VPap III

[elliejose]

I have a friend-neighbor-coworker that I discovered had a cpap that had been sitting in the top of his closet for about a year. I finally convinced the young man to remove the machine from the top of his closet, dust it off and try again. He says his problem seems to be that the machine kicks back in to make him inhale before he finishes the exhale. He has lost weight and gets a lot more exercise now than he did when he was first prescribed the machine and says he breathes much deeper and slower than he did then. He can't afford a new study right now so won't call the M.D. He is using a VPap III and asked me how he could reset this.. I have no idea. I have pulled up the manuals but I'm still not sure what he needs to change. Any help would be appreciated.

Thanks,
Josie

[SleepyDragon]

I use a VPAP III machine. Here is a quote from the clinician manual that may help.

"The TiCONTROL feature is also unique to the VPAP Series. It allows the clinician to set
minimum and maximum limits on the time the ventilator spends in IPAP. 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.

The minimum time limit is set via the IPAP Min Time parameter and the maximum
time limit is set via the IPAP Max Time parameter.

TiCONTROL's IPAP Max and IPAP Min Time parameters play a significant role in
maximising synchronization by effectively intervening to limit or prolong the inspiratory
time when required. This ensures synchronization even in the presence of large mouth
and/or mask leak."

If you PM me an e-mail address I'll send the clinician manual in PDF format. There is a post with a link to it on the Internet, but I don't remember where that is.

[Wulfman]

Don't know if what you need is in here, but Doug has quite a few here.

http://www.internetage.ws/cpapdata/manuals/


Den

[Slinky]

Unfortunately, Josie, when you get into the bi-levels and more technical xPAPs, and the NEED for them, a person needs quite a bit of experience under their belt to understand and play w/the various options to tweak the therapy. They're just NOT as simple and a nice plain ole CPAP w/or w/o Ramp and/or expiration pressure relief options. I've run into too many professionals who aren't even up on the technology of these higher level devices except for the one brand they are used to working with.

Your friend "might" have some luck going back to the local DME supplier he got his VPAP III from and "maybe" they will help him out in some manner, from finding a source for a sleep study to .... whatever. I certainly wish him good luck!!

All that being said, for those drawn to this thread by the subject title who might need or want the Clincians Manual.

http://www.resmed.com/en-us/products/se ... _us_en.pdf

[rested gal]

He says his problem seems to be that the machine kicks back in to make him inhale before he finishes the exhale.

Josie, is he SURE he's talking about more pressure coming back in before he's finished EXhaling? I'm asking, because a bilevel machine should not start the higher inhale pressure (IPAP) until the user himself actually starts to breathe in. As long as he's exhaling, and even during any pause of not breathing after finishing the exhale, the machine should be delivering only the lower EPAP pressure. Even if he holds his breath at the end of the exhalation, the machine should stay down at EPAP pressure. That is, unless he's using a VPAP S/T machine with a timed backup rate set for him, which can make the machine switch back and forth on its own at times.

What SleepyDragon is describing applies to problems when inhaling feels cut off. A very common problem if the length of time IPAP can last is set for too short a time. The Ti settings affect IPAP. There's no setting to affect length of time EPAP can last.

What you say your friend is describing is about his breathing OUT feeling cut off and more pressure coming in at him before he's ready to inhale again. That shouldn't happen, since all bilevels (that don't have a timed back up rate set) are supposed to stay at the EPAP pressure until the person starts to breathe in again.

Perhaps your friend is inadvertently making a mouth, tongue, or throat movement at the end of breathing out that is changing the airflow just enough that the machine interprets it as him starting to inhale, even though he really isn't. Perhaps there's a sensitivity setting that would keep that from being triggered so easily?

[SleepyDragon]

... What SleepyDragon is describing applies to problems when inhaling feels cut off. A very common problem if the length of time IPAP can last is set for too short a time. The Ti settings affect IPAP. There's no setting to affect length of time EPAP can last. ...

Good point, as always, Rested Gal. This makes me think the problem could be Rise Time. If Rise Time is too short it would be felt as being slammed with high pressure at the end of the exhale. By increasing Rise Time he could delay the onset of max pressure until he's ready for it. Thoughts?

[dsm]

EJosie,

Over the past year we have helped several VPAP III users tune their machines. But the only way I know how is if the person interacts with us as we get their settings sorted out.

There is an ability on S/T class machines (timed) to adjust the ratio between inhale:exhale duration. But as Rested Gal says, an S machine is triggered by the users breathing. In the later 'ENHANCED' model of VPAP III, the sensitivity of this triggering can be adjusted. The Enhanced model has 'Enhanced' written on the case & I have a set up guide (hardcopy).

DSM

[jnk]

This sounds like the problem I had with my VPAP III. The default Ti Max time on that machine (a mere 2 seconds) was not long enough for me. So, whenever my sinuses were stopped up at all, I was not finished breathing IN before the machine cycled to the breathing OUT pressure. Increasing Ti Max to 3 seconds solved my problem.

[dsm]

JNK,

Seeing your comment prompted me to look at the data in the clin manual as I have forgotten the relevance & in rereading the data thought it worth posting here as it is quite relevant to mouth leaks (also it corrects a few misunderstandings I had of some of the values) ...

SETTING IPAP MAX
The majority of patients on bilevel therapy experience mouth leaks, especially during
sleep. During mouth leak there may be poor synchronization between patient and
machine breaths which reduces both the comfort and effectiveness of therapy.
The VPAP allows clinicians to specify a maximum IPAP time (ie the time the device
spends delivering the inspiratory pressure during a spontaneous breath). Thus, if a
patient develops mouth leak, VPAP automatically cycles to EPAP after reaching the
maximum time set by the clinician.

Use the equation or table below to calculate a value for IPAP Max. This will generally
ensure the IPAP Max Time is set slightly longer that the patient’s inspiratory time.
IPAP Max time = (60 ÷ patient’s respiratory rate) ÷ 2

Respiratory Rate (BPM) = IPAP Max (seconds)
COL 1.......COL 2
=====.......=====
30 = 1.0 -- 19 = 1.6
29 = 1.0 -- 18 = 1.7
28 = 1.1 -- 17 = 1.8
27 = 1.1 -- 16 = 1.9
26 = 1.2 -- 15 = 2.0
25 = 1.2 -- 14 = 2.1
24 = 1.3 -- 13 = 2.3
23 = 1.3 -- 12 = 2.5
22 = 1.4 -- 11 = 2.7
21 = 1.4 -- 10 = 3.0
20 = 1.5

i.e. for an av resp rate of 15 BPM, the Max Insp would be 2.0

SETTING IPAP MIN
The IPAP Min Time parameter allows the clinician to set a minimum time the patient
spends in IPAP. It allows adjustment of the minimum inspiratory time parameter
ranging from 0.1secs to IPAP Max Time. IPAP Min is usually set to its default setting of
0.1 second.

SETTING RISE TIME
Rise Time is the time taken for the pressure to increase from EPAP to IPAP. Rise Time
can be set to MIN (the fastest or shortest rise time) and 150 up to 900 in 50 unit
increments. This will control the rate of pressure increase when the VPAP switches
from EPAP to IPAP. Generally this feature is adjusted to achieve maximum patient
comfort. The patient should feel that they are receiving adequate flow but not be
startled by each transition to the IPAP level.

The Rise Time scale can be approximately read as ‘milliseconds’ (eg 150 is
approximately 150ms). The actual rise time achieved is influenced by several factors,
such as compliance, resistance, leak, pressure differential, and patient breathing
patterns.

•Rise Time can not be set so that it is longer than the IPAP Max setting (otherwise the
IPAP pressure would never be reached).


DSM

(the manual reminded me that setting risetime is for max comfort )

[dsm]

Also helps clarify re I:E setting (S/T machine only)



DSM

[dsm]

Below are the default & range of values for the settings ...



DSM

[rested gal]

... What SleepyDragon is describing applies to problems when inhaling feels cut off. A very common problem if the length of time IPAP can last is set for too short a time. The Ti settings affect IPAP. There's no setting to affect length of time EPAP can last. ...

Good point, as always, Rested Gal. This makes me think the problem could be Rise Time. If Rise Time is too short it would be felt as being slammed with high pressure at the end of the exhale. By increasing Rise Time he could delay the onset of max pressure until he's ready for it. Thoughts?

That's why I'm asking elliejose to have her friend confirm that this is really what he's talking about:

"He says his problem seems to be that the machine kicks back in to make him inhale before he finishes the exhale."

THAT should not be happening at all...having the EXHALATION feel cut off and more pressure coming back in before the person actually STARTS to INHALE again. I'm really not "shouting"...LOL.. just trying to emphasize the words that are crucial to whether he's really feeling more pressure (the switch to IPAP) happening while he is still exhaling and/or before he actually STARTS to inhale again.

IPAP (the inhale pressure) does have a built in limited amount of time (can be adjusted) for how long the machine can blow "IPAP."

There is no such limit on EPAP (the exhale pressure. EPAP should stay down at EPAP until the cows come home. The trigger for a bilevel that is not a "Timed Back UP rate" machine to go from EPAP to IPAP is the person actually starting to breathe in again.

No bilevel machine (except an S/T type of machine set for a timed backup rate, which is a whole other ballgame) should ever let the IPAP pressure begin happening WHILE a person is exhaling or even if the person pauses (holds their breath) at the end of the exhalation. The non-timed-backup-rate bilevel machine should continue blowing the lower EPAP pressure "forever" ... until the person actually STARTS to breathe in again. Starting to breathe in again is what causes the bilevel machine to switch to the higher IPAP pressure.

During exhalation and AFTER exhalation is finished, the machine should STAY at the lower EPAP level, and stay there, and stay there, and stay there... UNTIL he starts to breathe in again. Only then should the machine switch to IPAP pressure. The switch up to IPAP can be rocky and abrupt, or smooth and almost unnoticeable, depending on how the IPAP Ti control is set. But that has nothing at all to do with how long EPAP can last.

So, I wonder if he does make some kind of hiccupy motion inside his throat or mouth, or take a little fluttery inward inspiratory breath that he isn't even aware of, interrupting his own exhalation...making the machine think that he is, indeed, starting to draw in a new breath... even though he's not quite through exhaling yet.

That's the only reason I can think of that the VPAP (or any other "plain" bilevel machine -- no timed back up rate being used) would switch to the higher IPAP in the midst of his exhalation.

Or... there was a mistake in communication from friend to elliejose to the message board, and the guy meant to say his INhalation felt cut off -- in which case, SleepyDragon's Ti settings discussion would be right on.

Or... the fellow is using a VPAP III S/T, not just a VPAP III -- and the machine is set to operate with a timed backup rate.

If it's a plain VPAP III, without S/T or ST A at the end of the name, what he described to elliejose should not happen.

[jnk]

I agree 100% with rested gal's post.

My experience was that when I was awakened by the sensation of the machine 'going out of sync' with me, my perception of it was that it felt like the machine was triggering IPAP incorrectly, even though it is almost certain that what I was actually experiencing was that the machine was triggering EPAP too early. Indeed, the fact that increasing Ti Max solved my problem indicates that.

The only other scenario I can imagine is that maybe I was also experiencing an extreme intermittent mouth-leak problem at the same time, so that perhaps a sudden change in mouth leak was misinterpreted by the machine as the start of an inspiration. I am not saying for sure that ever actually happened to me. I just remember that it felt to me as if something like that was happening that first night that I used the VPAP III as a total newbie.

Then again, it was a pretty traumatic night for me in many ways, so I may be having false memories as a component of post traumatic stress!

[dsm]

Yesterday Slinky & I were discussing something we have both been experiencing. Slinky on her Vpap & me (back on my Bipap AutoSV) this effect is that at the end of each breath the machine seems to 'pulse' or give a quick 'burst'. Both of us are on spontaneous breathing.

I had previously (dec & jan) been using my Vpap Adapt & only just switched back 2 nights ago to try the Bipap AutoSV again & remembered that I had previously (in oct) adjusted the Bipap machine for a faster rise time (from a setting of 3 to 2 which is the equiv of going from 300 millisecs risetime to a faster 200 millisecs risetime). This faster risetime meant I was being ventilated slightly more but it also introduced the 'pulse/burst' effect that has been occurring and Slinky is experiencing similar.

So last night with the risetime slowed by one setting, the 'pulse' went away & now spontaneous breathing is back to feeling normal and natural. Slinky's Vpap has adjustments for the sensitivity of the 'triggering' and 'cycling' (triggering is switching to Ipap fromepap & cycling is switching from ipap to epap). The ENHANCED Vpap III also has that extra sensitivity adjustment for both triggering & cycling. That combined with risetime setting can alter the sensation of a pulse/burst while inhaling & nearing the end of the inhale. JNK's point re mouth leaks is also an obvious thing that will have an impact. Rested Gal is spot on in saying that in spontaneous mode, the Vpap III should not be switching pressures before the user is ready, but as discussed above and in the prior posts, it can appear that an early switch is happening.

I don't know for sure that the risetime effect is the same issue with Josie's friend but it is an issue that some of us have experienced & again Rested Gal's point is a very good starting point.

#2 One other possibility re early Ipap cycling is if the user has nasal constriction/congestion that forces the user to breath very slowly - that happened to me until I just learned to mouth breathe with ease and to switch between nose & mouth without difficulty. The Vpap III though is very good at tolerating slow breathing - some of the older Bipap models weren't.

Good luck

DSM

[crossfit junkie]

Hi folks,
I'm very new so don't profess to know anything even close to you veterans. I haven't finished reading all the threads here, but, right now I'm on a trial run with a BiPAP, not CPAP, and yes, the same thing was happening to me....it wanted me to start the IN breath before I was ready. We're talking about breathing OUT, and I wanted to breath further and the machine didn't. It started going the other way-up.What did I do? Don't know why it helped , but if you play around with the IPAP MAX, (yes, I don't know why the IPAP would affect the out breath but it did), keep making it LONGER, and get it exactly so, you will not have the problem. It took me 4 hours yesterday to get it right, but I got it right.
CFJ