Dreamstation "SmartRamp" Feature

[thecpapguy!]

ADVANCED AUTO-BiPAP ADJUSTS TO YOUR CHANGING SLEEP NEEDS
The DreamStation BiPAP Auto is an advanced auto-bilevel machine that delivers one distinct higher pressure on inhalation, and a separate lower pressure on exhalation. As you sleep the BiPAP Auto monitors your breathing for flow limitations and adapts to them, automatically adjusting inhalation and exhalation levels to ensure you're receiving the optimum bilevel pressure for a comfortable and successful sleep.

SMARTRAMP MAKES THERAPY EASIER
In addition to the traditional pressure ramp available on most sleep therapy devices, DreamStation Auto BiPAP offers SmartRamp for an easier experience at the onset of sleep. When SmartRamp is enabled the DreamStation BiPAP Auto will monitor your therapy levels, during the ramp period, to deliver lower overall pressure until it detects an obstructive respiratory event. When an event is detected SmartRamp responds to resolve the event, raising pressures as required until the ramp period concludes.

So let me see if I understand. SmartRamp does not wait for the breath to even and slowly begin to ramp to full pressure automatically. It engages the ramp immediately will only allow the ramp to increase once the first apneic is sensed? Basically the same function as the Resmed version of Auto Ramp?

[palerider]

SMARTRAMP MAKES THERAPY EASIER
In addition to the traditional pressure ramp available on most sleep therapy devices, DreamStation Auto BiPAP offers SmartRamp for an easier experience at the onset of sleep. When SmartRamp is enabled the DreamStation BiPAP Auto will monitor your therapy levels, during the ramp period, to deliver lower overall pressure until it detects an obstructive respiratory event. When an event is detected SmartRamp responds to resolve the event, raising pressures as required until the ramp period concludes.

So let me see if I understand. SmartRamp does not wait for the breath to even and slowly begin to ramp to full pressure automatically. It engages the ramp immediately will only allow the ramp to increase once the first apneic is sensed? Basically the same function as the Resmed version of Auto Ramp?

yup, not your average DME.

and, no, that's not how auto ramp works. resmed auto ramp is documented thusly:

Ramp Time can be set to Off, 5 to 45 minutes or Auto. When Ramp Time is set to Auto, the device
will detect sleep onset and then gradually increase from the start pressure to the minimum
treatment pressure at a rate of 1 cm H 2 O per minute. However, if sleep onset is not detected, the
device will reach the target pressure within 30 minutes.

and, yes, typical awake breathing and typical asleep breathing look different on the waveform trace.

[Pugsy]

Respironics auto adjusting machines have long used the "the machine will increase the pressure during ramp if it senses and apnea event happening" so that part of it isn't new.
It wasn't available on fixed cpap pressures though that I could ever find....as it always said "when in auto adjusting mode".

Is this new Smart Ramp thing now offered on the fixed pressure modes...either cpap fixed or bilevel fixed?
I don't have any of the manuals yet for the new DreamStation machines.

I don't know why it would be different enough from regular ramp for a person to have it bother them.
Like someone using regular ramp for years and switch to smart ramp unless the starting pressure is different or the time frame selected for ramp is different and thus the timing of the increases might be different.
Smart ramp using the 30 minutes or first apnea event detection schedule would be different from someone using say a 15 minute ramp time to get up to pressure. Rate of increase will vary and that difference might be just "different" from what they were used to and thus disturbing. Sometimes the least little "difference" in anything is a disturbing factor especially for someone who has been using one thing one way for years.

[OKCSleepDoc]

SMARTRAMP MAKES THERAPY EASIER
In addition to the traditional pressure ramp available on most sleep therapy devices, DreamStation Auto BiPAP offers SmartRamp for an easier experience at the onset of sleep. When SmartRamp is enabled the DreamStation BiPAP Auto will monitor your therapy levels, during the ramp period, to deliver lower overall pressure until it detects an obstructive respiratory event. When an event is detected SmartRamp responds to resolve the event, raising pressures as required until the ramp period concludes.

So let me see if I understand. SmartRamp does not wait for the breath to even and slowly begin to ramp to full pressure automatically. It engages the ramp immediately will only allow the ramp to increase once the first apneic is sensed? Basically the same function as the Resmed version of Auto Ramp?

yup, not your average DME.

and, no, that's now how auto ramp works. resmed auto ramp is documented thusly:

Ramp Time can be set to Off, 5 to 45 minutes or Auto. When Ramp Time is set to Auto, the device
will detect sleep onset and then gradually increase from the start pressure to the minimum
treatment pressure at a rate of 1 cm H 2 O per minute. However, if sleep onset is not detected, the
device will reach the target pressure within 30 minutes.

and, yes, typical awake breathing and typical asleep breathing look different on the waveform trace.

It seems that you are not an "average DME" either. The op is clearly talking about a Respironics device and you are quoting the Resmed autoramp feature. 2 different machines, with 2 different algorithms.

[OKCSleepDoc]

SMARTRAMP MAKES THERAPY EASIER

and, no, that's now how auto ramp works. look different on the waveform trace.

That's "not" how auto ramp works.

now how is a typo. confusing to read.

[thecpapguy!]

Respironics auto adjusting machines have long used the "the machine will increase the pressure during ramp if it senses and apnea event happening" so that part of it isn't new.
It wasn't available on fixed cpap pressures though that I could ever find....as it always said "when in auto adjusting mode".

Is this new Smart Ramp thing now offered on the fixed pressure modes...either cpap fixed or bilevel fixed?
I don't have any of the manuals yet for the new DreamStation machines.

I don't know why it would be different enough from regular ramp for a person to have it bother them.
Like someone using regular ramp for years and switch to smart ramp unless the starting pressure is different or the time frame selected for ramp is different and thus the timing of the increases might be different.
Smart ramp using the 30 minutes or first apnea event detection schedule would be different from someone using say a 15 minute ramp time to get up to pressure. Rate of increase will vary and that difference might be just "different" from what they were used to and thus disturbing. Sometimes the least little "difference" in anything is a disturbing factor especially for someone who has been using one thing one way for years.

Thanks for the information Pugsy. I know that the older styled Phillips machines have that type of feature, but I think the smart ramp works differently. Maybe it doesn't and I am just having a hard time with instructing/utilizing it with patient's effectively. I'm not a hundred percent it works differently though as the ramp on the older machines is stationary (this is my made up term to characterize). The ramp is primarily in control of the CPAP patient meaning when it is activated by pressing the ramp button it will begin to ramp from the specific pressure over the set to the prescription pressure settings. The smart ramp works by sensing when the patient has an apnea and when that happens it triggers the ramp setting to begin increasing the air.
The problem I am encountering is that so many patients need the air quicker and the smartramp feature won't allow. I experienced it myself with my machine. If this is how the ramp works that explains it. But I'm still not a hundred percent sure.

[palerider]

....It engages the ramp immediately will only allow the ramp to increase once the first apneic is sensed? Basically the same function as the Resmed version of Auto Ramp?

yup, not your average DME.

and, no, that's now how auto ramp works. resmed auto ramp is documented thusly: ...

It seems that you are not an "average DME" either. The op is clearly talking about a Respironics device and you are quoting the Resmed autoramp feature. 2 different machines, with 2 different algorithms.

mebbe the above emphasis will help things make more sense for you.

and, nope, I'm certainly not your average DME.

[OKCSleepDoc]

LOL.

I think the breakdown is as follows then:

Resmed: starts when it senses sleep onset, otherwise after 30 min.

Respironics: starts once an obstructive event is detected. Otherwise would remain at starting ramp pressure.

Feel free to correct if the above is incorrect.

[Pugsy]

Thanks for the information Pugsy. I know that the older styled Phillips machines have that type of feature, but I think the smart ramp works differently. Maybe it doesn't and I am just having a hard time with instructing/utilizing it with patient's effectively. I'm not a hundred percent it works differently though.

I finally got the manual but haven't had a chance to really read what all they say and compare it to what I have seen in the past about how Respironics machines would deal with apnea events if they happen during the ramp period. From what it sounds like...it's what they used to do anyway in auto mode and they just gave it a fancy new name to compete with the new ResMed machines that essentially do the same thing but they word what they are doing differently and promote the fact that they sense when a person is asleep and terminate ramp at that time...if any apnea events occur then the person would already be asleep and if the machine in their AutoRamp mode is working properly then the apnea events would be dealt with because the machine would have already sensed sleep status (assuming this technology is accurate)...and we can't have a collapsed airway while we are awake. So the ResMed machines don't really interrupt Auto ramp to deal with airway collapse because it should have already sensed the person was asleep in the first place.
Resmed addresses sleep status (at least per their marketing) first and once asleep ramp is terminated so any response to apnea events is like it would respond otherwise even if ramp was never used because if ramp is terminated for whatever reason we have regular algorithm at work.

Respironics in the past have clearly stated that if the airway collapses that ramp is suspended and pressures increased in response but once that airway issue is resolved then ramp pressure goes back to where it was when the event happened and any remaining ramp time is used up normally.

So while the end result is the same with both brands...they do get it done in slightly different ways and market it a little differently.

In the past this auto adjusting correction in ramp on the Respironics machine has specifically mentioned "auto adjusting pressure mode" which I would assume means cpap mode doesn't do it during its ramp...I figure if they don't say it works in all modes then I assume it doesn't but I have never seen that question specifically asked or answered.

That's why I was wondering if this new Smart Ramp feature is available on fixed pressure modes. If it is available then I think it is a good thing.

I need to do some more reading and comparing the wording in the manuals to try to figure out if there is really any difference between this new marketing term and what the machines have always done in the past.
I will try to do that later when I have more time.

As to why your new patients are having issues with it...that's a mystery because I thought you were having issues yourself in your own cpap use. New to cpap therapy patients shouldn't be having any old habits ingrained in their brain to maybe be messing with what they are perceiving is going on. I might have issues with it simply because I never have used a ramp and I might have issues with lower pressure settings in general...no matter if it was ramp or not.

Are your patients that are having problems maybe experiencing the air starved feeling that often goes with the default pressure settings for ramp?

What I tell newbies is use ramp if you feel more comfortable using it and if the lower setting creates more air starved feeling then either turn ramp off or start a little higher at a setting that is more comfortable.
If the old mode feels better...use it... and don't worry about whether it's the smart mode or not. Use whatever it takes to get to sleep more easily. We gotta get to sleep first before we can let the machine work its magic. I wouldn't worry so much about the actual setting or time frame as much as I would worry about lessening anything that might prolong falling asleep.

The exception being if this new Smart ramp thing now works in fixed pressure modes...that means that apnea events will addressed during ramp and we won't have to worry about telling people that their sleep apnea events possibly aren't being dealt with during ramp time so they need to limit ramp time.

Maybe we can chat privately about this once I get a chance to read up on what all these new machines will do because to be honest...I haven't even started with it and it's unlikely that I will be seeing a DreamStation machine anytime soon.

[thecpapguy!]

What manual did you read Puggsy? Was it the clinical manual, because I got ahold of it and figured how it works. I think you described it correctly. Basically the smartramp feature is puting the machine in Auto CPAP mode, instead of a standard linear ramp feature. The setting is then a low of four and the max pressure is the low prescription pressure.

[Pugsy]

I got the combo DreamStation manual with the cpap/apap/bipap (plain bilevel and not ASV bilevel) models all included.

Yes, Smart Ramp appears to be the same as previous models where ramp in auto mode could self adjust.
Now they offer it in fixed modes also. At least from what I can tell from the manual.

Back to your question about what about SmartRamp could be causing some patients difficulties. Beats the heck out of me unless it is simply the lower pressures of ramp and they aren't comfortable with lower pressures and if that were the case I would think that they would have experienced issues with the "old" ramp method.
Or maybe this is just another one of those things that we just have to slap a big YMMV sticker on.

I do think that the most common issue with any brand's use of ramp is the low starting point of 4 cm and that starting point is simply not going to move enough air for the bulk of the cpap users out there.
I know that years ago I was screening my sister for OSA and when I attempted to use the 4 cm starting point she couldn't tolerate it. Yanked the mask off after about 30 seconds and said I was trying to suffocate her. It wasn't until we increased the starting pressure to 6 cm that she could breathe comfortably..ramp or no ramp.
She had never used cpap before so it wasn't that she was used to cpap pressures that were higher.

[thecpapguy!]

So the smartramp is the same in the new model as the system one or m-series? I though the restart auto system one was a standard linear ramp?

[Pugsy]

It really isn't made all that clear about the old ramp.
I think this (1st image below) was from the System One manual...I don't think I have anything from the pre System One manuals.
It just says it will "treat the events" then continue the ramp but it doesn't mention if it drops back down and continues where it was before "treating".
To be honest I don't think that how it does it is really that big of a deal...no matter if Smart Ramp is a little different or not.
From what I understand from the Dream Station manual the response to treat the events is what we saw in the old machine but they don't really state how that algorithm works...just that it works.

I think that the most important thing is that the auto algorithm now works in the ramp fixed pressure mode where as before I don't think it did as the manual was specific about the auto mode with no mention to fixed mode so I would assume that since there was no mention of it that it didn't work in fixed mode.
Now they are specific and include fixed pressure modes. See 2nd image below.
They still don't go into a lot of detail as to just what the auto algorithm does when it "treats" anything.

[WindCpap]

Resmed: starts when it senses sleep onset, otherwise after 30 min.

This is absolutely correct about the autoramp. I didn't realize the 30 minute part until today. It explains a lot of what I thought were occasional false ramps when watching TV before sleep.

The accuracy of the autoramp for the Resmed machines is extremely good. I like using it because it allows me to set a pressure/epr for natural erratic pre-sleep breathing, and then a constant pressure setting for sleep. I can yawn and talk without difficulty. I think a lot of people don't use the ramp, because without this option, the pressure is changing before sleep. I personally wouldn't find this useful.

I am not entirely sure on the algorithm, but I have noticed it ramp up from me forgetting to breath. It may very well be that it considers an apnea (central or otherwise) to be an indication of sleep onset. I should experiment some more to see if this is consistent.

[gwatuk]

I've just had my machine upgraded to a DreamStation.
I'm trying to make sense of what SmartRamp does.
I wondered if any of the contributors to this thread have anything new to say on this subject.
I'd very much appreciate a simple summary of how it works on a DreamStation Auto CPAP machine.

There's been no mention above of what the Clinicians Guide says:

When SmartRamp mode is enabled, the therapy device’s ramp function utilizes an Auto titrating algorithm during the ramp period.
It allows patients the ability to stay at lower pressures during the ramp period, to improve their acclimation to therapy.
SmartRamp mode functions differently, depending on the therapy mode that the device is using.

*In CPAP or CPAP-Check mode, the SmartRamp applies the Auto-CPAP algorithm during the ramp period.
The Ramp Start pressure becomes the Auto Minimum pressure during the ramp period.
The Auto Maximum pressure during ramp is the CPAP or CPAP-Check pressure.

*In Auto mode, the SmartRamp applies the Auto-CPAP algorithm during the ramp period.
The Ramp Start pressure becomes the Auto Minimum pressure during the ramp period.
The Auto Maximum pressure during ramp is the Auto Minimum under normal Auto mode.

*In BiPAP or Auto-BiPAP mode, the SmartRamp applies the a modified version of the Auto-BiPAP algorithm during the ramp period.
The Ramp Start pressure becomes the EPAP Minimum pressure, and the Pressure Support Minimum pressured is applied.
The IPAP Maximum pressure during ramp is the EPAP or EPAP Minimum under normal BiPAP or Auto-BiPAP mode.

The SmartRamp period will terminate in either of two ways:

1) If SmartRamp pressure reaches the minimum pressure of the therapy mode selected, then SmartRamp ends, and the device continues to deliver therapy under the selected therapy mode, or:

2) If SmartRamp pressure does not reach the minimum pressure of the therapy mode selected by the end of the Ramp Time, then pressure is increased at a rate of approximately 1 cm H2O per minute. Once the pressure reaches the minimum pressure of the therapy mode selected, then the device will continue to deliver therapy for that mode.

If SmartRamp mode is not enabled, then the standard, linear pressure ramp mode is active.

(Which I don't understand! )