and the max IPAP set to 14.5. Adjusting the EPAP up .5 CMS should have eliminated those last few OSAs but instead the machine was all over the place and my AHI went up to 5 from 1-2? I am going to try one more night at EPAP of 10 and the IPAP max at 15, PS = 5 and see what happens with oximetry. I did not wear an oximeter last night but I dont feel rested today. I would love to share my encore reports but dont know how to post the images? Would an SV be a better choice for me? Or whould I do better manually setting the BiPAP or maybe just leaving well enough alone and keeping it where I was at? Any suggestions would be greatly apprecaited. Thanks to all.
Jeff

dnaonejax wrote:I read the titration guidelines and I am read the foot noted study that was used to recommend the 4 CMS min EPAP IPAP differential. The study did not really give a reason as to why this minimum was chosen. They study was several years old and it was done with straight BiPAPs and not Auto BiPAPs.

Once you add autotitration to bilevel operation, you really are using quite a different type of therapy, so I don't think the study's recommendations for "bipap" need be applied to autotitrating bilevel therapy.

dnaonejax wrote:Would an SV be a better choice for me?

Unless you have a significant number of centrals that showed up in your sleep study or the sleep study titration, I doubt it.

dnaonejax wrote: Or whould I do better manually setting the BiPAP or maybe just leaving well enough alone and keeping it where I was at? Any suggestions would be greatly apprecaited. Thanks to all.
Jeff

Either of those ways sound like a good idea to me... using it in just bilevel mode, or continuing with the autotitrating bilevel settings that were doing a good job for you.

dnaonejax wrote:maybe I am looking for prefection. I am a bit of a perfectionist, perhaps I need to quit while I am ahead. The Max PS is not really an issue because there doesnt seem to be a big spread anyways on my Auto.

I think you're right. I'd be very well satisfied with the results you're getting. You've done a good job getting to where you are in your treatment. Sounds like your present machine is treating you very well. I don't think I'd be looking for another machine -- especially not an SV machine which is going to be a whole other ballgame. The extreme, rapid changes in pressure an SV makes might be quite sleep-disrupting to you. Unless a person has a type of sleep disordered breathing that truly needs that kind of specialized machine, I don't think it's a machine that would be comfortable for most people to use.

Yes, I'd quit while I was ahead.

Jeff,

Out of curiosity.......how much (heated) humidity are you using? (how high do you have your HH cranked up?)

Some of us who have nasal "issues", have done better with very low settings or turning the HH off and just using "passover" humidification. In my case, the cool air helps open up my nasal passages and I can breathe better.
It's also been noted that lower humidity helps make for better AHI numbers, too.

Den

dnaonejax wrote:There remains one thing I would like to change but I don't know eenoughabout the BiPAP/SV/VPAPs and I was hoping someone could point me in the right direction. I believe that not only have OSA and because of my weight also OHS.

Jeff, I agree with Rested Gal. I don't think the BiPAP autoSV or VPAP Adapt SV were designed for your type of sleep disordered breathing.

The obesity hypoventilation syndrome (OHS) you mentioned can be addressed with a larger PS (EPAP/IPAP differential). While you can't achieve a fixed targeted PS in auto BiPAP mode, you can experimentally run a fixed EPAP and a fixed IPAP to achieve that wider PS.

Also, I added to your other thread here: viewtopic/p323645/Original-2-patents--1 ... ml#p323645