ASV-what does my rx mean?

[TahoeGal]

I have an S9 VPAP Adapt. My rx reads: 25 max pressure/ 15 max EPAP/ 4 min EPAP/ 15 max PS/ 0 min PS/ 3 Biflex and auto BPM. What do the letters mean? I don't see on my machine anywhere it says "25 max pressure" or "3 Biflex and auto BPM". Also, what would I adjust to get a little more air on the startup? I do use ramp for 5 minutes, and feel suffocated most of the time.
Thanks!
TG.

[Pugsy]

BiFlex is a Respironics machine feature. It's Respironics exhale relief. It's not going to be on your S9 Adapt.

BPM Breaths per minute...on a Respironics machine it can be set to a minimum before the machine kicks in for you or it is set to Auto and the machine figures out what your normal is and if you go too low it kicks in. ...I think that is how it comes up with Auto or maybe it's just 10 or 12.
These features are not available on the Adapt.

The Adapt machine I have doesn't have ramp... I would think all you need to do is set the ramp starting pressure higher just like with other cpap machines.
My machine had a default EPAP of 5.0 I think it was...I experience some air hunger at that setting so changed it to 6.0 and it was more comfortable.
In the clinical setup menu there should be an EPAP setting available just for ramp time. It's probably starting out at 5.0 EPAP.
Do you have the provider manual for this model Adapt?
The prior model was 36007...the most recent model is 36047 I think.

EPAP is Exhale pressure
IPAP is Inhale pressure
PS is Pressure support which is the difference between EPAP and IPAP

Looks like your settings are with EPAP starting at 4 cm with max at 15 so that's what your exhale pressure is after ramp and the rest of it is pretty much wide open. The machine will decide what it needs to do.

Respironics and ResMed have similar models of ASV machines but they have slightly different settings and features available.
The end result is the same but they take slightly different paths to get to that end result.

[TahoeGal]

Thanks for the decoder ring.
I don't have the clinicians manual. I have unlocked my machine (thanks to this site) so that I can see my nightly AHI, and the settings. I tried to change my min EPAP setting, but I couldn't do it. My machine does not specify a ramp starting pressure in the menu.

TG

[Pugsy]

Send me a PM with your private email address and I will send you the providers manual as pdf attachment... for what I think is your machine..at least it mentions ramp and it may not have an adjustable minimum like I thought. It doesn't mention it anywhere from what I read but I just did a quick glance.

[squid13]

Be nice to know if you have the 36007 or the 36037 adapt. The 36037 has the Auto ASV selection in it.

[JDS74]

I have an S9 VPAP Adapt. My rx reads: 25 max pressure/ 15 max EPAP/ 4 min EPAP/ 15 max PS/ 0 min PS/ 3 Biflex and auto BPM. What do the letters mean? I don't see on my machine anywhere it says "25 max pressure" or "3 Biflex and auto BPM". Also, what would I adjust to get a little more air on the startup? I do use ramp for 5 minutes, and feel suffocated most of the time.
Thanks!
TG.

Max Pressure is the maximum pressure that is allowed for both inhale ( IPAP) and exhale (EPAP)
Max EPAP is the maximum exhale pressure
Min EPAP is the lowest exhale pressure
Max PS is the maximum pressure support
Min PS is the minimum pressure support
BiFlex is the difference between exhale pressure and inhale pressure
Auto BPM indicates allowing the firmware to select the time between breaths. If you take longer than this calculated time, the machine switches to ventilator mode and breathes for you at this rate. It is continuously calculated to take into account normal variation that occurs while you sleep. Apparently this feature is not available on a Resmed machine.

This Rx seems to have been written for a Respironics ASV machine. How did you end up with a Resmed?

So, without considering ramp functionality, you start out at Min EPAP + Min PS for what on other machines is called EPAP. Your IPAP would be the calculated EPAP plus the BiFlex value. (I think this is the way it would work on a ResMed machine)

So it looks like you start out as 4/7 and work your way from there. As obstructives are detected, the EPAP value is adjusted up. For centrals, the PS gets adjusted (I think???). In ventilator mode, PS is dropped but the current value for IPAP is maintained and allowed to increase until the value for Max Pressure is reached.

With a starting pressure of 4/7, feeling suffocated is understandable.

[Pugsy]

Your IPAP would be the calculated EPAP plus the BiFlex value. (I think this is the way it would work on a ResMed machine)

BiFlex is Respironics only.
The S9 Adapt..any model doesn't do BiFlex which is an exhale relief function found only in Respironics machines..
I don't see BPM on the Adapt manuals either.
OP has an S9 Adapt ASV...might be the new Auto model..unsure at the moment.
So it appears a Respironics settings RX but was dispensed a Resmed machine and not all the settings shown on RX are available on the Adapt.

IPAP on ResMed is EPAP plus Pressure support

[TahoeGal]

Well, I have the 36037 machine. I couldn't tell you how I ended up with the ResMed machine- maybe it was more expensive? In my situation, I did get a call from the DME saying that they got the rx and I would be getting the ResMed. Maybe because I am a cash patient, and they wanted to take advantage of me?

My machine has Mode: ASVAuto, ASV, or CPAP

It is set on ASVAuto. I can change that on the machine.

Pugsy, I'll send you my email. Thanks!

[shortcake]

Your EPAP will continually adjust between 4 - 15 based on any obstructive events recorded during the night. Based on a PS min of 0, your machine at times will have NO difference between inhale and exhale pressures. i.e. If your EPAP value is at 4 (which it will be when you first turn it on), your IPAP (EPAP + PS) range can be from 4 to 19. But your IPAP will never go above 25 (your max pressure setting). So if your EPAP is 15, your max PS is reduced to 10, since 15 + 10 = 25, the upper limit. If you're breathing well on your own and the EPAP is keeping events at bay for a time, it's very possible your machine will deliver straight CPAP pressures (again, because your PS min is 0), and it will increase your PS to sufficiently ventilate you if you begin having some central issues.

The above is the same for either the Resmed VPAP autoSV or the Respironics auto SV advanced, but their algorithms to decide pressure changes and target parameters differ. As others have mentioned Biflex is a Respironics-only technology and delivers a small amount of pressure relief during the end of inhalation and beginning of exhalation to make those transitions more smooth, and thus make breathing feel more natural. While your Rx did mention a Biflex setting, your therapy will not be affected at all due to lack of this feature on the Resmed machines (which have Easy-Breathe technology to make breathing feel more natural).

I'm wondering if you can't find the ramp min setting because your EPAP min is at 4, which is already the lowest possible setting, and therefore the pressure could not be ramped. Chances are that your average EPAP during the night is more than 4, but that's the starting pressure when you turn on the machine, which would explain the air hunger. If for some reason ramp does work while at EPAP 4, but the ASV thinks you need higher settings, it won't increase as much as it would otherwise as long as you're in the ramp mode. Ramp mode can really cause issues for ASV users, especially if the ramp time is long... it can skew the initial target values and lead to over- or under-ventilation. I've stopped using the ramp feature on my Respironics auto SV advanced because it causes a truckload of central events which don't resolve until the ramp time is over and the full ASV algorithms are allowed to kick in.

I have used both machines, just not the latest model from Resmed, so if you have any questions just let me know!

[TahoeGal]

Very interesting, shortcake.

So maybe I should not use the ramp at all. I've been using it since I got this machine. The DME tried to dump a used, old model on me (after trying to give me a ResMed Auto machine). They let me use the old model until they could get a new one(reluctantly ) ordered for me. When I would turn that machine on, the air would blast so hard that my ears would pop. Not very comfortable.

I have severe central apnea. My report showed that I had 6 obstructives total for the night, so I definitely want to target my therapy to the centrals.

TG

[shortcake]

Did you have a titration done in a sleep lab? Your settings are pretty wide open, so that's why I'm wondering.

I agree that your feeling of suffocation would be helped by a higher EPAP setting. It doesn't have to be drastic... even .5 or 1 cm higher can make a big difference. Raising your pressures too much may make it harder to exhale against, so aim for the lowest setting that makes breathing comfortable for you.

[shortcake]

It's interesting to note that the first version of the S9 VPAP Adapt (which I have) didn't even have a ramp feature. Just speculating here, but perhaps the original concept was geared more toward Central SA patients, which would probably have lower overall EPAPs and therefore the gradual ramping of pressure seemed unnecessary. I wonder if they decided to include it in later models because 1) Respironics did, and 2) it could be useful for Mixed or Complex SA patients prescribed higher EPAP mins.

[TahoeGal]

shortcake,

I was titrated in a study. It was a full night study, where it was found that CPAP and BiPAP both caused a rapid increase in centrals, and the VPAP reduced them dramatically. I could tell the difference in the morning- I was sleeping well and wasn't tired until mid-day. I always woke up tired prior to the VPAP therapy.

I'll turn off the ramp tonight and see how it goes. I should be able to eek out some time tomorrow to read the manual and learn how to tweek the dial a little. I don't want to go crazy- just a little adjustment.

TG

[Pugsy]

If turning off the ramp doesn't offer more breathing comfort..you may want to increase that EPAP minimum from 4 to maybe 5 or 6. I can't imagine ramp being any lower than 4 but maybe it is.
I struggled with 5.0 myself. That's the lowest my 36007 will go.
You would eventually most likely get used to the lower EPAP at 4 with time but why be uncomfortable when it doesn't have to be that way.

[TahoeGal]

I read part of the manual last night, and the rest this morning.

What I learned:
The current pressure is displayed on the screen, but you have to turn on the back light to see it.
The ramp starts out at 4 and min PS, then slowly ramps up to therapy pressure.
I can adjust the min EPAP, I was just turning the dial the wrong way. 4 is the min EPAP.
The machine does not track central apnea events (!). The AHI values are obstructive events only.

And so:
My start pressure is set to 4 per my rx, but, I was running at 7 when I woke up.
I turned off ramp, since it makes no difference to me at my min EPAP and min PS pressures. There is no ramping up to be done, and it may be harmful.
I adjusted my min EPAP to 5 this morning. Given that I was breathing at 7 this morning, I may want to go higher. I will monitor my morning EPAP and see what my pressures are when I am breathing free and easy.
My low AHI is about what I should expect from my sleep study-I had 6 obstructives during my 5 hours of sleep- my AHI is running below 1.5. This morning I scored 0.0. Feels good, but that tells me nothing about my central events.

I want to thank all of you for your help. I am better educated on my machine and therapy. If adjusting my min EPAP can make my therapy more comfortable, I'm all for it. This site and it's members ROCK!

TG