Help with ASV settings

[justbreathe]

I had my S9 VPAP Adapt exchanged for a Resperonics Bilevel AutoSV Advance today so the backup BPM could be set.

The DME set it up with these settings:
Max Press 25
EPAP Min 4
EPAP Max 10
BPM 12
PS Min 3
PS Max 15

My Recommended settings from my Sleep Doctor are:
ASV EEP 10
MIN PS 3
MAX PS 15
BPM Backup 12

Are these settings correct?

[Bons]

Looks correct. Min PS and Max PS are the same thing as EPAP min and EPAP max (just different terms for ResMed and Phillips Respironics machines, I think). Same with EPap Max and ASV EEP.

The bpm would be way too high for me. See how it goes for you.

Good luck with your new bed partner!

[JohnBFisher]

I had my S9 VPAP Adapt exchanged for a Resperonics Bilevel AutoSV Advance today so the backup BPM could be set.

The DME set it up with these settings:
Max Press 25
EPAP Min 4
EPAP Max 10
BPM 12
PS Min 3
PS Max 15

My Recommended settings from my Sleep Doctor are:
ASV EEP 10
MIN PS 3
MAX PS 15
BPM Backup 12

Are these settings correct?

Well, let me lay it out this way:

Max Press 25 = MAX PS 15 + ASV EEP 10 = 25cm H2O ... Looks good.
EPAP Min 4 = ASV EEP 10 - 6 ... That's 6cm H2O lower than prescribed. See note below.
EPAP Max 10 = ASV EEP 10 .... The max value is the same as the prescribed value. Good.
BPM 12 = BPM Backup 12 ... Looks good.
PS Min 3 = MIN PS 3 ... Looks good.
PS Max 15 = MAX PS 15 ... Looks good.

So, the DME set the minimum exhalation pressure to 4cm H2O. That's REALLY low. Though the Respironics BiPAP AutoSV Advanced (and/or the S9 version) can auto adjust as a BiLevel machine, 4cm H2O is normally WAY too low for most people. I would recommend increasing this value (EPAP Min) from 4cm H2O to at least 6cm H2O, if not all the way to 8cm H2O. The current range will create pretty strong swings on the exhalation pressure. A lower range will allow some additional relief without allowing obstructions to occur as frequently.

Hope that helps.

[justbreathe]

Thank you John. That is exactly as I was thinking it should be and even argued with the DME about the settings.

I will call advocate for the adjustment. 4 was way low last night.

[justbreathe]

Just got off phone with DME.

He agreed that it should be set:

Max Press 25 = MAX PS 15 + ASV EEP 10 = 25cm H2O ... Looks good.
EPAP Max 10 = ASV EEP 10 .... The max value is the same as the prescribed value. Good.
BPM 12 = BPM Backup 12 ... Looks good.
PS Min 3 = MIN PS 3 ... Looks good.
PS Max 15 = MAX PS 15 ... Looks good.

I made the adjustments.
I asked my doctor to allow me to lower pressure to 8 when he said he wanted to lower RR first to 12 then we could lower pressure later when we see what that does for me.

I have an appointment next Tuesday and we will discuss it at that time.

AGAIN Thank you for helping...

[JohnBFisher]

Your doctor is wise ... One change at a time. I used to be a high power trouble shooter for a computer company. You would be AMAzed how often people change two or three things at once and then can not sort out what did what. One change at a time!

[moresleep]

Just got off phone with DME.

He agreed that it should be set:

Max Press 25 = MAX PS 15 + ASV EEP 10 = 25cm H2O ... Looks good.
EPAP Max 10 = ASV EEP 10 .... The max value is the same as the prescribed value. Good.
BPM 12 = BPM Backup 12 ... Looks good.
PS Min 3 = MIN PS 3 ... Looks good.
PS Max 15 = MAX PS 15 ... Looks good.

I made the adjustments.
I asked my doctor to allow me to lower pressure to 8 when he said he wanted to lower RR first to 12 then we could lower pressure later when we see what that does for me.

I have an appointment next Tuesday and we will discuss it at that time.

AGAIN Thank you for helping...

What happened with EPAP Min? Did that get raised to 6 or 7cm? That's the one setting that definitely needed changed...

[jamiswolf]

Guys,
I don't understand why 4 is so bad for EPAPmin. That's what Respironics recommends as a start point on their titration protocol. The machine ramps up both EPAPmin and IPAPmin as needed to deal with OAs.

Or is it just that it's lower then his Resmed RX specified.
Striving to learn...
Jamis

[moresleep]

Two reasons I can think of are: (1) At a pressure of 4cm, CO2 is probably not being flushed out of the mask/hose sufficiently. (2) You do not really want the Cpap machine to waste too much time coming up to the therapeutic pressure. As the titration was for 10cm, we know that 4cm is way too low. A/H events would be happening while the machine carefully and slowly ramped from 4cm up to whatever was needed, and this would probably repeat in cycles throughout the night. EPAP Min=7, though, just might be enough, as PS Min=3, meaning that the machine starts with Bipap settings of 7/10. And even if it is not, the machine still will not waste as much time coming up to the right pressure.

Resmed's titration protocol is not a treatment protocol but a diagnostic protocol. It starts with pressures too low for treatment, to see what is happening without effective Cpap treatment, and then works these settings laboriously up the ladder from there, stopping at the configuration of settings that provides effective treatment.

[jamiswolf]

Thanks for the explanation Moresleep...

I'm a Respironics guy and I think a got a little lost in the translation.
J

[justbreathe]

What happened with EPAP Min? Did that get raised to 6 or 7cm? That's the one setting that definitely needed changed...

I set EPAP min and max to 10 this is the same as EEP 10.
PS 3 min and 15 max just like the doctor ordered.

[justbreathe]

As the titration was for 10cm, we know that 4cm is way too low. A/H events would be happening while the machine carefully and slowly ramped from 4cm up to whatever was needed, and this would probably repeat in cycles throughout the night. EPAP Min=7, though, just might be enough, as PS Min=3, meaning that the machine starts with Bipap settings of 7/10. And even if it is not, the machine still will not waste as much time coming up to the right pressure.

My titration was for 10 EEP (end-expiratory pressure), This is EPAP (expiratory positive airway pressure),
IPAP (inspiratory positive airway pressure) range is 13 to 25.

[JohnBFisher]

... I don't understand why 4 is so bad for EPAPmin. That's what Respironics recommends as a start point on their titration protocol. The machine ramps up both EPAPmin and IPAPmin as needed to deal with OAs. ...

[ Emphasis is mine ... ]

Jamis, just a couple notes. First, this is a Respironics unit. It is an ASV unit, so it a bit more complicated with all the settings.

Second, justbreathe already had a titration study. They set one pressure for EPAP not a range. Thus, either the sleep tech did not have time to deal with a range of pressures, did not know how, or was not requested to do so. At any rate, the prescribed pressure is for a BiLevel, not for an Auto-BiLevel setting.

Third, the Respironics ASV can act as an Auto-Setting Bi-Level Device. However, if it detects insufficient airflow it will switch to ventilator mode. To do this magic, it sets a minimum EPAP value and a maximum EPAP value. Then on top of this, it can increase the pressure support via a minimum and maximum value. If the EPAP minimum and maximum values are the same, then it disables the Auto-titration capability. The PS values set the maximum pressure the unit will use to maintain respiration in the event of one or more central apneas.

So, unlike a normal BiLevel device, you don't have a set "Pressure Support" to attain the IPAP value. You also have a range to allow it to maintain respiration, if it is needed. Thus, you effectively have the following

EPAP Values = Range from EPAPmin to EPAPmax
IPAP Values = Range from (EPAPmin + PSmin) to (EPAPmax + PSmax)

That top value can be limited by a Maximum Pressure value and/or the top end of pressure that the unit will apply.

Sounds complicated, but it is not all that complicated. The only thing is this is just the tip of the settings that can be adjusted. It's not as complicated as a ventilator, but is definitely more complicated than a BiLevel (even auto-titrating) device. Of course, it does more, so more is needed to control it.

Hope that helps.

[jamiswolf]

John,
Yes, I understand that this is a Respironics unit, but justbreathe was translating Resmed settings which is what I'm not familiar with.

I'm transitioning to a PR S1 BiPaP auto SV advanced soon...should arrive today. Too many central apneas and periodic breathing. So my interest is more then mere curiosity.

John wrote: Second, justbreathe already had a titration study. They set one pressure for EPAP not a range. Thus, either the sleep tech did not have time to deal with a range of pressures, did not know how, or was not requested to do so. At any rate, the prescribed pressure is for a BiLevel, not for an Auto-BiLevel setting.

I'm very happy you mentioned that. I was puzzling over why EPAPmin and EPAPmax were set the same.

So when functioning on the auto BiPap mode, it really only adjusts the EPAP upward to deal with OA? (always maintaining PSmin) Or is there an auto component to the IPAP as well?

I've read the entire asv thread and am working my way through Paper_nanny's thread. It's helpful to see a change made followed up by patient response.

I'm certain I'll have more questions and it's reassuring to know friendly help is available. My Doc knows nothing about the machine and RT neither. Never set one up...small town.

Justbreathe, best of luck with your new machine and thanks for undulgeing my little hijack on your thread.
Cheers,
Jamis

[justbreathe]

Jamis,

Were you titrated for ASV?

What is your prescription?

First night I struggled with the low pressure but last night was great.

I think I am finally being treated correctly.