Does the RAMP feature work with BiPAP "S" mode?

My BiPAP Machine is on fixed level "S" at 19/4 and even though the RAMP feature is enabled (and not grayed out in the options) for 45 minutes, when I turn on the machine it starts at a slightly lower pressure of 15/4 but only for about 10 seconds and then it goes up to the prescribed pressure and remains there.

Go into the clinical setup menu and write down each setting option and the setting choice.
Tell us what those settings/numbers are.

Clinical settings are as follows:

Mode: S
IPAP: 19.0
EPAP: 4.0
Easy Breathe: On
Ti Max - 2.0 s
Ti Min - .03 s
Trigger - Med
Cycle - Med
Mask - Full Face
Ramp Time - 45 min
Start EPAP: 4.0

Matt00926 wrote:IPAP: 19.0
EPAP: 4.0

Wow...that is a big difference between EPAP and IPAP. Do you have any lung/respiratory issues that might cause a need for such a big pressure support of 15 cm (Pressure support is the difference between EPAP and IPAP and 15 is a bit unusual).

As for ramp...ramp can't drop the pressure lower than 4 cm on EPAP
What ramp does is let a person start out at a lower EPAP pressure and gradually work up to a higher EPAP pressure but in your case your pressure setting is already set with EPAP at 4 cm and that's as low as it can go.

It takes a few seconds for the machine to work up to 19 cm and that's why you see it take a few seconds...but the 4 cm is always the EPAP pressure because it can't go lower...so ramp is essentially non functioning or you can look at it the other way in that you are using ramp EPAP all night.

I would be questioning that 4 cm EPAP...that's not a normally seen useful EPAP setting with that high of IPAP.

Do you have a copy of the RX where it says the pressure settings to be used? I am wondering if a mistake was made and PS should be 4 and that would make EPAP 15.
I would be verifying the settings...it would be highly unusual to have these settings unless you have some significant lung issues going on.

Pugsy wrote:

Matt00926 wrote:IPAP: 19.0
EPAP: 4.0

Wow...that is a big difference between EPAP and IPAP. Do you have any lung/respiratory issues that might cause a need for such a big pressure support of 15 cm (Pressure support is the difference between EPAP and IPAP and 15 is a bit unusual).

As for ramp...ramp can't drop the pressure lower than 4 cm on EPAP
What ramp does is let a person start out at a lower EPAP pressure and gradually work up to a higher EPAP pressure but in your case your pressure setting is already set with EPAP at 4 cm and that's as low as it can go.

It takes a few seconds for the machine to work up to 19 cm and that's why you see it take a few seconds...but the 4 cm is always the EPAP pressure because it can't go lower...so ramp is essentially non functioning or you can look at it the other way in that you are using ramp EPAP all night.

I would be questioning that 4 cm EPAP...that's not a normally seen useful EPAP setting with that high of IPAP.

Do you have a copy of the RX where it says the pressure settings to be used? I am wondering if a mistake was made and PS should be 4 and that would make EPAP 15.
I would be verifying the settings...it would be highly unusual to have these settings unless you have some significant lung issues going on.

I will scan in a copy of the Rx in a bit.

I have kyphoscoliosis, restrictive lung disease as a result, and then secondary pulmonary hypertension as a result of both. I have nocturnal hypoventiliation and hypercapnia with a low oxygen saturation and high carbon dioxide level.

During the sleep study titration they found that 19/4 is what was needed in order to keep my lowest oxygen saturation at 92% (without PAP therapy it was below 88% for extended periods of time; lowest was 73%) and my CO2 level below 50 (was above 50 without PAP therapy for 85% of the two hours pre-test).

Because of the crazy pressure I am having problems with the Airfit F10 full face mask, there are no leaks when I'm sitting up but in most positions laying down I will eventually feel a slight leak or it will make funny fart-sounding noises and I keep having to adjust.

With proper titration I was registering zero OSA's, Zero Hypo's. Now I am getting close to zero hypo's and 2-5 OSA's per night and overall feel very frustrated even though I do feel better overall (only on day 5).

Ahhh...that makes more sense now.
You do have significant lung issues and I suspect that the unusual settings are so that it is easier for you and keeps the oxygen levels more stable.

Unfortunately those widely changing pressures are going to play hell with the seal on the full face mask...any full face mask really.

I wonder if you would benefit from using a mask line?
http://www.padacheek.com/PAC_Maskliners.html
Seems to help a lot of people at the higher pressures and might be worth a try. You can make your own out of an old Tshirt to give yourself and idea if it would help or not.

Alternately if you could use a nasal mask or a nasal pillow mask the pressure changes might be easier to manage but I would talk to the doctor to make sure he was okay with it in your situation because of the oxygen issues.
Normally I would just say go for it if you can but your situation is a bit unique.
I use a nasal pillow mask and I see pressures in the 20s IPAP (with EPAP around 7) almost every day but I don't have any lung issues. My leaks are minimal and never wake me up.
Some DMEs think that these higher pressures mean people can't use a nasal interface mask but we have lots of forum members here that use them with great success with pressures in the 20s.
So unless your nose is not clear enough and you just have to mouth breathe...and the doctor is okay with it...there's no reason to not at least try a nasal interface mask. The surface area needing to be kept sealed is simply a lot less and it's easier at the higher pressures.

Pugsy wrote:Ahhh...that makes more sense now.
You do have significant lung issues and I suspect that the unusual settings are so that it is easier for you and keeps the oxygen levels more stable.

Unfortunately those widely changing pressures are going to play hell with the seal on the full face mask...any full face mask really.

Yes it is crazy, the pressure system makes the mask expand and you can feel the straps moving. I eventually tighten the top and bottom pretty substantially which is not that comfortable.

Pugsy wrote: I wonder if you would benefit from using a mask line?
http://www.padacheek.com/PAC_Maskliners.html
Seems to help a lot of people at the higher pressures and might be worth a try. You can make your own out of an old Tshirt to give yourself and idea if it would help or not.

I will try this.

Pugsy wrote: Alternately if you could use a nasal mask or a nasal pillow mask the pressure changes might be easier to manage but I would talk to the doctor to make sure he was okay with it in your situation because of the oxygen issues.
Normally I would just say go for it if you can but your situation is a bit unique.
I use a nasal pillow mask and I see pressures in the 20s IPAP (with EPAP around 7) almost every day but I don't have any lung issues. My leaks are minimal and never wake me up.
Some DMEs think that these higher pressures mean people can't use a nasal interface mask but we have lots of forum members here that use them with great success with pressures in the 20s.
So unless your nose is not clear enough and you just have to mouth breathe...and the doctor is okay with it...there's no reason to not at least try a nasal interface mask. The surface area needing to be kept sealed is simply a lot less and it's easier at the higher pressures.

This is probably a dumb question - you can use a nasal mask in BiPAP mode? I tried CPAP nasal mask during the sleep test and I could not tolerate it. I tend to be a mouth breather at times, I think because my body is trying to get rid of excess CO2?

I am going to try the mask liner first.

I have an appointment with the sleep doc in June so I'm not sure if I need to wait and obtain more data? Would it be helpful to post my Sleepyhead Data overview?

Matt00926 wrote:Clinical settings are as follows:

Mode: S
IPAP: 19.0
EPAP: 4.0
Easy Breathe: On
Ti Max - 2.0 s
Ti Min - .03 s
Trigger - Med
Cycle - Med
Mask - Full Face
Ramp Time - 45 min
Start EPAP: 4.0
I have kyphoscoliosis, restrictive lung disease as a result, and then secondary pulmonary hypertension as a result of both. I have nocturnal hypoventiliation and hypercapnia with a low oxygen saturation and high carbon dioxide level.

what's strange is that this doesn't seem to be written to take advantage of the resmed vpap s capabilities to help people with restrictive lung disease.

I'm assuming that TiMin above is .3, which means all the assistive settings in the vpap are set at default normal lung settings.

Patients with restrictive lung disease have a difficult time maintaining the inhalation phase long enough to ensure adequate tidal volume and gas exchange. This can be caused by a physical restriction of the lungs or by neuromuscular weakness.
The recommended settings use a low cycle sensitivity and a longer Ti Min time to provide a longer inhalation time to
help increase tidal volume and gas exchange.

example settings from the resmed titration guide are:
ipap:11
epap:5
Ti Max: 1.5
Ti Min: .8
rise time: 300
trigger: HIGH
cycle: LOW
PS 6

also, if I remember rightly, when using bipap to treat lung conditions, (not just for comfort) you raise epap to increase oxygenation, and increase ipap to decrease co2.

you've definitely got the ipap for co2, but the low epap might make it harder to oxygenate, and the trigger/cycle/ti default settings could make it harder to breath.

I'd definitely take that up with your doctor.

Sure you can use a nasal mask (if you want to) with BiPap/Bilevel. Lots of people do it including myself. Not a big deal. Now some docs and some DMEs believe the old wives tale that nasal masks can't be used with higher pressures because someone told them that and that's not true at all. Yeah, a little bit of a challenge to keep sealed at higher pressures but it's not near the challenge that full face masks are at the higher pressures.
Contrary to popular belief the nasal pillows/cushion doesn't go flying across the room like a balloon that is deflating. There are people using pressures like 20 EPAP and 24 IPAP and being quite successful with nasal pillows.

The only reason I suggest running it by your doc is the oxygenation issue as sometimes docs want patients to be on a full face mask because of maybe using the carbon dioxide in the mask as part of the trigger to inhale. They sometimes will do that for people with central apnea which it doesn't sound like you have that issue...just severely limited lung function.

Now if your nose is so congested and you can't get it clear enough to breathe comfortable through your nose only then obviously your mouth breathing is out of physical necessity but a lot of people find that mouth breathing is more of a habit than from a physical need and those people can and do learn to keep their mouths shut (for the most part) and be quite successful with a nasal interface mask. I was one of them and I am not the only one.

Wish you the best and hope the xPap therapy works well. As for the pressure and mask issues, you can read a great deal on the following thread regarding NateS's experiences working with the F10 mask.

viewtopic.php?f=1&t=103073&st=0&sk=t&sd=a

Best,

Mike C.

palerider wrote:

Matt00926 wrote:Clinical settings are as follows:

Mode: S
IPAP: 19.0
EPAP: 4.0
Easy Breathe: On
Ti Max - 2.0 s
Ti Min - .03 s
Trigger - Med
Cycle - Med
Mask - Full Face
Ramp Time - 45 min
Start EPAP: 4.0
I have kyphoscoliosis, restrictive lung disease as a result, and then secondary pulmonary hypertension as a result of both. I have nocturnal hypoventiliation and hypercapnia with a low oxygen saturation and high carbon dioxide level.

what's strange is that this doesn't seem to be written to take advantage of the resmed vpap s capabilities to help people with restrictive lung disease.

I'm assuming that TiMin above is .3, which means all the assistive settings in the vpap are set at default normal lung settings.

Yes the TiMin is .3, I copied it down wrong.

Patients with restrictive lung disease have a difficult time maintaining the inhalation phase long enough to ensure adequate tidal volume and gas exchange. This can be caused by a physical restriction of the lungs or by neuromuscular weakness.
The recommended settings use a low cycle sensitivity and a longer Ti Min time to provide a longer inhalation time to
help increase tidal volume and gas exchange.

palerider wrote: example settings from the resmed titration guide are:
ipap:11
epap:5
Ti Max: 1.5
Ti Min: .8
rise time: 300
trigger: HIGH
cycle: LOW
PS 6

also, if I remember rightly, when using bipap to treat lung conditions, (not just for comfort) you raise epap to increase oxygenation, and increase ipap to decrease co2.

you've definitely got the ipap for co2, but the low epap might make it harder to oxygenate, and the trigger/cycle/ti default settings could make it harder to breath.

I'd definitely take that up with your doctor.

Any suggestions as to how I bring this up to my doctor? I do feel that the inhalation period is rather brief. I feel better when I wake up but I still feel a bit shallow of breath when I first wake up.

After reading a bit it seems that iVAPS or AVAPS machine would be best for restrictive lungs. I feel frustrated my doctor would not know this or suggest a night of titration with such a machine. He has a background in both sleep medicine and pulmonology.

I am pretty sure that the settings are not optimized for me. If I take out the SD card and change the settings to test, would the doctor know?


Maybe I should just get a new doctor...

Matt00926 wrote:Any suggestions as to how I bring this up to my doctor? I do feel that the inhalation period is rather brief. I feel better when I wake up but I still feel a bit shallow of breath when I first wake up.

After reading a bit it seems that iVAPS or AVAPS machine would be best for restrictive lungs. I feel frustrated my doctor would not know this or suggest a night of titration with such a machine. He has a background in both sleep medicine and pulmonology.

I am pretty sure that the settings are not optimized for me. If I take out the SD card and change the settings to test, would the doctor know?

Maybe I should just get a new doctor...

I'm afraid I don't have any advice on dealing with the doctor, I've been doing all my cpap stuff on my own from the word go. hopefully, others will chime in with advice on that.

an ivaps might work better, but there's still a lot that can be done with a plain vpap s model, due to the trigger/sensitivity and Ti settings.

the doc that I got those settings from is: http://www.resmed.com/assets/documents/ ... lo_eng.pdf take a look at it.

I hope you have your own oximeter to keep an eye on your readings, a good recording one can be had for under 100$ from aliexpress.com in china, (I recommend the cms50f or cms50i models) and an adequate cheap one can be had for under 50 from various places, amazon, etc, the cms50d+ it eats batteries and is much bulkier and hard to keep on your finger at night, but if cost is a big issue, it's an option.

if it were me, with my "devil may care" attitude, I'd try adjusting the settings, bumping up the epap some, changing trigger/cycle, and timin/max (maybe even more timax that the example above...) I'm *NOT* recommending that you do that, certainly not without an oximeter to help monitor results, it's just what I would do if it were me.

as to changing doctors, maybe if you get the old "I'm the doctor, I know best, quit reading crap on google" a change would be good for your health. it's also quite possible the doctor doesn't KNOW about the advanced settings in the vpap line. and taking in a printout of the relevant parts of the titration guide could get doc moving in the right direction.

the machine will record what settings it has, but if you take out the sd card, you won't be able to examine the data to see how it affected your breathing during the night. in other words, if the doc looked close enough, he could tell, unfortunately, most never care enough about the data from the machine, beyond 'hours of use'.

palerider wrote:

Matt00926 wrote:Any suggestions as to how I bring this up to my doctor? I do feel that the inhalation period is rather brief. I feel better when I wake up but I still feel a bit shallow of breath when I first wake up.

After reading a bit it seems that iVAPS or AVAPS machine would be best for restrictive lungs. I feel frustrated my doctor would not know this or suggest a night of titration with such a machine. He has a background in both sleep medicine and pulmonology.

I am pretty sure that the settings are not optimized for me. If I take out the SD card and change the settings to test, would the doctor know?

Maybe I should just get a new doctor...

I'm afraid I don't have any advice on dealing with the doctor, I've been doing all my cpap stuff on my own from the word go. hopefully, others will chime in with advice on that.

an ivaps might work better, but there's still a lot that can be done with a plain vpap s model, due to the trigger/sensitivity and Ti settings.

the doc that I got those settings from is: http://www.resmed.com/assets/documents/ ... lo_eng.pdf take a look at it.

I hope you have your own oximeter to keep an eye on your readings, a good recording one can be had for under 100$ from aliexpress.com in china, (I recommend the cms50f or cms50i models) and an adequate cheap one can be had for under 50 from various places, amazon, etc, the cms50d+ it eats batteries and is much bulkier and hard to keep on your finger at night, but if cost is a big issue, it's an option.

if it were me, with my "devil may care" attitude, I'd try adjusting the settings, bumping up the epap some, changing trigger/cycle, and timin/max (maybe even more timax that the example above...) I'm *NOT* recommending that you do that, certainly not without an oximeter to help monitor results, it's just what I would do if it were me.

as to changing doctors, maybe if you get the old "I'm the doctor, I know best, quit reading crap on google" a change would be good for your health. it's also quite possible the doctor doesn't KNOW about the advanced settings in the vpap line. and taking in a printout of the relevant parts of the titration guide could get doc moving in the right direction.

the machine will record what settings it has, but if you take out the sd card, you won't be able to examine the data to see how it affected your breathing during the night. in other words, if the doc looked close enough, he could tell, unfortunately, most never care enough about the data from the machine, beyond 'hours of use'.

Thanks for the information. I am going to shoot my Doc a nice e-mail and see what his thoughts are.

I fiddled with the settings per the guide for restrictive lungs and customized the Ti Max and Min based on my respiratory rate. I also adjusted the trigger to high and the cycle to low. I'm going to give it a try for a night and see how it goes.

Sent a general e-mail to my Doc...hopefully will get some insight!

"Good Afternoon Dr. _____,

Thank you for meeting with me previously, I received and have been
using the BiPAP since Friday, April 24th. I am feeling better overall
but just have a few questions.

I've noticed that the inhalation phase seems really brief. Is it
possible to increase the inhalation time before it switches to
exhalation? I also notice that my respiratory rate seems to change a
lot and I am still waking up a little breathless. I'm not sure if
restrictive lungs require customization aside from the main
inhale/exhale pressures?"



Best,

Me