How Come? Auto Bipap seems to be fighting me.

dllfo · Post by **dllfo** » Tue May 16, 2006 7:45 am

Anyone have a Respironics Auto Bipap "fight" them? Last night, just like the
previous several nights, I went to bed, put my Mirage Swift on and laid down
to go to sleep. It did not happen. No outside worries, pressures, etc. I laid
there for around two hours. Finally I took it off and eventually went to sleep.
I woke up with what MAY be a head cold. My nose was stopped up. BUT it
was not closed when I laid down. I know that.

The machine and I never seemed to be "in synch" last night. I have had a
few instances over the last several days where I went to breathe and it felt
like the machine had "blocked" me. I called Apria and the DME lady told
me she had not really heard much feedback on the Respironics Auto Bipap.

The night before this I slept the best since...who knows....a year?

And please...don't waste your time writing that I MUST wear the mask if I
want to be healthy, etc. Don't bother. I know that. I am asking this group
for thoughtful answers.

WHY would a properly operating Auto Bipap (a week old) block my breathing?
It is obviously not in "rhythm" with me. I was trying very, very hard to breathe in a steady rhythm. I use the words "synch" or "rhythm" for lack of
better terms. The machine and I did NOT work well together.

My wife did comment that the "machine" sounded much louder to her than
on previous nights. After flying many years in KC-135s, I have a huge hearing loss. For me not to hear it is not unusual. So I listen to her.

I asked myself, what did I do different? When I first put the mask on I
noticed my cheeks puffing out. I never noticed that before. When I went
to bed I turned the machine on before I put it on. For maybe a minute?
Maybe less? I let the machine blow some of the "plastic smell" out of the
hose. Maybe it decided I needed higher pressures from that? Actually, I
noticed my cheeks pushing out after I had been wearing it awhile.
I almost had to make a conscious effort to "hold" my cheeks in a normal position. Again, too much pressure?

Anyway, I know I need to wear it. We all know that. So why am I out of
synch with the machine?

1. The machine is malfunctioning? It is a week old.
2. I am coming down with a "head cold" and the machine was fighting the
congestion, so it HAD to use more pressure? (5-25cm is the setting)
3. I do not have my heated humidifier yet. I did notice a discomfort and
the air felt cold...harsh at least once last night.
4. Without it, regardless of any damage to my body or the universe, I slept
fromabout 1:15am to about 6am. And you are right, I do NOT feel as
fresh and rested. I still feel ....uh...tired? A little cranky. Irritable.
5. It is set on auto. I don't know how to change anything on it. And I don't
remember getting an owner's manual. Maybe the auto should be set
from 5-25 to 5-18 or something??? I am brainstorming.

Any ideas?

_________________

CPAPopedia Keywords Contained In This Post (Click For Definition): respironics, bipap, humidifier, mirage, hose, swift, DME, auto

NightHawkeye · Post by **NightHawkeye** » Tue May 16, 2006 9:07 am

Welcome to the Respironics-screwed-up-algorithm club, Dave. DSM and I seem to be the out-spoken ones here who have problems with the Respironics BiPAP algorithm in a manner similar to what you are describing.

I could get real long-winded in my answer, but since I'm at work now, I'll avoid that, and just say that the key to solving it is as follows:
1) You have to minimize your leaks. For me this means that my nasal pillows cannot be perceptibly leaking. If I experience a perceptible leak, then I usually have problems.
2) When the machine has gone out-of-control, I've had much better luck shutting it off and starting over than trying to re-sync.

Going to fixed BiPAP therapy also has reduced the problem to insignificance for me. Monitoring with the software will also provide you with useful insights about how well you are doing in minimizing this problem.

Before anyone flames me, I am not saying that the Respironics algorithm doesn't work, and I'm not saying it's a bad algorithm. I am saying though that the algorithm is not always stable, and it is a design flaw that Respironics needs to deal with.

You've still got a good machine, Dave. But it's not perfect. Before returning the machine, you might want to go to fixed BiPAP mode, because that is the best you can do with any of the competing machines. Plus, you'll still have Bi-flex with your current machine, another feature that the competition cannot provide. Like I said, you've still got a good machine, but you could say it's got a few warts. (BTW, if I wasn't clear earlier, swapping the machine out for another BiPAP-auto won't fix the problem, because it's a software problem.)

Regards,
Bill

PS: You can get your DME to change settings or you can enter Provider mode yourself as follows:
- remove power cable at rear of unit
- depress the two buttons below display while reconnecting power
- keep buttons depressed for at least five seconds until the unit enters Provider mode (it will beep - but some of us can't hear the beep)
- you can scroll through Provide mode using the same two arrow buttons
- to change any of the selections use the HEATER and RAMP buttons

Guest · Post by **Guest** » Tue May 16, 2006 9:35 am

OK Bill,

I was hoping the machine was not "bad".

I asked Apria about replacement of machine, warranty, etc. yesterday and the
lady said they would give me a new machine if this one malfunctions, so that
is encouraging to hear. Encouraging to the fact they won't be fighting me on
everything.

Software problem? "Al Gore Rhythms" huh? Well, I will try all you suggested
when I try for a nap this afternoon.

I know the machine worked pretty well for a few days, then the problems last
night....it just didn't make sense.

My heated humidifier will be here today, so that should help the sore throat.

thanks again...

dllfo · Post by **dllfo** » Tue May 16, 2006 10:20 am

That last post.....saying Guest.....was me...dllfo.....from my laptop. I guess
I did not log in.

Anyway, Bill.......does the software and card reader give you enough info to
understand this algorithm problem?

I think you said you get away from the auto function to solve it.

I am going to try a nap in a few minutes......see if I can use it then.

NightHawkeye · Post by **NightHawkeye** » Tue May 16, 2006 11:04 am

dllfo wrote:Anyway, Bill.......does the software and card reader give you enough info to understand this algorithm problem?

It can show you if the pressure is running away, for instance, and it can tell you what your titration pressure normally is (not the sleep lab titration value). It sounds like run-away pressure may be part of what you are experiencing, since you stated that an objective observer (your wife) said the machine was louder.

dllfo wrote:I think you said you get away from the auto function to solve it.

That's one way, if you are ready to use fixed pressure. Probably, the better thing to try first is to limit the maximum pressure to your titration pressure to keep the machine from running away on you.

dllfo wrote:I am going to try a nap in a few minutes......see if I can use it then.

Remember to keep leaks to a minimum.

Regards,
Bill

Guest · Post by **Guest** » Tue May 16, 2006 1:01 pm

NightHawkeye wrote:Welcome to the Respironics-screwed-up-algorithm club, Dave. DSM and I seem to be the out-spoken ones here who have problems with the Respironics BiPAP algorithm in a manner similar to what you are describing.

Before anyone flames me, I am not saying that the Respironics algorithm doesn't work, and I'm not saying it's a bad algorithm. I am saying though that the algorithm is not always stable, and it is a design flaw that Respironics needs to deal with.

I've come to flame! Ok not really. I wonder about your contention this is a design flaw. If it were a true 'flaw' - which I take to be synonymous with 'defect' - wouldn't it happen to everyone? Wouldn't there have been a recall over the past years or a new version produced with the "flaw" fixed? Wouldn't there be some documentation somewhere about it?

I never gave this issue much thought, but it's a subject that's hard to avoid here at cpaptalk from a couple of people. (As with any product, you don't hear much from the satisfied customers, but you hear a lot from the ones who have a complaint.)

It seems to me the million dollar question is whether or not this is a flaw, or if this is one of those cases where a particular individual's breathing patterns are not well-suited to the particular manufacturer's algorithms. Those algorithms can't be all things to all people all the time. Algorithms are set up by each manufacturer based on their research of what will effectively treat the majority of typical-breathing-pattern users, right? Not everyone is typical, so not everyone will see the same results. But does this mean it's a design flaw? Or does this mean it can't be all things to all people, and once in a while someone will find it doesn't work for them.

And as long as I'm asking about this, do you think we'll ever know the true answer to the "flaw/not a flaw" debate? Or will it just remain a matter of opinion?

NightHawkeye · Post by **NightHawkeye** » Tue May 16, 2006 1:33 pm

Guest wrote:I've come to flame! Ok not really. I wonder about your contention this is a design flaw.

Well, I suppose since we're down to semantics now . . .

In the design world we sometimes jokingly refer to "flaws" as "features", so maybe I should refer to this run-away pressure phenomenon as a "feature". Respironics could even have this feature listed in their sales brochures as a specially crafted algorithm designed to punish the user if he/she has allowed any leaks to occur in the interface. Or, maybe, semantically speaking, it would be more useful to sell this as a reward "feature", rather than punishment, to encourage minimal mask leaks.

Hope this helps clarify.

Regards,
Bill

Guest · Post by **Guest** » Tue May 16, 2006 1:53 pm

NightHawkeye wrote:In the design world we sometimes jokingly refer to "flaws" as "features", so maybe I should refer to this run-away pressure phenomenon as a "feature". Respironics could even have this feature listed in their sales brochures as a specially crafted algorithm designed to punish the user if he/she has allowed any leaks to occur in the interface. Or, maybe, semantically speaking, it would be more useful to sell this as a reward "feature", rather than punishment, to encourage minimal mask leaks.

LOL!

NightHawkeye wrote:Hope this helps clarify.

Not really, but thanks for that great example of 'design-world' humor!

I guess we'll never know if it's a design flaw or the fact that it's impossible for the algorithms to get everybody right, but I thought it was a question worth asking.

rested gal · Post by **rested gal** » Tue May 16, 2006 1:58 pm

dllfo, with all due respect to NightHawkeye, who gives some very good advice...just because a few people say they think there is an inherent algorithm problem in some machines by a particular manufacturer, I'd take that with a grain of salt.

It's very true that some machines and/or some settings don't suit some people as well as others, but that doesn't mean there's a "screwed up algorithm" at fault.

As an example...the factory default of IFL1 being "On" in Puritan Bennett autopaps mistreats me, but I don't start pounding away that there is a flaw in that manufacturer's algorithms. Having that trigger on doesn't suit me or a few others, but apparently works fine for MOST people who use the 420E. The 420E is my machine of choice, btw...I use it every night...with IFL1 "off", of course. Great treatment for me.

In your case, I'm betting your machine is working fine and suits you very well. Why do I think that? Because you mentioned these things:

A. I know the machine worked pretty well for a few days, then the problems last night.

B. The night before this I slept the best since...who knows....a year?

I think the real clues to what caused your bad night are in the additional info you provided here:

C. I woke up with what MAY be a head cold. My hose [typo for "nose", I'm guessing] was stopped up. BUT it was not closed when I laid down.

It's very common to have a clear nose while sitting up, then have one or the other nasal passage get congested after a few minutes of lying down. It's also common during the night for stuffiness to switch from one nostril to the other, back and forth.

The congestion you experienced that night is also very common when not using heated humidification. And if a person did happen to have a mild cold or anything else (allergies acting up, for example) that could cause stuffy nasal passages, the lack of heated humidification could very well exacerbate the congestion problem.

At any rate, even if there is no head cold or allergy at play, and even if you normally do not have stuffiness, your nasal passage may have finally rebelled on that night.

You may have been doing just fine without benefit of heated humidification for the first days or week, but as your nasal passages kept getting dried out, night after night, they may have finally become congested when that cold, dry air hit them yet again on the night of the problem. Kind of like the straw that broke the camel's back.

D. I noticed my cheeks pushing out after I had been wearing it awhile. I almost had to make a conscious effort to "hold" my cheeks in a normal position.

It's very possible the machine was having to use more pressure than usual on you, if not enough air was able to get through congested nasal passages.

It also sounds to me as if you were well on the way to the dreaded mouth air leaks. CPAP air detouring into the mouth and puffing the cheeks out is a sign you were just one step away from air blowing out your mouth. You were awake when you were noting your cheeks puffing out with air held in your mouth. You can imagine what happens when you relax in sleep and the tongue drops away from its natural sealing position inside the mouth.

Air gushing out the mouth can certainly interfere with any bi-level machine or auto-titrating machine doing its job. Even if you were using a straight cpap machine, mouth air leaks can wreck treatment. The air's gotta go down to hold the throat open...not detour out into the bedroom.

NightHawkeye is absolutely right about the need to deal with possible leaks. That's true to get good treatment with any xpap machine. You might need to tweak the settings some more, but I wouldn't worry at this point about the machine being faulty or having "screwed up" algorithms.

When your nasal passages are clear, perhaps you won't normally have a mouth air leak problem at all; but on that particular night, if nasal stuffiness while you were lying down was making breathing difficult, you might have begun gasping for air through your mouth during your sleep.

As for the machine getting out of sync with your breathing (a problem you've apparently not had very often until that night) it's also possible that nasal congestion was causing you to sometimes inhale in stutter steps...inadvertently using some quick in/out sniffs occasionally, rather than taking your usual smooth breaths.

An interruption, even an extremely brief one, in the progress of an inhalation (like a quick sniff in/out) can make any bi-level machine think you are starting to exhale...it will drop the pressure for that. That could certainly give you the feeling that the machine was blocking you.

E. I do not have my heated humidifier yet. I did notice a discomfort and the air felt cold...harsh at least once last night.

Bingo.

I liked NightHawkeye's definition of a "feature"...good one, NHe !!

sthnreb · Post by **sthnreb** » Tue May 16, 2006 2:44 pm

I have had the Auto Bipap since November of last year, shortly after it first came out. You really have to get it set up correctly for it to operate right for you. I found I had to run the lowest Epap level up to my Rx Epap setting or it would actually act like a ramp feature starting to slow for me. The high or Ipap can be several cm's above your test Rx. Mine was 12/8 so I have the high set at 18. Also adjusting the biflex or the time it takes to swap from Ipap to Epap helps. I set the maximum difference of Ipap/Epap at 4 as per my Rx. If when you first put the mask on and it swaps to Ipap when in Epap, try taking deep breathes and exhaling (in the mask) until the machine matches your breathing and then you can breath normally. Puffy cheeks means you are not closing your throat and letting the air blow into your mouth, which will eventually cause leaks and make the machine maybe "erratic" as you say. Mine has never gone wild as described. Read your uses/providers manuals for what each function does and adjust them accordingly. It is a good machine. I feel qualified to say that because it is my third Bipap. Hope this helps a little too.

dsm · Post by **dsm** » Tue May 16, 2006 3:02 pm

Re talking about 'flaws' in xPAPs

There have been many stupid exchanges taking place between us on this matter, over recent months.

Enough is enough !.

If someone comes to cpaptalk and describes problems with their machines please let them do so without intimidation or badgering.

Let the person have their say. Most people *are* intelligent enough to weigh up the issues for them selves.

Let the regulars have their say (such as in this case Bill).

I am bluntly accusing those who repeatedly 'jump' on anyone who dares criticize the way a particular machine works as taking the 'Pollyanna' approach to looking at possible machine problems. It wouldn't be so bad if these Pollyannas put up reasonable discussion points in support of a contrarian view but too often the interference is pure Pollyanna.

As we all know the celluloid character Pollyanna could see no wrong in anything no matter how wrong it was.

So please just let the discussions flow & allow the followers to form their own conclusions and will the Pollyannas of this board please just go bake cookies for a while!. There are times discussions should be allowed to take their natural course.

Said !!!

DSM

Guest · Post by **Guest** » Tue May 16, 2006 4:02 pm

dsm wrote:If someone comes to cpaptalk and describes problems with their machines please let them do so without intimidation or badgering.

Well said, dsm. I'd add to that: if someone comes to cpaptalk and describes problems with their machine we should offer suggestions to help them. Further, we should do so without intimidating or badgering them into thinking their problem indicates there is a flaw or defect in their machine.

sthnreb wrote:I have had the Auto Bipap since November of last year, shortly after it first came out. You really have to get it set up correctly for it to operate right for you. I found I had to run the lowest Epap level up to my Rx Epap setting or it would actually act like a ramp feature starting to slow for me. The high or Ipap can be several cm's above your test Rx. Mine was 12/8 so I have the high set at 18. Also adjusting the biflex or the time it takes to swap from Ipap to Epap helps. I set the maximum difference of Ipap/Epap at 4 as per my Rx. If when you first put the mask on and it swaps to Ipap when in Epap, try taking deep breathes and exhaling (in the mask) until the machine matches your breathing and then you can breath normally. Puffy cheeks means you are not closing your throat and letting the air blow into your mouth, which will eventually cause leaks and make the machine maybe "erratic" as you say. Mine has never gone wild as described. Read your uses/providers manuals for what each function does and adjust them accordingly. It is a good machine. I feel qualified to say that because it is my third Bipap. Hope this helps a little too.

Appreciate the input, sthnreb. Now that was actually helpful.

We are all entitled to our opinions. If someone makes a statement I believe is erroneous or misleading, I will continue to speak up and say so. Nothing personal, no name-calling, no euphemisms, no accusations.

It goes something like this:

Reply from Jane Doe: I think the problem you're describing indicates the machine has a flaw or defect.

Reply from John Doe: I don't think this problem means the machine has a flaw or defect. I suggest you try....

shtnreb's reply is a perfect example of this.

So please just let the discussions flow & allow the followers to form their own conclusions. There are times discussions should be allowed to take their natural course. Nothing personal, no name-calling, no euphemisms, no accusations.

dsm · Post by **dsm** » Tue May 16, 2006 4:19 pm

NO!

There are too many times when legitimate discussion on odd behavior of machines is jumped on and squashed!.

The opposite view Guest is that if there are problems in the algorithms they should be discussed - there are 2 ways to look at this.

1) That machines have no problems (the pollyanna view)

2) That there are issues with some machines & people should be allowed to express this view if their investigations show it

The Pollyanna view has thus far been used to kill discussions on machine issues esp on Respironics machines for some reason or other.

It is not a very good argument to say "oh my machine doesn't do that, so I think you are wrong".

For heaven's sake let the people talking about problems get it all out - yes, ask them questions about the environment & if you have the grounds to lead them to a legitimate conclusion than do so but please don't take the stupid approach that there are no problems because 'I' can't see them !!!!!.

DSM

Linda3032 · Post by **Linda3032** » Tue May 16, 2006 4:30 pm

Wow DSM,

I'm not really sure who your "Pollyana" is, but I sure hope you are NOT referring to RG. Because she is one of the most helpful, most knowledgeable, posters on this board. Plus, she is also the MOST polite. Her post was very respectful to Nighthawkeye in offering her "take" on the situation.

RG is the first to admit she is not an "engineer", nor has the most technical information here. But she is very knowledgeable about the causes and affects of cpap problems. The military has a saying KISS - keep it simple stupid. And my guess would be that the majority of the problems that newbies experience are "grass root" problems that can be solved by "the basics". Why worry about rocket science when you are trying to fix a lawn mower?

DSM, you talk about "stupid exchanges"? I don't think our "Pollyana" would ever have written such insulting words.

dsm · Post by **dsm** » Tue May 16, 2006 4:39 pm

Linda,

yes I am feeling a bit hot under the collar.

RG is someone I have had the greatest respect for - her tireless efforts her breadth of knowledge & her commitment to helping people.

But there are times (repeated) when any attempts to explore odd behaviour in machines gets squashed - there are various techniques.

I am saying that we need to let threads that may highlight possible problems, go their natural course. By this I mean let the person with the issue explain it in their best detail. But the norm is to immediately squash *any* criticism of algorithms.

That is what I am against because it never allows the issues to reach a fair conclusion.

DSM

Machine

Additional Comments: Resmed AirCurve 10 VAuto BiLevel with HumidAir