How REFRESHING! A Doc Who Says "I Don't Know"

[Slinky]

The new regular doc at the sleep lab couldn't keep his appointments today. They called and asked if I would prefer to reschedule or see his "stand in". Curiosity rules so I opted for the stand-in. He's suggested we go to straight bi-level now rather than auto bi-level, bleed 2 Ls of 02 in and see how I'm feeling in two weeks. I told him I had considered going to straight bi-level but didn't know what to set Rise Time at. Deer in headlights look. He said he really didn't know all the various brands and models of bi-levels and their various manufacturer recommended settings. Just use Default settings except for the IPAP and EPAP which he scripted. I was disappointed as I had some questions I wanted to ask. BUT, I WAS impressed that he's the first sleep doc or pulmo I've run into who had the guts to say "I don't know" (except the first sleep pulmo no longer at this sleep lab). I found it rather refreshing!! Disappointing but ... evidently quite honest. He did say he was inclined to up my IPAP to 15 but wouldn't do so just yet as he wasn't familiar enough w/my background and titrations, etc.

And my sleep lab manager was back!!! She's not been there when I've been by in quite a while. Its always such a pleasure to see her. I really like all the staff, but she's special.

[smurf]

Yea for you!!! Honest is the best.....

Just want to know that the advise I see from Slinky is best. I saw a lot of her posts the first time I started looking around and found her to be very calming and matter of fact. Thanks for all the infomation SLINKY!!!!!

[Banned]

I told him I had considered going to straight bi-level but didn't know what to set Rise Time at.

Unless anyone would like to correct me (I'm sure everyone will line-up), Rise Time is a patient adjustable 'Comfort' setting. For 'OSA' patients you would set a Rise Time from 1 - 3. For 'Restrictive' patients the Rise Time would be a bit longer, 3 - 6. In general terms, the longer the Inspiratory Time, the longer the Rise Time. My experience has been, 'Where goeth the Inspiratory Time, goeth the Rise Time'. I would imagine a patient with COPD would be more Restrictive in nature. Respironics recommends a longer rise Time for Restrictive patients, 3 - 6.

Banned

[Snoredog]

I told him I had considered going to straight bi-level but didn't know what to set Rise Time at.

Unless anyone would like to correct me (I'm sure everyone will line-up), Rise Time is a patient adjustable 'Comfort' setting. For 'OSA' patients you would set a Rise Time from 1 - 3. For 'Restrictive' patients the Rise Time would be a bit longer, 3 - 6. In general terms, the longer the Inspiratory Time, the longer the Rise Time. My experience has been, 'Where goeth the Inspiratory Time, goeth the Rise Time'. I would imagine a patient with COPD would be more Restrictive in nature. Respironics recommends a longer rise Time for Restrictive patients, 3 - 6.

Banned

I agree w/Banned, and to add to that, one should keep the lowest EPAP possible, only removing the obstructive apnea or AI. Longer inspiratory time would allow for a deeper breath to take place. I would use caution increasing pressure support beyond 4 cm.

[jnk]

For the VPAP Auto, the S mode is straight bilevel, and here is what the manual says about rise time:

Rise Time Adjustment

(S mode) Rise Time is the time taken for the pressure to increase from EPAP up
to IPAP. Rise Time can be set to MIN (the fastest Rise Time) and then in 50-unit
increments from 200 to 900. This will control the rate of pressure increase when
the VPAP Auto 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 higher the Rise Time setting, the longer it
takes for the pressure to increase from EPAP to IPAP. If the patient has a high
ventilatory demand then the Rise Time should be set to MIN, as this is the
fastest Rise Time setting.

Notes:
• The Rise Time should not be set so that it is longer than the time spent in
IPAP (otherwise the IPAP pressure would never be reached). For this reason,
Rise Time cannot exceed the Ti Max setting.
• The Rise Time scale can be approximately read as ‘milliseconds’ (eg, 200 is
approximately 200 ms). The actual rise time achieved is influenced by several
factors, such as compliance, resistance, leak, pressure differential, and
patient breathing patterns.

My understanding is that a short rise time moves more air since it gets you to the ipap treatment pressure quicker. But, like banned says, corrections to my understanding are welcome, as well.

[-SWS]

Just to set the record straight guys: COPD is categorized as an obstructive disorder and not a restrictive disorder.

Anyway, Chronic Obstructive Pulmonary Disorder (COPD) generally fares better with faster rise times (not longer), lower EPAPs and higher IPAPs, and slower machine frequencies (respiratory rates). Specifically those parameter preferences are to minimize the work of breathing (WOB) for COPD patients.

However, bear in mind that Slinky's concomitant OSA may preclude getting her EPAP as low as a COPD patient might otherwise benefit/prefer. Also bear in mind that unintentional biologic respiratory-controller skew (a common BiLevel side effect) may prevent WOB-ideal rise times or WOB-ideal IPAP levels. That's the purpose of getting a good pulmo/RT team in the loop. They really need to know what they're doing IMO. Good luck, Slinky!

P.S. Jnk, you sure do come up with a lot of correct answers for such a newcomer! One smart cookie who manages to write in English, none the less.

[Banned]

Just to set the record straight guys: COPD is categorized as an obstructive disorder and not a restrictive disorder.

Exactly like I said, "I would imagine a patient with COPD would be more Obstructive in nature. Respironics recommends a shorter Rise Time for Obstructive patients, 1 - 3."

Are you taking notes, Slinky? The good news is, Rise Time is still a comfort setting. And holistically speaking, Inspiratory Time should also be a Comfort Setting.

Banned

[-SWS]

Exactly like I said, "I would imagine a patient with COPD would be more Obstructive in nature. Respironics recommends a shorter Rise Time for Obstructive patients, 1 - 3."

Heheh! I agree with that second "exactly as I said" statement!

...It's those darn parallel-universe anti-statements that occasionally seep in from the far side!

[Snoredog]

Just to set the record straight guys: COPD is categorized as an obstructive disorder and not a restrictive disorder.

Anyway, Chronic Obstructive Pulmonary Disorder (COPD) generally fares better with faster rise times (not longer), lower EPAPs and higher IPAPs, and slower machine frequencies (respiratory rates). Specifically those parameter preferences are to minimize the work of breathing (WOB) for COPD patients.

However, bear in mind that Slinky's concomitant OSA may preclude getting her EPAP as low as a COPD patient might otherwise benefit/prefer. Also bear in mind that unintentional biologic respiratory-controller skew (a common BiLevel side effect) may prevent WOB-ideal rise times or WOB-ideal IPAP levels. That's the purpose of getting a good pulmo/RT team in the loop. They really need to know what they're doing IMO. Good luck, Slinky!

P.S. Jnk, you sure do come up with a lot of correct answers for such a newcomer! One smart cookie who manages to write in English, none the less.

yeah but this is Slinky we get to experiment with her

[Slinky]

Yeah, THANKS, SnoreDog. Its a real pleasure to be a "guinea pig".

Unfortunately, altho my local DME supplier has been very good about working w/me I DO NOT have access to a savvy RT/RPSGT thru them. I wish I did!

You know, if you allow yourself to give it much thought at all, it is d*mn scarey how FEW "professionals" in sleep medicine actually KNOW what the h*ll they are doing or what xPAP equipment is capable of!!!!! God help those patients if they don't have access to this forum!!!

jnk, Banned, SWS: MANY THANKS for your information and suggestions and advice and .... aw shucks, guys, just THANKS.

And thanks for your comments, Smurf. I've been thru the insurance bit, the local DME supplier bit, the data the Resmed's can provide, etc., etc. but when it comes to pressure settings, and all these "fancy" bi-level options ... I'm dumb as a rock (shu' up, SnoreDog! ) and I bow to the "big boys" (and gals) here who've come up thru the ranks and educated themselves.

[jnk]

" . . . getting a good pulmo/RT team in the loop. . . .

Amen.

Thanks for your kind generosity and for having everyone's backs, SWS. I think both have been vital in making many of us newer ones comfortable in our attempting to be helpful whenever we think we can. Just promise me, if you don't mind my asking, that as I continue to learn, you'll never hesitate to nudge me or redirect any of my posts. It is always appreciated.

[-SWS]

Haven't seen a whole lot of need to nudge, jnk!

[Wulfman]

Slinky,

I've been wondering since I read your original post, whether you actually had to PAY anything for that trip to the sleep lab folks when you actually got better information HERE........and no "deer-in-the-headlights look", either.

And, YES, it IS scary to realize how many clueless sleep professionals there are out there.

Den

[marshaeb]

Jnk, you sure do come up with a lot of correct answers for such a newcomer! One smart cookie who manages to write in English, none the less.

And thank goodness he does!!! Frees me up for translating the posts of others, who either have such incredibly amazing vocabularies that they don't realize they regularly use words I have to look up or else have mastered the art of subtle verbal arms-length distancing. For instance, I'm still working on this one:

Perhaps an ethereal epiphany of the human condition is offered: if we cannot manage a way in our hearts to succeed together then we are destined to fail together. And if that is the intended pearl, a pair of alternate paths toward that lesson is inherent.

HUH???


Marsha

[-SWS]

Egad, Marsha! Whoever wrote that cryptograph needs to be summarily ejected from this message board!

I think that person was trying to say something about human pearl divers sinking or swimming together. Sure doesn't affect me! We happen to live far inland and I've never even met a pearl diver. Aunt Weeza knows quite a few.