dsm wrote:Snoredog,Snoredog wrote:The AdaptSV doesn't respond with increased EPAP in the presence of obstructive events does it?dsm wrote:EncorePro outputs reports in pdf format as a standard feature.
If you can get me one of your reports I'd like to have a look at it.
Just off the top of my head the epap of 5 seems very low by any standards even if you have no OSA component at all.
My 1st question though is this . Does your PSG say you had any OSA in the sleep study ? if yes then someone may well have set your machine up incorrectly. But that PSG data is important to determine these matters.
My 2nd Question is are you overweight ? - if yes then the 30CMs suggest the doc thinks you are quite overweight. If you aren't then I would be interested in why the RT set IpapMAX so very high.
Cheers & good luck
DSM
As I understood it, it was static from where you set it and only IPAP and other parameters adjusted automatically to SDB events.
Yup the BipapSV requires the RT to tune for OSA as the 1st as part of the titration. If OSA is detected it is ironed out 1st with Epap pretty much as you described. The IpapMAX is used to apply rapid pressure (can increase my several CMs in one single breath).
The machine tracks Peak Flow & seeks to maintain that withing a tracked value plus tracks breathing rate & seeks to maintain that (as SWS described).
This presentation covers the aspects pretty well (see chart 15)
http://www.internetage.com/cpapdata/dsm ... -preso.pdf
Cheers
DSM
respironics autoSV & new software - why AHI so high?
someday science will catch up to what I'm saying...
What makes this case interesting is that there is no reported periodic breathing & thus a Bipap S/T would address OSA + Centrals.
What is unclear to me though is just how the BipapSV treats centrals - this aspect is not well clarified in any docs.
The usual Bipap S/T method of controlling Centrals is to
1) Titrate for OSA & set Epap
2) Adjust INSP to set a max inhale time
3) Set a backup rate that ensures the sleeper breathes at least that many BPM
But if the sleeper fails to meet the back-up rate then the machine cycles from epap to ipap to epap to ipap at that rate until the sleeper starts driving the rate again
But with the BipapSV, there is the added IpapMAX & this is where it differs.
If someone has a central, then they will probably be at a low peak-flow target.
The machine is tracking 2 aspects of the sleeper, the peak flow & the rate (or if set back-up rate).
But, when a central occurs, the machine will be triggered to cycle to Ipap by the lack of airflow. But it appears it will disable the Peak Flow tracking for this cycle as the machine is now driving the sleeper - this ois the part that is not clear from the docs. If for example the sleeper doesn't breathe spontaneously after the 1st central is dealt with, does the machine up the pressure for the 2nd go ? - by inference the docs say no.
If the Epap to Ipap gap is set too low then the Epap-Ipap-Epap-Ipap cycling may not be very effective at getting the sleeper breathing again.
In the case of periodic breathing, the machine has no hesitation in whacking up the pressure very high very quickly. 30 CMs is one hell of a high CMs to be applying to anyone.
I may try some tests to see what the pressure does if I simulate centrals.
DSM
What is unclear to me though is just how the BipapSV treats centrals - this aspect is not well clarified in any docs.
The usual Bipap S/T method of controlling Centrals is to
1) Titrate for OSA & set Epap
2) Adjust INSP to set a max inhale time
3) Set a backup rate that ensures the sleeper breathes at least that many BPM
But if the sleeper fails to meet the back-up rate then the machine cycles from epap to ipap to epap to ipap at that rate until the sleeper starts driving the rate again
But with the BipapSV, there is the added IpapMAX & this is where it differs.
If someone has a central, then they will probably be at a low peak-flow target.
The machine is tracking 2 aspects of the sleeper, the peak flow & the rate (or if set back-up rate).
But, when a central occurs, the machine will be triggered to cycle to Ipap by the lack of airflow. But it appears it will disable the Peak Flow tracking for this cycle as the machine is now driving the sleeper - this ois the part that is not clear from the docs. If for example the sleeper doesn't breathe spontaneously after the 1st central is dealt with, does the machine up the pressure for the 2nd go ? - by inference the docs say no.
If the Epap to Ipap gap is set too low then the Epap-Ipap-Epap-Ipap cycling may not be very effective at getting the sleeper breathing again.
In the case of periodic breathing, the machine has no hesitation in whacking up the pressure very high very quickly. 30 CMs is one hell of a high CMs to be applying to anyone.
I may try some tests to see what the pressure does if I simulate centrals.
DSM
xPAP and Quattro std mask (plus a pad-a-cheek anti-leak strap)
Snoredog,
Re shallow breathing - this machine seems to address it very well. The thing I have noticed above all is that my SpO2 data is remarkably consistent compared to all prior SpO2 data gathered from most other types of machines.
There is less fluctuation through the night & pulse is far more consistent.
Prior to a week ago, the machine regularly would to go to my IpapMAX of 20 CMs (typically 12-16 times per night) but since you posted that explanation of silent GERD, I went to my doc & got him to agree to double my dose of GERD med to 1 tablet in am & 1 in PM & since then the machine whilst still raising pressure, now rarely hits IpapMAX. Last night it did but I had a backache from lifting heavy stuff the day before.
What this is telling me is that GERD & silent GERD may play havoc with people's OSA therapy & many may never quite realize it. If it proves to be the cause in my case then it has taken me 3 years to get to the realization.
I am more than impressed with the tuneability of this machine.
DSM
Re shallow breathing - this machine seems to address it very well. The thing I have noticed above all is that my SpO2 data is remarkably consistent compared to all prior SpO2 data gathered from most other types of machines.
There is less fluctuation through the night & pulse is far more consistent.
Prior to a week ago, the machine regularly would to go to my IpapMAX of 20 CMs (typically 12-16 times per night) but since you posted that explanation of silent GERD, I went to my doc & got him to agree to double my dose of GERD med to 1 tablet in am & 1 in PM & since then the machine whilst still raising pressure, now rarely hits IpapMAX. Last night it did but I had a backache from lifting heavy stuff the day before.
What this is telling me is that GERD & silent GERD may play havoc with people's OSA therapy & many may never quite realize it. If it proves to be the cause in my case then it has taken me 3 years to get to the realization.
I am more than impressed with the tuneability of this machine.
DSM
Last edited by dsm on Sat Jul 12, 2008 9:12 pm, edited 1 time in total.
xPAP and Quattro std mask (plus a pad-a-cheek anti-leak strap)
how to acess providers menu for pressure changes?
I'm not overweight and did have OSA and some centrals during my sleep study. During the titration, CPAP made the centrals much worse.
Unfortunately I won't have time to digest all this great info and observations today. I won't be back till late tonight and hopefully I can get my EPAP adjusted.
Can anyone with the respironics autoSV suggest why the simultaneously pressing of both arrows won't access the providers menu?
thanks again everyone
Unfortunately I won't have time to digest all this great info and observations today. I won't be back till late tonight and hopefully I can get my EPAP adjusted.
Can anyone with the respironics autoSV suggest why the simultaneously pressing of both arrows won't access the providers menu?
thanks again everyone
This link is helpful in understanding just what the BipapSV can do.
Note that it states that OSA baseline gets established 1st (unless already done before) and also note that it 'advises' setting IpapMAX no more than 10 CMs gap above IpapMIN (so 30 CMs max (20CMs gap) has me wondering what the RT was up to).
The 5 CMs for Eap seems far too low for anyone who has had a baseline titration & has OSA. I don't think I have ever heard of anyone getting an Epap of 5CMs out of a study that shows OSA.
http://bipapautosv.respironics.com/faq.aspx
DSM
I am left suspicious that the RT doesn't understand that the Epap is a static setting & might be thinking it works like the BipapAuto (Biflex model). It has always struck me that the names of the two machines were so similar that people were going to confuse them and the functions & the settings. That is what I am thinking may have occurred here. Epap=5 seems ridiculous.
_________________
CPAPopedia Keywords Contained In This Post (Click For Definition): Titration
Note that it states that OSA baseline gets established 1st (unless already done before) and also note that it 'advises' setting IpapMAX no more than 10 CMs gap above IpapMIN (so 30 CMs max (20CMs gap) has me wondering what the RT was up to).
The 5 CMs for Eap seems far too low for anyone who has had a baseline titration & has OSA. I don't think I have ever heard of anyone getting an Epap of 5CMs out of a study that shows OSA.
http://bipapautosv.respironics.com/faq.aspx
DSM
I am left suspicious that the RT doesn't understand that the Epap is a static setting & might be thinking it works like the BipapAuto (Biflex model). It has always struck me that the names of the two machines were so similar that people were going to confuse them and the functions & the settings. That is what I am thinking may have occurred here. Epap=5 seems ridiculous.
_________________
CPAPopedia Keywords Contained In This Post (Click For Definition): Titration
Last edited by dsm on Sat Jul 12, 2008 9:01 pm, edited 1 time in total.
xPAP and Quattro std mask (plus a pad-a-cheek anti-leak strap)
Re: how to acess providers menu for pressure changes?
[quote="kolchak"]I'm not overweight and did have OSA and some centrals during my sleep study. During the titration, CPAP made the centrals much worse.
Unfortunately I won't have time to digest all this great info and observations today. I won't be back till late tonight and hopefully I can get my EPAP adjusted.
Can anyone with the respironics autoSV suggest why the simultaneously pressing of both arrows won't access the providers menu?
thanks again everyone
Unfortunately I won't have time to digest all this great info and observations today. I won't be back till late tonight and hopefully I can get my EPAP adjusted.
Can anyone with the respironics autoSV suggest why the simultaneously pressing of both arrows won't access the providers menu?
thanks again everyone
Last edited by dsm on Sat Jul 12, 2008 6:12 pm, edited 1 time in total.
xPAP and Quattro std mask (plus a pad-a-cheek anti-leak strap)
Re: how to acess providers menu for pressure changes?
[quote="kolchak"]I'm not overweight and did have OSA and some centrals during my sleep study. During the titration, CPAP made the centrals much worse.
Unfortunately I won't have time to digest all this great info and observations today. I won't be back till late tonight and hopefully I can get my EPAP adjusted.
Can anyone with the respironics autoSV suggest why the simultaneously pressing of both arrows won't access the providers menu?
thanks again everyone
Unfortunately I won't have time to digest all this great info and observations today. I won't be back till late tonight and hopefully I can get my EPAP adjusted.
Can anyone with the respironics autoSV suggest why the simultaneously pressing of both arrows won't access the providers menu?
thanks again everyone
someday science will catch up to what I'm saying...
Re: how to acess providers menu for pressure changes?
To change settings push down the 'silence' key & the right arrow
THANK YOU !!!!!! That was the only combo I didn't try.....not sure why the manual states pushing the left & right arrow keys though.
THANK YOU !!!!!! That was the only combo I didn't try.....not sure why the manual states pushing the left & right arrow keys though.
The tech originally set the machine according to his understanding of the Dr’s prescription, which was confusingly written as 9/19 & EEP @ 5. The tech set both min & max IPAP to 19 and decided EEP @ 5 was the BPM setting.
I immediately knew this was wrong and changed the settings to 10, 30 and 5 assuming EEP @ 5 was the EPAP setting. Instead of following the golden rule about max IPAP = min IPAP + 10, I used 30. I figured if 30 cm’s is required to quell a central, why not?
In addition to increasing my EPAP as discussed, I’ll also lower my max IPAP back to 19 or 20 as the good Dr. intended.
Thanks again for your help guys and I’ll be sure to post the results of these corrections.
I immediately knew this was wrong and changed the settings to 10, 30 and 5 assuming EEP @ 5 was the EPAP setting. Instead of following the golden rule about max IPAP = min IPAP + 10, I used 30. I figured if 30 cm’s is required to quell a central, why not?
In addition to increasing my EPAP as discussed, I’ll also lower my max IPAP back to 19 or 20 as the good Dr. intended.
Thanks again for your help guys and I’ll be sure to post the results of these corrections.
[quote="kolchak"]The tech originally set the machine according to his understanding of the Dr’s prescription, which was confusingly written as 9/19 & EEP @ 5. The tech set both min & max IPAP to 19 and decided EEP @ 5 was the BPM setting.
I immediately knew this was wrong and changed the settings to 10, 30 and 5 assuming EEP @ 5 was the EPAP setting. Instead of following the golden rule about max IPAP = min IPAP + 10, I used 30. I figured if 30 cm’s is required to quell a central, why not?
In addition to increasing my EPAP as discussed, I’ll also lower my max IPAP back to 19 or 20 as the good Dr. intended.
Thanks again for your help guys and I’ll be sure to post the results of these corrections.
I immediately knew this was wrong and changed the settings to 10, 30 and 5 assuming EEP @ 5 was the EPAP setting. Instead of following the golden rule about max IPAP = min IPAP + 10, I used 30. I figured if 30 cm’s is required to quell a central, why not?
In addition to increasing my EPAP as discussed, I’ll also lower my max IPAP back to 19 or 20 as the good Dr. intended.
Thanks again for your help guys and I’ll be sure to post the results of these corrections.
someday science will catch up to what I'm saying...
[quote="kolchak"]The tech originally set the machine according to his understanding of the Dr’s prescription, which was confusingly written as 9/19 & EEP @ 5. The tech set both min & max IPAP to 19 and decided EEP @ 5 was the BPM setting.
I immediately knew this was wrong and changed the settings to 10, 30 and 5 assuming EEP @ 5 was the EPAP setting. Instead of following the golden rule about max IPAP = min IPAP + 10, I used 30. I figured if 30 cm’s is required to quell a central, why not?
In addition to increasing my EPAP as discussed, I’ll also lower my max IPAP back to 19 or 20 as the good Dr. intended.
Thanks again for your help guys and I’ll be sure to post the results of these corrections.
I immediately knew this was wrong and changed the settings to 10, 30 and 5 assuming EEP @ 5 was the EPAP setting. Instead of following the golden rule about max IPAP = min IPAP + 10, I used 30. I figured if 30 cm’s is required to quell a central, why not?
In addition to increasing my EPAP as discussed, I’ll also lower my max IPAP back to 19 or 20 as the good Dr. intended.
Thanks again for your help guys and I’ll be sure to post the results of these corrections.
xPAP and Quattro std mask (plus a pad-a-cheek anti-leak strap)
[quote="Snoredog"][quote="kolchak"]The tech originally set the machine according to his understanding of the Dr’s prescription, which was confusingly written as 9/19 & EEP @ 5. The tech set both min & max IPAP to 19 and decided EEP @ 5 was the BPM setting.
I immediately knew this was wrong and changed the settings to 10, 30 and 5 assuming EEP @ 5 was the EPAP setting. Instead of following the golden rule about max IPAP = min IPAP + 10, I used 30. I figured if 30 cm’s is required to quell a central, why not?
In addition to increasing my EPAP as discussed, I’ll also lower my max IPAP back to 19 or 20 as the good Dr. intended.
Thanks again for your help guys and I’ll be sure to post the results of these corrections.
I immediately knew this was wrong and changed the settings to 10, 30 and 5 assuming EEP @ 5 was the EPAP setting. Instead of following the golden rule about max IPAP = min IPAP + 10, I used 30. I figured if 30 cm’s is required to quell a central, why not?
In addition to increasing my EPAP as discussed, I’ll also lower my max IPAP back to 19 or 20 as the good Dr. intended.
Thanks again for your help guys and I’ll be sure to post the results of these corrections.
xPAP and Quattro std mask (plus a pad-a-cheek anti-leak strap)
Actually it is a valid part of the titration guide, it takes you down a flow chart starting with CPAP and observing Central (2nd page of guide) then the procedure steps you would go through to get to the Bipap mode then switch to AdaptSV.dsm wrote: Snoredog,
That titration guide (BiapSV) is a bit ambiguous - at one point it says to set C-Flex !!! - that sure isn't a feature of the BipapSV
I think it is very very generic perhaps taken from a standard cpap titration process. I am certain though that months back I saw a guide that did make sense for the BipapSV so am puzzled that the current one is so incomplete and not at all like the one I recall.
DSM
So the CPAP chart and reference of it is included for steps to obtain obstructive pressure needed to set EPAP setting and observe for Centrals.
If you follow that guide, you follow the procedure steps needed to also satisfy insurance requirements for coverage should they question the medical necessity or need.
someday science will catch up to what I'm saying...
I agree that the C-Flex part of the titration protocol serves the following scenario: that the patient may not need BiPAP autoSV. In that case Respironic$ presumably wants to impart the patient with one of their proprietary machine$ anyway.
A couple interesting observations about the Respironics SV titration flowchart found at: http://global.respironics.com/UserGuide ... 042977.pdf
Page 2 of 4 describes the standard CPAP titration steps. However, that page does not go into any detail whatsoever about the steps involved in a BiPAP S titration.
Page 3 of 4 describes only the steps necessary for adding SV modality to CPAP. Note the reiterative procedures always keep EPAP equal to IPAP min. That's clearly SV modality applied to CPAP---not BiPAP.
Again, note on page 3 of 4 that the steps for adding SV modality to BiPAP (as opposed to CPAP) are not even delineated on that flow chart. However, according to the Respironics FAQ preliminary BiLevel titration protocols can be applied toward SV modality as well.
Resmed wants the obstructive component of SDB completely addressed by EEP. Note that requirement probably has to do with the "sawtooth" rate of inspiratory attack of the Resmed IPAP waveform.
By contrast Respironics allows for SV modality to be applied after a standard BiLevel S titration. And a standard BiLevel S titration allows for obstructive apnea elimination during EPAP with obstructive hypopnea elimination allowed during IPAP. Because the inspiratory pressure wave shape here is not a gradually increasing sawtooth (like Resmed's inspiratory sawtooth) some obstruction can implicitly be addressed during IPAP.
Nowhere in the Respironics literature is a requirement imparted to eliminate the entire obstructive component exclusively with EPAP (standard BiLevel titration protocols for obstruction are even allowed). By contrast Resmed ASV titration protocol asks that the obstructive component be eliminated with EEP.
The other interesting observation is that the Respironics SV flowchart exclusively highlights a modality option currently not available on the Resmed ASV model: SV modality applied to CPAP.
A couple interesting observations about the Respironics SV titration flowchart found at: http://global.respironics.com/UserGuide ... 042977.pdf
Page 2 of 4 describes the standard CPAP titration steps. However, that page does not go into any detail whatsoever about the steps involved in a BiPAP S titration.
Page 3 of 4 describes only the steps necessary for adding SV modality to CPAP. Note the reiterative procedures always keep EPAP equal to IPAP min. That's clearly SV modality applied to CPAP---not BiPAP.
Again, note on page 3 of 4 that the steps for adding SV modality to BiPAP (as opposed to CPAP) are not even delineated on that flow chart. However, according to the Respironics FAQ preliminary BiLevel titration protocols can be applied toward SV modality as well.
Resmed wants the obstructive component of SDB completely addressed by EEP. Note that requirement probably has to do with the "sawtooth" rate of inspiratory attack of the Resmed IPAP waveform.
By contrast Respironics allows for SV modality to be applied after a standard BiLevel S titration. And a standard BiLevel S titration allows for obstructive apnea elimination during EPAP with obstructive hypopnea elimination allowed during IPAP. Because the inspiratory pressure wave shape here is not a gradually increasing sawtooth (like Resmed's inspiratory sawtooth) some obstruction can implicitly be addressed during IPAP.
Nowhere in the Respironics literature is a requirement imparted to eliminate the entire obstructive component exclusively with EPAP (standard BiLevel titration protocols for obstruction are even allowed). By contrast Resmed ASV titration protocol asks that the obstructive component be eliminated with EEP.
The other interesting observation is that the Respironics SV flowchart exclusively highlights a modality option currently not available on the Resmed ASV model: SV modality applied to CPAP.
Last edited by -SWS on Sun Jul 13, 2008 5:59 am, edited 1 time in total.
SWS
I have seen a version of that chart that is different to what is there now - I have a copy at work - if it is quite different, as I recall it to be, it poses some very interesting questions
But, I doubt that anyone would post a file called BipapSV titration, then refer to another model. If they named the manual 'Titration process & machine selection' yes, but that is not the situation here.
PS the clinicians manual has confirmed for me that when BPM = OFF, then the Respironics classic INSP setting appears (I hadn't got round to looking on my machine).
The manual also confirms that the Central mechanism is exactly as it is in the Bipap S/T right down to 3 secs max inspiration.
DSM
#3 - the manual also mentions that under some circumstances, the BipaSV can go up to 40 CMs static pressure !!! That surely is enough to create a michelin man ?
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CPAPopedia Keywords Contained In This Post (Click For Definition): respironics, bipap, Titration
I have seen a version of that chart that is different to what is there now - I have a copy at work - if it is quite different, as I recall it to be, it poses some very interesting questions
But, I doubt that anyone would post a file called BipapSV titration, then refer to another model. If they named the manual 'Titration process & machine selection' yes, but that is not the situation here.
PS the clinicians manual has confirmed for me that when BPM = OFF, then the Respironics classic INSP setting appears (I hadn't got round to looking on my machine).
The manual also confirms that the Central mechanism is exactly as it is in the Bipap S/T right down to 3 secs max inspiration.
DSM
#3 - the manual also mentions that under some circumstances, the BipaSV can go up to 40 CMs static pressure !!! That surely is enough to create a michelin man ?
_________________
CPAPopedia Keywords Contained In This Post (Click For Definition): respironics, bipap, Titration
Last edited by dsm on Sun Jul 13, 2008 6:29 am, edited 2 times in total.
xPAP and Quattro std mask (plus a pad-a-cheek anti-leak strap)