ResMed VPAP Machine Family Tree

[rogelah]

Can someone enlighten me on the currently available ResMed VPAP line of machines?

[jnk]

Can someone enlighten me on the currently available ResMed VPAP line of machines?

ResMed calls their bilevels VPAPs. VPAP S is their standard bilevel these days in the U.S. VPAP Auto 25 is their standard auto-titrating bilevel now. The VPAP Adapt SV is for treating people with trouble relating to central apneas.

Did you have one in particular in mind?

http://www.resmed.com/us/products/devic ... c=patients

[rogelah]

I had a CPAP study Monday night. Net result is that I can move on to a bi-level machine. Of course the doctor knew from the beginning but Medicare requires proof that CPAP doesn't work.

Well, after the RT started me on straight CPAP Monday night he soon changed me to BiPAP. He said I was having to many arousals. To me it felt like I was in a wind tunnel testing what happens in a hurricane.

I tried to ask him what the BiPAP IPAP and EPAP numbers were and if he thought I needed a backup rate. He politely deferred to the doctor for that info.

One thing he did say was that after a "regular" BiPAP the next step up is Adapt SV, the "Cadillac" of therapies. My thinking is that if I'm going to need Adapt SV why not now?

I did feel much better at the end but I know he was moving the IPAP and EPAP around during the night and don't know yet what, if any, sleep with low or nil apneas/hypopneas I had.

I meet with the doctor this coming Monday. I want to be machine knowledgeable before then.

[jnk]

It really depends on the kind of breathing problems you are having at night. If your problem is purely obstructive apnea, there would be no reason to use an SV, according to present standard practice. The SV is designed for dealing with breathing problems that include specific kinds of brain and heart issues. So, the next step for you is likely the VPAP Auto 25, unless the tech was hinting to you that you had central events and might want to get educated about the SVs.

It may be that if you fail the use of autobilevel, or if it causes central events (apneas and hypopneas caused more by the brain failing to tell you to breathe than from obstructions of the airway) or doesn't resolve them, the next step might be an SV, depending. Sometimes going through the process of trying machines is part of the diagnostic process, so it can be in your best interest to play along with the little dance that occurs between your doctor and insurance. However, if you want to get educated about what is happening, you should ask to see complete copies of your sleep tests, which should be handed to you for asking, according to the law, as I understand it. That information will show you how many central events you had and whether the titration seemed to cause some problems for you involving central apneas or central hypopneas.

I'm no doc, and I'm new at this stuff, so please don't put too much stock in my answer above without confirmation from more experienced members of this forum. Feel free to keep asking questions. It can take a while to get answers, but this is the best place I've found for getting answers. Keep at it!

jeff

Here are some links to machines designed for the more complicated forms of sleep-disordered breathing:

http://bipapautosv.respironics.com/
http://www.vpapadaptsv.com/

[rogelah]

Thanks for your help. The VPAP Auto 25 looks good. I just don' know yet whether I will need backup support i.e. timed breathing. There isn't much information regarding FSHMD and sleep apnea. Sleep apnea is the symptom but the cause may or may not be blockage of the airway but due to muscle inability to complete a breathing cycle. I haven't met a doctor yet who has ever treated someone with FSHMD (fascioscapiohumeral muscular dystrophy) even though they know it from a neurology course. Even the neurologists I have had learned more from me than in their courses of study or exposure to other forms of MD. I have learned long ago to be proactive in my treatment.

[jnk]

I would probably look at the VPAP ST to get a timed backup, if that's what my doc thought I needed, for now:

http://www.resmed.com/us/products/vpap_ ... c=patients

"By and large, respiratory involvement leading to ventilatory decompensation is unusual, but does occur occasionally."--"FACIOSCAPULOHUMERAL MUSCULAR DYSTROPHY" / http://www.pneumonologia.gr/articlefile ... ophies.pdf

[dsm]

Thanks for your help. The VPAP Auto 25 looks good. I just don' know yet whether I will need backup support i.e. timed breathing. There isn't much information regarding FSHMD and sleep apnea. Sleep apnea is the symptom but the cause may or may not be blockage of the airway but due to muscle inability to complete a breathing cycle. I haven't met a doctor yet who has ever treated someone with FSHMD (fascioscapiohumeral muscular dystrophy) even though they know it from a neurology course. Even the neurologists I have had learned more from me than in their courses of study or exposure to other forms of MD. I have learned long ago to be proactive in my treatment.

The purpose of timed mode is to deal with centrals.

If for example, you show symptoms of OSA (obstructions) during the sleep study, then when they put you on cpap therapy, you start showing both obstructive and 'significant' central apneas then they deem it as CompSA (Complex Sleep Apnea). Timed mode allows the machine to operate between epap & ipap pressures at the minimum backup rate set into it. The machine in cycling between the two pressures is attempting to induce the sleeper back to regular breathing.

ASV (or Servo Ventilation) is more like a tri level machine and with a self adjusting backup rate (aslo know as AUTO RATE).

The ASV basically works like a timed mode bilevel but the ipap pressure can be adjusted upwards very quickly if the sleeper's breathing becomes irregular (in particular if they start to exhibit a fluctuating tidal volume of air - breathing shallow then deep then shallow then deep etc: ), The ASV can increase pressure by 3 CMs per breath for 3 breaths if the current settings allow it to go that high. That is a very rapid & dynamic increase of ipap pressure & AFAICT works exceptionally well. Thus, ASV is seen by many as the Rolls Royce of therapy. The machines if correctly titrated for the obstructive component, will handle most other common & uncommon irregularities.

The AUTO backup rate allows the machine to track the sleepers normal (regular) rate of breathing (say 15 BPM) & if it varies outside a tracked target the machine can use its epap/ipap cycling (plus ipap pressure boost) to steer the sleeper's breathing back to a target rate of breathing. The ASV machines do this same tracking of the tidal volume of air being breathed & if it varies to far from a tracked target (say 90% of the past 3 or 4 min average volume), the machine applies ipap pressure boost to induce the sleeper to vary their volume back to the targeted range.

ASV therapy is not the ideal where the patient requires a fixed volume of tidal flow to be maintained at a fix breathing rate. There are other machines suited to that but (e.g. Respironics AVAPS), few people have a need for that level of controlled ventilation.

DSM

[dsm]

PS

If you are in the US, this is the Resmed product line (look for the bilevel devices section)
http://www.resmed.com/us/products/devic ... c=patients

Outside the US - these are the models (some have different names)
http://www.resmed.com/int/products/slee ... c=patients


The US product line does appear a bit confused due to them introducing several variations of models.
i.e.

After the VPAP III range came ...

Vpap Malibu (no longer sold used the old big case same as the Vpap III)
Vpap S (the S8 version of the Malibu - The S8 shape is a small compact design)
Vpap ST (S8 design)
Vpap Auto (S8 shape but now dropped)
Vpap Auto 25 (updated version of the Vpap Auto)
Vpap Adapt SV (uses same case as the Vpap III - top of the line sophisticated bilevel)


Outside the US, Resmed call the Vpap S & ST the Vpap IV S & ST.

DSM

[rogelah]

Thanks for the info. I feel I know more about what to ask when I go next Monday.

[dsm]

Thanks for the info. I feel I know more about what to ask when I go next Monday.

If your breathing is defective due to a muscle disorder, it may very well be that an AVAPS type machine is the better choice. I say this based on the way ASV machines track to a target. If your muscles are not up to the job, there is the risk that the ASV keeps tracking to 90% in a decline & your tidal volume may reach a low where it is not enough but your muscles can maintain that 'not enough' level & aslong as the 'not enough' is not fluctuating in volume the ASV will maintain it.

Get the doctor to talk you through his rationale for choosing whatever type of machine he does choose.

The point about an ASV though, is that it is better than a timed bilevel in that an ASV can be set to the exact same epap & ipap & backup rate as a timed bilevel, but adds the Ipap pressure boost algorithm so can be expected to do better than any timed bilevel can because of that extra capability.

The Respironics AVAPS machine works this way, it is a bilevel (called the Synchrony model) and has added pressure support (called AVAPS) but rather than tracking to 90% of a 3/4 min 90% average like the ASV machines do, it allows the doc to dial in a tidal volume say (500 ml )& the machine will raise pressure (boost ipap) if that exact flow is not being seen. It is also timed & will mostly force you to breathe the way it is set up. That makes it a bit irritating to some people but it is very capable of maintaining the needed tidal airflow that keeps you breathing.

Another issue with AVAPS is that most of us do vary our tidal flow as we go through different phases of sleep & ASV machines adapt to this. AVAPS don't they just keep you chugging away at the prescribed tidal volume.

You do seem to have a unique requirement & as said above, get the doc to explain in detail his rationale for which machine he chooses. ASVs aren't the answer to everything even if they do cover a very broad band of breathing irregularities.

Cheers

DSM

[rogelah]

Basically, I am unable fully expand my lungs because my diaphragm does not contract enough to draw air into the lower lobes. So, most of my breathing, even awake, is thoracic. Occasionally, by yawn reflex, I get a good deep breath which feels great.

When I am lying down my breathing is even more shallow...hypopneic...so when I am sleeping it is even worse. As I understand hypopnea, an event is at least a 50% reduction in airflow.

As for apneic events it is at least a cessation of breathing for 10 seconds or more. I asked the RT if he could tell me if my obstructive apneas were caused by blockage of the upper airway or rather a cessation of the breathing cycle due to lack of muscle function. He said they could only be caused by an upper airway blockage. This could be true if the throat muscles are weakened but I would also have trouble swallowing (I don't) However, there is weakness in the ventilatory muscles and it is possible they just stop. I really have no idea as to the cause of the OSAs. It is a question I will ask the doctor. Of course thy could be CSAs.

I understand the effect of inhale pressure support. I wish I could get my head around how exhale pressure reduction can help exhalation if the muscles just don't have the juice, even with pressure relief.

Any thoughts?

[jnk]

Basically, I am unable fully expand my lungs because my diaphragm does not contract enough to draw air into the lower lobes. So, most of my breathing, even awake, is thoracic. Occasionally, by yawn reflex, I get a good deep breath which feels great.

When I am lying down my breathing is even more shallow...hypopneic...so when I am sleeping it is even worse. As I understand hypopnea, an event is at least a 50% reduction in airflow.

As for apneic events it is at least a cessation of breathing for 10 seconds or more. I asked the RT if he could tell me if my obstructive apneas were caused by blockage of the upper airway or rather a cessation of the breathing cycle due to lack of muscle function. He said they could only be caused by an upper airway blockage. This could be true if the throat muscles are weakened but I would also have trouble swallowing (I don't) However, there is weakness in the ventilatory muscles and it is possible they just stop. I really have no idea as to the cause of the OSAs. It is a question I will ask the doctor. Of course thy could be CSAs.

I understand the effect of inhale pressure support. I wish I could get my head around how exhale pressure reduction can help exhalation if the muscles just don't have the juice, even with pressure relief.

Any thoughts?

I had not read your earlier posts in this forum. I have no excuse for that laziness on my part.

The questions you are asking are good ones, but in my opinion there are only a few posters at this forum qualified to address them with any real knowledge, and I am not one of them.

I will give you my thoughts as the average joe on the street, but my words are based only on what little I think I know about sleep apnea as a patient using a machine for about a year.

It sounds as if the extent to which your MD is playing a role in your sleep apnea is an unknown. It is unlikely that the sleep study tech fully understood the information he was getting from the bands around you during your sleep study if your MD was playing a significant role in how you breathe.

If you have a doctor with experience in pulmonology working well with an educated, experienced respiratory therapist, they may be able to figure out a game plan together for getting you set up well on a bilevel with enough distance between inhale pressure and exhale pressure to do more for you than address your obstructive apneas.

You may need to separate your thoughts about MD and your thoughts about sleep apnea in your thinking, even though they may interrelate. People get a kind of weakness in their throat with OSA who do not have MD. So the trick may be to find good treatment for the OSA and to think of the ventilatory benefits from bilevel to be a side benefit, in a sense.

RTs sometimes have a hard time looking at a little cute home machine and applying the principles of how a true ventilator works. But if you, your doc, and an RT are willing to work together on an approach, then a machine, such as the VPAP ST, may end up doing you a world of good.

My understanding is that a true central apnea occurs in the brain in a specific way. I can see weak muscles and the other complications of MD looking like a central during a test, but that doesn't, as I understand it, make it a central in the context of sleep medicine. Obstruction of the airway is one issue, and that's what home PAP machines are really good at dealing with. Shallow breathing from weak muscles and other things may not be exactly what home bilevels were designed to deal with, but a bilevel does ventilate, so it may come in handy for you along those lines. A timed backup may come in handy too, just in case there comes a time when the machine has trouble reading your effort to inhale because of the way you breathe.

Hopefully some more-experienced members in this forum can correct anything I got wrong with what I said above, since it is little more than guesswork on my part.

jeff

[rogelah]

My doc is a pulmonologist. He is in a large hospital/medical center and the sleep lab is also part of it. Since my neurologist and family care docs are also there he has access to all my medical records because they are all online.

It is a rare event for even a neurologist to treat someone with FSHMD and I have experienced this with other docs over the last 28 years I have sought treatment. The pulmo doc said he suspected sleep apnea when I went to him with the complaint of having trouble breathing, particularly when in bed, and when I went for followup after the PSG he was pretty excited when he showed me where I had stopped breathing for 60 seconds 2 times close together. I attributed it to his not knowing what to expect where FSHMD was involved.

My next visit is the followup to the titration and I am well-armed for discussion thanks to folks on this site.

The MDA website has a two part article on sleep apnea and MD. I am going to print them out and take them with me.

[Slinky]

GOOD LUCK, rogelah!!!!

[ozij]

Normal (healthy) human breathing does not need muscles for exhalation. Healthe lung tissue is elastic, and when you stop inhaling it collapses naturally - no need to use muscles. Exhalation becomes on effort for people wiht COPD, because they have force the air out of their stiff lungs, and when we breathe against the cpap pressure.

I your case, you have a volume restriction (on inhaling) and may have trouble exhaling against any pressure. So I suggest you look up Respironics' solution for people with restricted volume, the BIPAP AVAPS . http://bipapavaps.respironics.com

Who potentially benefits from AVAPS™ technology?

Restrictive patients benefit because AVAPS™ provides the comfort and leak compensation of a pressure mode and the safety of a guaranteed volume.

Obese hypoventilation patients benefit because the algorithm compensates for changes in body position and maintains ventilation.

COPD patients benefit because AVAPS™ achieves a combination of ventilation comfort and efficiency without compromise. The algorithm applies the right pressure at the right time.

AVAPS stands for Average volume assisted pressure support - I think you may need that The site has a link to has a training presentation.

Ask the doctor about that machine as well - and remember he may not even know it.

O.

Edited link - thank's to jnk's comment.