Newbie on AVAPS

[Banned]

I ended the first night as follows:

Mode: S/T (spontaneous/timed) AVAPS
EPAP: 9 cmH2O
IPAP Min: 12 cmH2O
IPAP Max: 22 cmH2O
Tidal Volume (Tv): 600 ml
Breath Rate (BPM): 11
Inspiratory Time (Ti): 2.1 (seconds)
Rise Time: 0.5 (second)

I ended the second night as follows:

Mode: T (timed) AVAPS
EPAP: 10 cmH2O
IPAP Min: 14 cmH2O
IPAP Max: 25 cmH2O
Tidal Volume (Tv): 610 ml
Breath Rate (BPM): 13
Inspiratory Time (Ti): 1.9 (seconds)
Rise Time: 0.3 (second)

I found the 'Timed' mode to be an easier transitional solution on night 2 vs. 'S/T' mode on night 1.
I raised the Tidal Volume 10 ml with no detrimental effects (e.g. aching lungs).
It is definitely nice to be getting more volume.
I do feel very refreshed this morning, without the more sluggish morning starts on the SV.

My only question to timed bi-level engineers would be if they can build a patient adjustable algorithm for 'Rise Time' at the beginning of the square inspiratory wave, what would be so difficult about building a patient adjustable algorithm for 'Drop Time' on the back side of the square inspiratory wave?

Banned

[Banned]

I ended the third night as follows:

Mode:: PC (pressure control) AVAPS
EPAP: 10 cmH2O
IPAP Min: 16 cmH2O
IPAP Max: 25 cmH2O
Tidal Volume (Tv): 620 ml
Breath Rate (BPM): 12
Inspiratory Time (Ti): 2.2 (seconds)
Rise Time: 0.6 (second)

The BiPAP AVAPS can operate in the following (9) modes:

CPAP---Breath Trigger: Patient
S (Spontaneous)---Breath Trigger: Patient
S AVAPS---Breath Trigger: Patient
S/T (Spontaneous/Timed)---Breath Trigger: Patient/Machine
S/T AVAPS---Breath Trigger: Patient/Machine
T = (Timed)---Breath Trigger: Machine
T AVAPS---Breath Trigger: Machine
PC (Pressure Control)---Breath Trigger: Patient/Machine
PC AVAPS---Breath Trigger: Patient/Machine

I have sampled S AVAPS, S/T AVAPS, T AVAPS, and PC AVAPS modes over the last 3 nights.

The clear winner for me is PC AVAPS mode.

While briefly trialing PC AVAPS mode during my first 2 nights, the air-delivery felt like a pile-driver smashing into my face. PC AVAPS is clearly an aquired taste for the 'elective' user, such as myself. PC AVAPS, like the BiPAP Auto SV in SV mode, utilizes the full capability of the machine.

The BiPAP AVAPS in PC AVAPS mode has a very different feel from the SV. PC AVAPS mode will never let you miss a breath, which on rare occasions I would on the SV. The IPAP cycle feels like a rolling wave, and I can feel my chest expanding on each breath. That feeling continues until I'm unceremoniously dropped over the edge into EPAP. To better accommodate the unceremonious drop (IPAP/EPAP switch) it would be nice if the BiPAP AVAPS could accommodate Inspiratory Time in increments of 0.100 second, rather than 0.10 second, and make those small increments a patient adjustable feature. I did lengthen the Inspiratory Time to accomodate the Tidal Volume and my mormal bi-level pressure settings. I don't know if there is a corrrelation between Inspiratory Time and Rise Time, but it also felt better to increase the Rise time (which is a patient adjustable 'comfort' feature). The increased Inspiratory Time and Rise Time seem to maximize that 'rolling-wave' sensation that I'm getting used too.

Again, I raised the Tidal Volume 10 ml with no detrimental effects. My goal with self-titration on the BiPAP AVAPS is for lung recruitment and maintenance of optimal lung volume without concomitant lung over-distention (e.g. lung damage), while concurrently addressing periodic breathing and upper airway blockage/restrictions.

So far, it seems to be working for me. I have increased my Average Tidal Volume by 20% and my upper airway stays open (much more so than on the SV).

Was the investment in a BiPAP AVAPS worth it? Do I really need a device that is, or does a pretty good job of mimicking a true NVVP machine? Maybe not. I did goto bed at 9pm last night and woke up at 1am for a bathroom break, refreshed and ready to go. I woke up again this morning ready to go.

It may be tough to go back to the SV

At higher pressure and higher tidal volume the FF mask (Quattro) is superior to the Mirage Micro nasal mask.

Banned

[dsm]

Banned,

Couple of questions, I know you had the original Vpap Adapt SV & then got a replacement new model, did you also get & try a Bipap Auto SV ?.

Re the fall-time. IIRC the last model of the Vpap III line added adjustments, I think, that smoothed fall-time but am not aware of any others.

One point (I think you already know this) re adjusting rise time - the 1 2 3 4 5 6 numbers represent millisecs (i.e. 3 = 300 milliseconds ) .
If you increase rise time you are also reducing the volume of air delivered in the breathing cycle. The longer the rise time for a given BPM, the slower the pressure ramp-up & thus the slower the tidal flow. e.g. 600ms really bites into the breath-in phase of 1 breathing cycle. So the setting is partly a comfort adjustment but it also affects tidal volume.

I have managed to get by on 200 ms rise-times but it does get delivered quickly - 100 ms is too fast a delivery for me. That lung dropping feeling after the breath-in ends is something you can get used to but it is a source of arousals.

You mention chest pain & having had that many times am now sure it is a normal aspect of cpap, apap, bipap etc:. The 1st time I experienced it was on cpap about 3 years ago jsut when I began therapy - I would have to get up & walk around. It seemed to me to be like a looming heart attack. The most recent time was about 3 weeks back but I have always found it passes but it did occur 2 nights in a row this last time. If anyone else has any info re this chest pain effect & what triggers it I would very much like to hear. I can't relate it to anything by way of food, activity etc: but did wonder if it was stress related as I did once experience it before going on cpap & after heart specialist visit & stress ECG was given a very clean bill of health but was at that time in a very stressful project at work.

Please keep your flow of info coming re comparisons with the other machines. The really big info will be how you feel long term.

Back to your Adapt SV, did the new machine feel any different to the earlier model ?

DSM

[Banned]

Banned,
Couple of questions, I know you had the original Vpap Adapt SV & then got a replacement new model, did you also get & try a Bipap Auto SV ?

Never have tried a BiPAP Auto SV. I was thinking about one because you raved about it much. Then I started thinking about Average Tidal Volume with AVAPS and went that route. it did not factor into my decision, but AVAPS is also a cheaper machine than the Adapt or Auto SV.

Re the fall-time. IIRC the last model of the Vpap III line added adjustments, I think, that smoothed fall-time but am not aware of any others.

Fall time is the only complaint I have with AVAPS.

One point (I think you already know this) re adjusting rise time - the 1 2 3 4 5 6 numbers represent millisecs (i.e. 3 = 300 milliseconds ) .
If you increase rise time you are also reducing the volume of air delivered in the breathing cycle. The longer the rise time for a given BPM, the slower the pressure ramp-up & thus the slower the tidal flow. e.g. 600ms really bites into the breath-in phase of 1 breathing cycle. So the setting is partly a comfort adjustment but it also affects tidal volume.

I'll keep that in mind it I ever decide to crank Tidal Volume up to 630 ml. I went to Rise-Time 6 to keep up with the Increased Inspiration Time. Inspiration in PC AVAPS mode is so smooth it feels like rising in a gentle ocean wave. Only the drop is a annoying.

That lung falling feeling after the breath-in ends is something you can get used to but it is a source of arousals.

I'm getting used to the drop. I can't remember sleeping any sounder or deeper than I do with AVAPS. All the time I was on the Adapt SV I felt like I was partially awake or conscious. I don't get that partially conscious feeling and am much more refreshed immediately upon waking up with AVAPS.

The Rise and Delivery of inspiration (pressure) is much more dramatic, smoother, and more 'fill-filling' than on the SV. But then again, you might never buy an AVAPS if there wasn't a thought about Tidal Volume.

I ordered the Respironics USB card reader today so I should be able to read the data soon.

You mention chest pain & having had that many times am now sure it is a normal aspect of cpap, apap, bipap etc:. The 1st time I experienced it was on cpap about 3 years ago jsut when I began therapy - I would have to get up & walk around. It seemed to me to be like a looming heart attack. The most recent time was about 3 weeks back but I have always found it passes but it did occur 2 nights in a row this last time. If anyone else has any info re this chest pain effect & what triggers it I would very much like to hear. I can't relate it to anything by way of food, activity etc: but did wonder if it was stress related as I did once experience it before going on cpap & after heart specialist visit & stress ECG was given a very clean bill of health but was at that time in a very stressful project at work.

I have not had any chest pain since being on the Adapt SV. I did go to the ER on several occasions both prior to CPAP and while on CPA therapy as a result of periodic breathing.

Please keep your flow of info coming re comparisons with the other machines. The really big info will be how you feel long term.

Will do. I don't think AVAPs devices are flying off the shelves. I don't think anybody is prescribing these machines. God knows where they keep the overstock. Happy to have one.

The advantage to AVAPS over other Bi-level devices is that it can concurrently:

1. Provide an optimal Average Tidal Volume without concomitant lung over-distention.
2. Mitigate periodic breathing associated with CSDB (Complex Sleep Disordered Breathing) and CSA (Central Sleep Apnea).
3. Mitigate upper airway anomolies including, but not limited to turbinate and septum restrictions.
4. Provide a solution for restrictive patients.
5. Provide a solution for COPD patients.
6. Provide solution for CSR (Cheyenne Stokes Respiration) that may out-perform the SV.
7. (Possibly, but not confirmed) provide a solution for morbidly obese patients.

Back to your Adapt SV, did the new machine feel any different to the earlier model ?

The Enhanced Adapt SV does seem to exhibit some improvement over it's predecessor besides the increased pressure. But, that is hard to quantify. I did experience a vary occasional periodic breathing (or other arousal episode) that did not require taking off my mask with the original Adapt SV. I have had no issues with the Enhanced Adapt SV. other than both SVs left me feeling like I was sleeping a little light.

Thanks, dsm!

David

[dsm]

Quote:
"I'm getting used to the drop. I can't remember sleeping any sounder or deeper than I do with AVAPS. All the time I was on the Adapt SV I felt like I was partially awake or conscious. I don't get that partially conscious feeling and am much more refreshed immediately upon waking up with AVAPS."

Banned, That is very much the feeling I had with the Vpap Adapt SV compared to the Bipap Auto SV. I seemed fine the next day but never seemed to get the deep restful sleep that is consistently occurring with the Bipap Auto SV. This happened with the two SV brands despite setting the machines up to mimic each other. The same happened with a PB330 vs a VPAP III S/T - the Vpaps left me with a 'I slept lightly' feeling. It is a difference that intrigues me & to hear that you too were feeling it is very interesting. I know of one other person on a Vpap Adapt SV who I have been in contact with who reports a similar experience.

DSM

[Banned]

DSM,

If you would, sir when you have time, since we know your mean (average) Tidal Volume on the the BiPAP Auto SV is 650 ml. As a comparison, I would be curious to know what your mean (average) Tidal Volume was while you were using the Adapt SV? It would be interesting to compare the two.

Thanks!
Banned

[dsm]

Sir Banned,

I have all my data up to about a week recent on this website (lots n lots of data)

I'll take a peek at some recent examples but there is data from AdaptSV BipapAutoSV one night from a regular BipapAuto & some nights from a S8 Vantage using EPR.

http://www.internetage.ws/cpapdata - if that site fails to respond, which ithas done for me on the odd occasion - try ...

http://www.internetage.com/cpapdata (but this is not nearly as up-to-date)

DSM

[Banned]

Thanks dsm!

It looks like the average tidal volume from your Adapt SV and your BiPAP Auto SV may vary between 3-50 ml. I was trying to ascertain if there was any unusual disparity in average tidal volume between the two SVs. There is no significant difference. So to increase average tidal volume, AVAPS is the device of choice.

Thank you for the data,
Banned

[dsm]

Banned,

Thanks for your input - it has now sunk in that the way to increase TV (Tidal Volume) is to use a machine that commits a TV & AVAPS is that machine.
It took a while for me to pick up on your message re this aspect.

Obviously for me TV is not the big deal as I am delighted with the Peak Flow (SV mechanism) in the Bipap Auto SV. To me it is great to have the machine
recognize that within one breath, I won't reach the 4 min rolling Peak Flow target & that it can and will bump IpapMAX within that breath (half way through
in fact) so that the target gets met. What is great is that as I slow my breathing down gradually it will slow its SV adjustment. But if in the night I roll
on my back - or from back to my side - it will make sure within that breath, that I sustain the peak flow target.

The proof of how effective this has been is that the SpO2 data and pulse rate taken with a recording SpO2 machine, shows very clearly a more stable
& slightly higher SpO2 % as well as a more stable pulse rate compared to using my PB330 S/T set with similar bilevel settings. But like you, I could not get
that deeper restful sleep when I tried the Vpap Adapt SV. Am fairly sure I have good reasons for the difference (different target disorders).

It is good you are already feeling the AVAPS is delivering what you want. That is an important part of this whole xPAP experience.

So I guess we will both be putting up Vpap Adapt SV machines forsale soon (But I will hang on to my PB330).

DSM

[Banned]

Well, I may not be selling my 'Enhanced' Adapt SV anytime soon.

On the upside, I used the same AVAPS settings as on day 3 and that works great.

On the downside, Last night I had an episode similar to the rare episodes I encountered with the non-enhanced Adapt SV. I believe it is related to to my upper airway turbinate issues which my ENT, after turbinate/septum surgery, said was still a mess. I didn't have to pull the mask off, but it was uncomfortable. Since AVAPS cannot operate in servo-ventilation mode on a breath-by-breath basis, it can't spike the pressure in real-time in order to blast air through a restricted upper airway.

So, the only flaw with AVAPS is that it doesn't have SV/SV-AVAPS mode. That machine would allow for delivery of servo ventilation with a set average Tidal Volume on a breath-by breath basis.

Where can I find a BiPAP Auto SV-AVAPS machine?

Banned

[Snoredog]

I gotta ask, I see a lot of numbers there, none remotely resemble AHI, so I assume with the use of this particular machine you have to "know" what it takes to resolve your obstructive events and set the machine and assume those are taken care of? While the Respironics version of that machine does the same, it does give AHI where you can observe what obstructive is doing.

but out of those numbers and in the absence of AHI, WHAT is your goal or what are you striving to obtain? How are you gaging improvement?

With CPAP we strive for lowest AHI and better quality of sleep,

What is the criteria you are trying to obtain here? I assume avoiding periodic breathing, machine triggered breathing but I don't see that in your list of changing variables. Am I missing something here?

[Banned]

but out of those numbers and in the absence of AHI, WHAT is your goal or what are you striving to obtain? How are you gaging improvement?

With CPAP we strive for lowest AHI and better better quality of sleep.

What is the criteria you are trying to obtain here? I assume avoiding periodic breathing, machine triggered breathing but I don't see that in your list of changing variables. Am I missing something here?

Hi Snoredog,

I don't talk much about AHI because my Bi-level settings of EPAP 10 and IPAP 16 keeps my AHI <1.0.

The SV (or a timed rate in AVAPS, in theory) does seem to address my periodic breathing and gasping issues.

I have another issue with upper airway distress (turbinates restriction/closure) that sometimes comes into play.

What I'm looking for is better quality of sleep (as measured in how do I feel the day).

I felt I was sleeping too lightly with the Adapt SV, somehow in a semi-conscious state. I thought perhaps a higher Average Title Volume would help with my quality of sleep. Hence, the AVAPS trial.

With AVAPS I'm able to wring out a 20% increase in average tidal volume (620 ml on AVAPS vs. 500 ml on the Adapt SV). I'm sleeping better (sounder and deeper) with the increased average tidal volume on AVAPS. I wake up more refreshed. However, I believe I still have upper airway turbinate restrictions that may interfere with AVAPS therapy. And such was the case last night.

At some level, I still need servo-ventilation (SV) to blast through my distressed turbinate issues on a breath-breath-basis, when they occur. AVAPS cannot help me in those occurances.

So, like a good CPAPPER, I trial different machines looking for better sleep.

Since the SV cannot provide an assured Tidal Volume and AVAPS cannot blow through my distressed turbinates on a breath-by-breath basis, the solution for me would be combined SV and AVAPS therapy. My perfect machine would be a BiPAP Auto SV-AVAPS which doesn't exist, and would require very clever engineering to combine a pressure controlled SV and volume controlled AVAPS into one device.

Long winded, hope it helps,
Banned

[Snoredog]

banned,

thanks for the reply, that is what I thought, as for your turbinates, did your ENT indicate it was excess tissue or excess bony structure?

I then have to ask why you haven't had that fixed? I had it done over 25 years ago along with a deviated septum fixed and it was best thing I ever had done, now that I too am on CPAP I know it was worthwhile procedure. For a total of a week's worth of discomfort it was well worth it, pain was never really a problem that I recall.

But with the use of the full face mask, how do you know it is your turbinate resistance and/or not the tongue causing the obstruction?

Sudden events would seem to indicate the tongue is somehow involved. I would think that if it were turbinate resistance that use of the Quattro would pretty much resolve that as therapy would come in via the mouth totally bypassing that anatomy.

But we know use of the FF mask makes it much more difficult for that splint pressure to dislodge your tongue if it is the cause. Over time I guess you could determine if that was what was happening, by comparing differences in sleep position.

[dsm]

banned,

thanks for the reply, that is what I thought, as for your turbinates, did your ENT indicate it was excess tissue or excess bony structure?

I then have to ask why you haven't had that fixed? I had it done over 25 years ago along with a deviated septum fixed and it was best thing I ever had done, now that I too am on CPAP I know it was worthwhile procedure. For a total of a week's worth of discomfort it was well worth it, pain was never really a problem that I recall.

But with the use of the full face mask, how do you know it is your turbinate resistance and/or not the tongue causing the obstruction?

Sudden events would seem to indicate the tongue is somehow involved. I would think that if it were turbinate resistance that use of the Quattro would pretty much resolve that as therapy would come in via the mouth totally bypassing that anatomy.

But we know use of the FF mask makes it much more difficult for that splint pressure to dislodge your tongue if it is the cause. Over time I guess you could determine if that was what was happening, by comparing differences in sleep position.

Snoredog,

I can't speak on behalf of the AVAPS (but am sure it is similar) but, the Bipap AUTO SV does give minute by minute HI & AI numbers as well as Tidal Flow Peak Flow & Minute Ventilation. Where did you get the idea it doesn't ?

Also, for my eval I used an SPO2 recorder to note the difference compared to my former PB330 Bilevel & the improvement was very obvious (as previously explained). Also,
as with any of the xPAPs the real issue is does it make any difference over time (for me 6 months). I can tell you I don't need any convincing

Perhaps we should recall the comment that xPAP therapy really is an individual journey and if someone is convinced they have reached a milestone then that is good for them.

DSM

[Snoredog]

Snoredog,

I can't speak on behalf of the AVAPS (but am sure it is similar) but, the Bipap AUTO SV does give minute by minute HI & AI numbers as well as Tidal Flow Peak Flow & Minute Ventilation. Where did you get the idea it doesn't ?

Also, for my eval I used an SPO2 recorder to note the difference compared to my former PB330 Bilevel & the improvement was very obvious (as previously explained). Also,
as with any of the xPAPs the real issue is does it make any difference over time (for me 6 months). I can tell you I don't need any convincing

Perhaps we should recall the comment that xPAP therapy really is an individual journey and if someone is convinced they have reached a milestone then that is good for them.

DSM

Doug,

I knew the Bipap Auto SV reported AHI on the reports, I wasn't sure on the AVAPS, I am assuming that is Resmed version?

I thought you mentioned a while back when you tried that one it was difficult because it didn't give AHI info? But maybe that was the earlier version of the Adapt SV. So in the absence of that, I asked Banned how he determined if he was improving with the settings used other than the subjective way you feel. But if it does give that info like the Bipap then that answers that question.