BiPAP needed

I have been using a CPAP for 2+ years. I've have recenlty been prescribed a BiPAP. I know auto-titration is very important as is a data card. Unfortunately, that's all I know. Any recommendations on what to look for?

Thanks!

Mr Sleepy wrote:I have been using a CPAP for 2+ years. I've have recenlty been prescribed a BiPAP. I know auto-titration is very important as is a data card. Unfortunately, that's all I know. Any recommendations on what to look for?

Thanks!

Well, this looks like a good deal here, if it hasn't already been snapped up:

"Respironics BIPAP Auto with BI-FLEX for sale Price Reduced"
topic started by awake_again - Nov 23, 2011 (and update edited on Dec 2, 2011, so it was apparently still for sale on Dec 2.)
viewtopic.php?p=658048#p658048

You'd need to register on this forum (registration is free) so you could send the person a private message (the "PM" button at the left of his post) to discuss mailing address, etc.

Hi,
The machine RestedGal linked to is an older Legacy machine and is overpriced. Just to get that out of the way. Though he says he'll consider offers.

Are you looking for a used machine or a new machine that insurance will pay for...big difference.

Sometimes, even with insurance and co-pays, it's cheaper to pay for it yourself and eliminate the DME.
Jamis

try to stick to either a PR (Phillips Resiprionics) S1 (System 1) or an S9.

The auto's are great, with lots of flexibility

What you don't want is a PR S1 Bipap Plus... it's a compliance only machine.

Is insurance paying for the new machine because it's medically necessary?

In any case, both the Resmed S9 VPAP Auto and the PR System One BiPAP Auto are nice machines. There are some differences between them, however.

The three big categories of differences, in my humble opinion are:

• The comfort features
• The on-board data and software choices
• The auto algorithm itself

Which machine to chose may depend on your own needs and preferences in each of these categories.

The Comfort Features
The S9 has the ClimateLine heated hose as an option. And its anti-rainout system is based on the ClimateLine hose. The System One's anti-rainout is based in how the humidifier takes the room's relative humidity and temperature into account in how hot it heats the water and how much water it allows to evaporate into the air going into the tube. Some insurance companies (such as mine) will refuse to cover the additional cost of the ClimateLine hose.

The System One has Bi-Flex as an exhalation relief system. Bi-Flex will provide a small bit of additional pressure drop beyond that provided by simply going from the IPAP to EPAP settings. In other words, if IPAP = 15 and EPAP = 10, at the start of the exhalation, the pressure will actually drop a bit below 10 cm and then the machine will increase the pressure back up to 10cm before the exhalation is complete. I believe the S9 VPAP does not have any additional pressure relief: The transition between IPAP and EPAP and back to IPAP is already a modified version of the EPR system in the S9 Elite/AutoSet. What I mean by "modified" is that in the S9 VPAP, the pressure drop at the beginning of the exhale obviously not limited to a max of 3 cm. And there is a very slight difference between how and when the VPAP and the Elite/AutoSet increase pressure back up at the end of the exhale or start of the inhale.

On-board data and software choices
The on-board data on the System One is very, very limited. The AHI is only 7 and 30 day rolling averages and is not broken down at all by event type. And the System One's on-screen "Percent time spent in Large Leak" data are virtually meaningless: Not only is 1% of seven nights of data a very long time, but also PR doesn't seem to define or describe what constitutes a Large Leak anywhere. And there's the annoying fact that the System One updates its data at noon Greenwich Meridian Time. And you can't change this. And you can't change the clock setting either. And the DME cannot change the clock setting from inside the clinician's menu.

The on-board data on the S9 VPAP is excellent: You get nightly, weekly, and 30 AHI numbers broken down by type of event. You get 95% unintentional leak rate figures. And there's a mask-fit feature that may be useful. The overnight data is available within a minute of turning the machine off. But you do have to view the overnight data before noon local time. The patient can't change the clock from the patient set up menu if I recall correctly. But the DME can set the clock through the clinician's menu.

As for the software: SleepyHead can be used for either of the machines, although it's still a bit buggy with the S9 VPAP Auto if I understand correctly. For more information about SleepyHead, see the SleepyHead wiki for more details. The newest version of ResScan should work with the S9 VPAP. Encore Viewer, the patient oriented software sold by PR, will work with the System One BiPAP Auto. Both machines record the following data on the SD cards:

• AHI broken down by types
• time of each event
• leak rate data
• wave form data---i.e. you can see each breath you took all night long
• some form of flow limitation data
• some form of snoring data
• pressure setting data

In addition to the above data, the S9 also records information about minute ventilation and respiratory rate. In addition to the above information, the System One records RERAs and periodic breathing (Cheney-Stokes breathing). (Update: JediMark sent email today to the SleepyHead user's list over at sourceforge.net that indicates he's found a way to derive tidal volume, minute ventilation & respiratory rate from processing the flow rate waveform for the System One machines; he describes them as "a little bit noisy, but [they] still look good." and he's double checked the graphs "by overlaying against a fancy ASV models data.")

The leak data on the System One is total leak---i.e. it includes the expected leak built into the mask. The S9 reports unintentional leaks---i.e. the S9 subtracts off the expected leak rate for the type mask you are using at the pressure you are using and reports any excess leak.

The System One "flags" flow limitations and snoring as discrete events; the S9 provides a continuous graph indicating the amount of flow limitation and the severity of the snoring as functions of time. Note that the System One does record enough snore data for SleepyHead to provide a snore graph as well as the tick marks. The Flow Limitations are only recorded on the System One BiPAP Auto when it is running in Auto mode.

The Auto Algorithms
The Auto Algorithms used by the Resmed S9 VPAP and the PR System One BiPAP auto are NOT the same. And the differences may be important to you in the sense of how it feels to use the machine all night long. And which algorithm would feel best to you may be hard to predict.

That said, here is my understanding of the differences between the two Auto algorithms:

Both the Resmed S9 VPAP Auto and the PR S1 BiPAP Auto have algorithms that automatically adjust the IPAP and EPAP pressures in response to the various events detected by the machine. But the two companies have taken quite different approaches in their algorithms. Informally this difference can be described as follows:

• The Resmed S9 VPAP adjusts BOTH the EPAP and IPAP by the same amount in response to OAs, hypopneas, snoring, and flow limitations. Like the S9 AutoSet, the VPAP tends to respond quickly to clusters of events and then slowly reduces both pressures back down at the same rate until more events occur.
• The PR S1 BiPAP Auto adjusts EPAP and IPAP independently of each other: EPAP is increased in response to OAs and snoring, and IPAP Is increased in response to hypopneas, flow limitations, and RERAs. In addition to these things, the PR S1 also uses the same "hunt and peck" algorithm that the PR S1 Auto uses to test whether the shape of the wave flow data improves with a slight increase in pressure. The hunt and peck algorithm is only applied to the IPAP pressure for increasing pressure. After events that trigger an increase in IPAP or EPAP are resolved, the S1 does a reverse hunt and peck to find out how far it can lower the pressure: As long as the flow wave remains stable, the PR keeps lowering the appropriate pressure, but if the flow wave becomes more ragged, the S1 will raise that pressure back up to the last level where the flow wave was stable

To make the some of the differences between the two machines' auto algorithms clearer, we need to introduce a setting that only Auto Bi-level PAP machines have---the PS (pressure support setting). Loosely PS is the difference between IPAP and EPAP and the value of the PS setting affects the way the EPAP and IPAP pressures are adjusted. The way PS is implemented on the S1 and the VPAP is quite different however:

• On the S1 BiPAP Auto, the PS setting is the maximum allowable value for IPAP - EPAP. And the minimum value the S1 will allow for IPAP - EPAP is 2. The upshot of this is that whenever 2 < IPAP - EPAP < PS, the IPAP and the EPAP are allowed to vary independently of each other. But when IPAP - EPAP = 2 or IPAP - EPAP = PS, there are some constraints on how the pressures are increased or decreased. In other words:
  
  • When 2 < IPAP - EPAP < PS:
    • If the IPAP needs to be increased, only the IPAP will be increased, the EPAP stays the same.
    • If the IPAP needs to be decreased, only the IPAP will be decreased, the EPAP stays the same.
    • If the EPAP needs to be increased, only the EPAP will be increased, the IPAP stays the same.
    • If the EPAP needs to be decreased, only the EPAP will be decreased, the EPAP stays the same.
  • When IPAP - EPAP = PS:
    • if the IPAP needs to be increased, then both IPAP and EPAP will increase at the same rate.
    • If the IPAP needs to be decreased, only the IPAP will be decreased, the EPAP stays the same.
    • If the EPAP needs to be increased, only the EPAP will be increased, the IPAP stays the same.
    • if the EPAP needs to be decreased, then both IPAP and EPAP will decrease at the same rate
  • When IPAP - EPAP = 2:
    • If the IPAP needs to be increased, only the IPAP will be increased, the EPAP stays the same.
    • if the IPAP needs to be decreased, then both IPAP and EPAP will decrease at the same rate.
    • if the EPAP needs to be increased, then both IPAP and EPAP will increase at the same rate.
    • If the EPAP needs to be decreased, only the EPAP will be decreased, the EPAP stays the same.
  • And at the start of the night, EPAP = min EPAP and IPAP =min EPAP + 2.
• On the VPAP, the PS setting is the fixed value for IPAP - EPAP. Hence IPAP and EPAP are always increased together on the VPAP. (And that's why the ResScan reports for VPAP mahcines can show the pressure info with only one curve.) At the start of the night EPAP = min EPAP and IPAP = min EPAP + PS.

Of course the big questions are: Which system is more effective? and Which system is more comfortable? As a mere patient, I haven't the foggiest if one of these systems is inherently better at treating apnea. And obviously both machines have been run through the full range of efficacy testing required by the government. But it's easy to believe that some folks might respond better to one of the two algorithms than the other.

Wow...thanks for all of the information. This is VERY helpful.