Question from new VPAP user

shortspark · Post by **shortspark** » Thu Jul 10, 2008 1:12 pm

I think I may have been a poster here long ago when I first started using CPAP but have not been back in some time. About seven years ago, the doctor had me do a sleep study, ordered me a CPAP, set the pressure and that was the end of it.

A few weeks ago I told my new doc that I was not sleeping well, even with the machine and he ordered a sleep study as he felt the pressure might need to be adjusted after so long a time. The specialist recommended a BIPAP and ordered for me a ResMed VPAP Auto with Humidaire3i. She also suggested I use the Comfort Gel nasal mask. I had been using BreezeAire nasal pillows. I have done pretty well with this set-up. A little better than before so any improvement is welcome. I may sleep an hour longer than I use to (sometimes even up to six hours) but I feel the same in the morning which has always been pretty good.

That's the background. My question is about a sensation I feel with the VPAP that is difficult to describe. I asked the medical supply tech who set it up in my home if this sensation was normal and he said that it was - but I don't think so. What I feel is a "pulse" coming from the machine which I feel in the mask. It is almost like the machine has a "heart beat" but it is sporadic. It does not occur while the machine is ramping up for the first ten minutes but when it hits pressure (11.3) I sense the "pulse" on my face. It is not severe but I would describe it as bothersome.

The tech said I take very deep breaths and is the reason the "pulse" sometimes occurs two or three times during one breath and is therefore more noticeable. But I have experimented and even if I don't breathe I feel this "pulse". I have experimented also with shallow breaths and the machine will still "pulse". Sometimes it happens at the start of my breath and causes me to shorten it and sometimes it occurs at the top of my breath. And as I say, sometimes it happens two or even three times during a single breath. Most often I feel it at the bridge of my nose.

I thought the transition (if that is what is causing this) would have been smoother so that the "in" and "out" would not be so noticeable. Could any VPAP users please give me some insight on this? If it is normal so be it but if not I am going to insist on a new machine.

jnk · Post by **jnk** » Thu Jul 10, 2008 2:08 pm

You MAY be describing the way it feels when a bilevel machine cycles between the inhale pressure and the exhale pressure but does not, for some reason, sync up with your natural breathing pattern.

You may be able to get the technician to consider looking at a setting on your machine called "Ti Max." That adjustement limits how much time the machine will allow you to inhale a breath before it changes its pressure in an attempt to get you to exhale. If, because of congestion for example, it takes you a long time to breathe in, that "Ti Max" setting may need to be adjusted higher to give you a longer amount of time to breathe.

This is only one possible explanation of what you describe. I'm just a guy who went through something similar, I think, a few weeks ago.

Guest · Post by **Guest** » Thu Jul 10, 2008 2:26 pm

Thank you. I never heard of that setting. They set me up but left no instructional guide. When I asked for one they said they do not have one for the patient and all settings are to be adjusted by "qualified" personnel. Sounds fishy to me because I downloaded the PDF manual from the ResMed site myself. Still, I must have missed this "Ti Max" setting.

dsm · Post by **dsm** » Thu Jul 10, 2008 2:56 pm

Slinky uses a Vpap Auto & yes Iirc it does have the Insp Time & also a ratio setting that determines the ratio of insp to exhale.

These may well be causing the feeling you mention.

I'll see if I can find that link but I am sure Slinky can probably dig it up

Slinky, its that post where I put all te data from your clin manual

DSM

jnk · Post by **jnk** » Thu Jul 10, 2008 2:56 pm

I don't think it is a "user adjustment." So you would have to get into the clinician's menu to mess with it, if you want to do it yourself. Be very careful though. It is a decision that means taking a lot of resonsibility on yourself once you go down that road. Most techs and docs don't like it, I hear. So I'm not comfortable suggesting someone do that, even though I did it myself. (Does that make me a total hypocrite?) I did it because I have no knowledgeable technician available to me. Yeah, that's why. Sure.

Problem is, changing the "Ti Max" setting is sort of a comfort adjustment, but then again sort of a treatment adjustment, depending on your specific situation or diagnosis. The machine comes to the clinician with a default setting of "2," 2 seconds for inhale. When I had a bad cold, that was not enough time for me. So I hacked into my machine to set the adjustment up to 3. My sleep doctor said I should try to work it slowly back down to two. (He also said 'No comment on your getting into the clinician's menu.') I think he said that because he wants to make sure my respiration rate stays high and that I move enough volume of air, or something, but I'm just guessing. I don't understand much about that stuff yet. One thing at a time.

Anyway, all of that hinges on whether your machine is set to "Spontaneous" anyway. If it is set to "Timed," things may be different in that it isn't trying to sync up with your breathing. That can be OK, too, since it may all sync up fine once your asleep, so I hear. (I've never been conscious when I was awake, so I don't know!;-)) There is a school of thought that says we shouldn't be judging how the machine is working, especially when it comes to timing, since that is all supposed to kick in after we are asleep--and how we breathe when we are asleep and what we find "comfortable" when we experience it awake are supposedly two very different things. I guess that's part of the idea between the "ramp" or "settling" time on these machines, to let us fall asleep before the machine takes over our souls.

Please keep in mind that I am VERY new to this, so I may not know what the sam-hill blazes I'm talking about. If so, hopefully one of the more experienced posters will set us both straight eventually.

jnk

jnk · Post by **jnk** » Thu Jul 10, 2008 3:01 pm

jnk · Post by **jnk** » Thu Jul 10, 2008 3:29 pm

Is this the passage you are looking for?:

"The TiControl feature . . . allows the clinician to set minimum and maximum limits on the time the device spends in IPAP [inhale pressure]. The minimum and maximum time limits are set at either side of the patient’s ideal spontaneous inspiratory time, providing a ’window of opportunity’ for the patient to spontaneously cycle to EPAP [exhale pressure]. The minimum time limit is set via the Ti Min parameter and the maximum time limit is set via the Ti Max parameter. TiControl’s Ti Max and Ti Min parameters play a significant role in maximizing synchronization by effectively intervening to limit or prolong the inspiratory time when required."

Words in brackets are mine.

dsm · Post by **dsm** » Thu Jul 10, 2008 3:47 pm

jnk wrote:Is this the passage you are looking for?:

"The TiControl feature . . . allows the clinician to set minimum and maximum limits on the time the device spends in IPAP [inhale pressure]. The minimum and maximum time limits are set at either side of the patient’s ideal spontaneous inspiratory time, providing a ’window of opportunity’ for the patient to spontaneously cycle to EPAP [exhale pressure]. The minimum time limit is set via the Ti Min parameter and the maximum time limit is set via the Ti Max parameter. TiControl’s Ti Max and Ti Min parameters play a significant role in maximizing synchronization by effectively intervening to limit or prolong the inspiratory time when required."

Words in brackets are mine.

jnk

Thats the info needed good work

I think max insp time can be set to 4 secs (by default it is 3 secs on most Resp bipaps).

D

DSM

jnk · Post by **jnk** » Thu Jul 10, 2008 4:00 pm

Glad to help out. Thank Slinky.

The VPAP Auto default is 2 for Ti Max. Don't know why.

I have inched that setting down to 2.7 so far on my VPAP III. Can't get it to 2 for the life of me. Seems like a very short time to me. Three as a default would make much more sense in my opinion--especially since my DME seems to leave everything on the default settings anyway.

Slinky · Post by **Slinky** » Thu Jul 10, 2008 4:43 pm

Well, playing w/your therapy settings w/a straight CPAP is a LOT easier - and "safer" (shall we say?) than playing around w/all the various settings on a bi-level auto, let me tell you!!! I thought I was ready to play around w/and change my therapy settings last night. Ha!

I opted to wait until I see my sleep doc tomorrow. I'm flat gonna tell him what I had been thinking of doing and seeing just how much he ventures to say in response.

You aren't going to see ME making ANY suggestions, etc. about ANY setting changes on these VPAP Autos for quite some time yet!!!! Intimidating if you are thinking of going from Auto mode to S mode as I had intended to do.

Chicken poo that I am I've decided, unless sleep doc instructs otherwise, maybe, to just leave her in Auto mode and drop EPAP from 8 to 7 and IPAP from 13 to 12. I'm such a daring soul. NOT!

And thanks, jnk, for finding that quote for us. I was out filling my face at our favorite Chinese buffet and shopping w/my daughter and neighbor most of the day.

Ooops. Sorry. I have NOT experience this "pulse" you've mentioned you are experiencing w/your VPAP Auto. The first night or two, when I was changing masks between the Respironics Simplicity and the Resmed Mirage Micro, I didn't find the changes real smooth or as smooth as changes w/the S8 Elite and EPR or the AutoSet Vantage. But after that one or two nights, regardless of which mask, this baby produces the SMOOOOOOTHEST breathing I've yet to experience on xPAP!!!!

Guest · Post by **Guest** » Tue Jul 15, 2008 7:13 am

Thanks for all the information folks. I waited to post again until I saw the doctor. This gal is very good I think, at least she spends time with me. We met one afternoon at the hospital clinic and she had me lay down and take a nap while she observed and made various adjustments. I told her about the Tmax setting and she was certainly aware of that (in fact, I think she set it as high as it could go to 4).

I dosed off a couple of times and despite all her efforts over about a three hour period she was unable to completely eliminate this "pulse" effect. She did set the ramp in such a way that I would fall asleep before the high pressure was reached. It does not bother me while in ramp, only when it reaches full pressure (11.3). If I awake during the night I find it difficult to fall back to sleep because of the "pulse" on my face so next time I have to fall back to sleep I think I will simply shut it off and start over with the ramp. Hopefully I will fall asleep again within the ten minutes it takes to get to full pressure. The whole problem is probably related to the fact that I seem to take two or three short breaths then one huge breath. Maybe that is throwing off the machine. I don't know and the doc can't get it to be smooth during transitions. I feel the "pulse" on my face sometimes at the start of my breath, sometimes at the middle and sometimes at the top of the breath. Sometimes I feel it two or three times within a single breath.

I would have thought that, as slinky said, the transitions would be smooth. I have used several masks including Comfort Gel and Mirage Liberty and the sensation is with all of them. It is less so with the Liberty than the Comfort gel but I leak and do not like the Liberty at all. The best for me is going back to my old CPAP Nasal Pillows from Puritan. I seem to do much, much better with these although a technician I spoke to at ResMed said the VPAP Auto is not compatible with the nasal pillows. My doctor said pay no attention to that if the pillows work. I also told her I would like to know how to adjust settings myself and she said she could tell me a couple of things but I might do more harm than good so I let it go. Heck, my insurance pays for everything except a $30 co-pay so when I think I need an adjustment I'll just let the pros do it and not take the chance myself.

Well, any other thoughts or suggestions would be appreciated and I'm really wondering if I should have the health equipment service bring me out another machine, set it up like this one and just see if the "pulse" is gone. BTW, how do you become a member here instead of a "guest"? I can't find a place in these threads to join.

Slinky · Post by **Slinky** » Tue Jul 15, 2008 7:55 am

Ha! Its been so long since I registered (short memory span ) but I believe you just click on Profile at the top of the page and then proceed to fill in the info.

In listing your equipment, please choose text instead of the avatars. I don't think there is an avatar choice for your VPAP Auto anyway.

I would take that VPAP Auto back to your local DME supplier and discuss your problem w/this "pulse" effect w/them. It will give you an idea of how savvy they are about the VPAP Auto if nothing else. They may understand more about the various "unfamiliar" settings these bi-levels have than your sleep doctor. Ideal would have been if the sleep lab's RPSGT would be able to go thru the settings w/you as your doctor did.

I doubt the DME is going to be real happy about replacing this VPAP. I'm assuming you had to wait whilst they special ordered it for you? But if they will allow you to try another VPAP Auto that would be ideal.

Even if a Resmed mask is not comfortable for you still just to "satisfy" Resmed it would have been best to try this VPAP w/a Resmed mask to see if you still get that "pulse" effect (I don't doubt that you would but at least you can then truthfully tell Resmed it occurs w/their masks too). Its just not a phenomenom I've experienced w/the VPAP Auto. Since Resmed said the VPAP Auto won't work correctly w/a pillows system, try the Resmed Mirago Micro w/it when they are trying to get rid of that "pulse" for you. I think I mentioned it took 2 nights on the VPAP Auto to get that REALLY SMOOTH pressure transition right from the get-go each night. (No setting changes)

jnk · Post by **jnk** » Tue Jul 15, 2008 8:26 am

ResMed's view may be more a matter of brand than the use of pillows. Resmed's VPAP Auto manual lists its Swift and Swift II nasal pillows as being compatible with the VPAP Auto, even in VAuto mode. The manual states as follows:

"Mask Systems
The following ResMed mask systems (supplied separately) are recommended
for use with the VPAP Auto system:
Nasal Masks
• Mirage Vista™ Nasal Mask
• Ultra Mirage™ Nasal Mask
• Ultra Mirage™ II Nasal Mask
• Mirage Activa™ Nasal Mask.
Nasal Pillows Systems
• Mirage Swift™ Nasal Pillows System
• Mirage Swift™ II Nasal Pillows System.
Full Face Masks
• Mirage™ Liberty Full Face Mask
• Mirage™ Quattro Full Face Mask
• Ultra Mirage™ Full Face Mask.
Notes:
• Not all masks are available in all regions.
• In VAuto mode, only ResMed masks are compatible for use with the
VPAP Auto."
[/quote]

Slinky · Post by **Slinky** » Tue Jul 15, 2008 8:56 am

Thanks, jnk, I was too lazy to think to look that up. And for those who like nasal pillows interfaces, I keep hearing good things about that new Swift LT. I'm not a fan of nasal pillows but ....hey, whatever works for each of us is what counts!!

Snoredog · Post by **Snoredog** » Tue Jul 15, 2008 9:16 am

jnk wrote:Is this the passage you are looking for?:

"The TiControl feature . . . allows the clinician to set minimum and maximum limits on the time the device spends in IPAP [inhale pressure]. The minimum and maximum time limits are set at either side of the patient’s ideal spontaneous inspiratory time, providing a ’window of opportunity’ for the patient to spontaneously cycle to EPAP [exhale pressure]. The minimum time limit is set via the Ti Min parameter and the maximum time limit is set via the Ti Max parameter. TiControl’s Ti Max and Ti Min parameters play a significant role in maximizing synchronization by effectively intervening to limit or prolong the inspiratory time when required."

Words in brackets are mine.

that sounds more like the settings for the backup mode?

Does that machine in the auto mode provide you with the spontaneous inspiratory time? It would seem you would set Ti Min and Ti Max on each side of that, then when the machine goes in backup mode it knows what it should be seeing. This is similar to the rise time found on other machines.