Resmed VPAP Adapt SV - for Central Sleep Apnea

frequenseeker wrote:DSM -
That is SUPER DATA!

Look at the difference when a VPAP is set more properly.

Your resp volume is better too. You might be having high BPM right now as you body adjusts. You previously had very slow BPM and very large volumes.
You won't need that backup from the S/T, it looks like.

Will be looking forward to seeing the next night's results. And how do you feel??!

WTG

Wife has been asking me if this machine as backup on it - I have told her no (this is the S model VPAP III). She has said well don't you think it won't be long before I am pushing you to start breathing again (it was this originally that prompted me to do a Sleep study ) then 5-6 months into what started as great xpap therapy the stopping breathing returned. The PB330 came next & the good therapy returned but again after 5-6 months deterioration set in.

As for today I didn't think I was feeling any better - head feels the slightest bit sore. But I did feel quite alert & surprisingly (nicely) felt more confident.

This is a strange phenomenon that I have noticed. If I am getting poor therapy, my confidence & sense of purpose/direction wanes markedly. If it appears I am getting good therapy my confidence & sense of purpose rise markedly. People notice it, very much.

I wonder if this is just me or a common experience among people on xpap therapy ?

I am looking forward to checking tonight's data. Having a mchine that captures the data is just precious.


One other thing re this machine that I noticed last night is that it seems to act like a machine with back-up. If I slowed my breathing it did the epap to ipap flip & seemed to be nursing me back to a faster rate. I am not used to that. Previously when I tried setting the PB330 to 12-15 bpm (as recommended in the clinical manual) I just couldn't get used to it so dropped bpm to 6. Anyway FrequenSeeker, your suggested settings seem to be working a charm

DSM

#2

PS here are my readings taken from an Autoset Spirit back in october last year. I was pretty happy with the results back then. Range was 13-16 on AUTO & AHI was acceptable (not as good as last night).

http://www.internetage.com/cpapinfo/autoscan-grabs-1/

Last night's data - seems that just increasing cms from 13 to 14 starts the deterioration. But most problems show up just before waking up.

There is a marked jump in AHI. Face mask squeaks increased noticably as well.

http://www.internetage.com/cpapdata/dsm-vpap3-3/

DSM

Yes, DSM, I didn't think you needed a higher pressure with your previous results being so good. And since they were so good, if you really wanted to raise the pressure, my approach would recommend raising both of them, to keep the spread the same between them.

But you were doing well, so why tinker with success? I suspect you couldn't believe you got it so drastically improved on your first try

As for feeling better, yes the confidence feeling is very important as an indicator of improvement. You might have to have a few good nights to feel better on other levels, since you have such miserable event history.

Best wishes.

DSM, looking again at all your data.

The old data from the auto shows how limited this is, with no respiration data included.

There seems to be a possible REM related pattern on the recent VPAP, with the increased events in the early morning. Also, the variability on the minute vent is possibly not a great thing. I don't know enough about it, but if you look at correlations between the MV patterns and the events, it might suggest CSDB.

We need -SWS to contribute opinion here.

You might do well to play with the rise time, make it slower so you get less of a large total volume (which you continue to have) and retain more CO2??

Frequenseeker, if I had a back porch like that I'm not so sure I'd ever get around to using the rest of the house. What a view!

DSM, here's a thought. GERD flare-ups can be very episodic. And if you think your AHI flare-ups might be directly related to your GERD flare-ups... then presumably your AHI flare-ups can be just as episodic as GERD itself. My idea is to pick what you think is a good IPAP/EPAP setting and rise time---one that yields a low AHI---then stick with it for at least a week. I've personally never been a big fan of frequent/nightly pressure changes, but that's just my own take.

When you change your pressures nightly, you don't know if you should attribute significant AHI deltas to the pressure change itself or episodic flare-ups of GERD. Was it a bad GERD night, was it too much pressure, or both? Too much pressure can even exacerbate GERD if LES closure is poor. GERD itself is a moving diagnostic target because it is so episodic. Add nightly pressure changes to the fold, and you now have two moving targets, which make attributing AHI deltas all the more difficult. My advice is to pin down a good working pressure, and then watch for highly episodic AHI deltas which might implicate GERD. If your GERD turns out to be that problematic, then you're going to have to see a specialist rather than continue relying on pariet tablets occasionally augmented by OTC remedies.

As far as CSDB goes, it's supposed to be one very rare condition. GERD is not so rare, however. I'd personally be more inclined to think about first solving the GERD and any LES closure problems before I'd worry about CO2 issues and possible CSDB. CSDB patients do not typically have CSDB events during REM. Rather, their CSDB events are supposedly during NREM. DSM, what's the story with your doctor? Don't you have a good one you can put to work on this? You probably explained all that long before I resumed posting on cpaptalk.com.

FS & SWS,

I have already booked a meeting with my respiratory specialist. Did that 2 weeks ago.

Also I had been wanting to get a bilevel machine apart from the cpap/autos I still have, that records detailed nightly data. That really only happened a few weeks back when I got a good Bipap Pro 2 and the VPAP III at the same time - I had the Bipap S/T in April but discovered it doesn't record detailed nightly data just the AHI for the whole night + minute vent & bpm. Also had other problems getting it set up (as well covered ).

When I go see this guy I wanted lots of good data. I will also do some PO night session readouts. He is so hard to get to that it won't be until Oct 9th this year (he is in great demand).

I will back down the epap to 13 - my titration recomm was 15 - when I was on cpap I dropped it to 14. On auto I set the range to 13 - 17. The machine tended to go to 14/15. Both Remstar AUTO & Spirit AUTO.

I really was taken aback at the difference in results. Certainly feel clearer headed & sharper these past 2 days.

DSM

#2 GERD is a possibly a cause. I have been aware of more sensation in stomach but nothing serious. I get the same feeling if I forget to take a pariet tab in the morning. Raw reflux (when not on pariet) is awful - can't eat some types of lunch, can't drink much, etc:. Am not having that type of trouble but nose is congested daily & I do think it is somehow related.

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DSM, there are good natural supports for the reflux situation: digestive enzymes, aloe, slippery elm, flaxseed tea, chlorophyll, grapefruit extract as an antibiotic for H Pylori (did you get that checked out for your stomach condition??), and more.

DSM wrote:Am not having that type of trouble but nose is congested daily & I do think it is somehow related.

DSM, acid reflux disease can be tricky to perceive, which is why so many of us have "silent" acid reflux disease. Some of us just don't perceive all the symptoms of acid reflux disease accurately. I fall in that category, by the way---in no small way. Again, if acid reflux disease is the cause of your nasal congestion and drainage problems, then you really have LPR and not GERD. Both are types of acid reflux disease. However, as acid reflux diseases go, LPR is an even more extensive problem than GERD.

However, it is possible that your congestion and sinus drainage problems are completely unrelated to acid reflux disease. Regardless, I should point out that vocal chord dysfunction (VCD) can be severely triggered by: 1) acid reflux, 2) post nasal drainage, 3) a combination of those two, as well as a variety of other triggers. Unfortunately the vast majority of medical practitioners seem completely unaware that apneas can be caused by VCD, let alone severely triggered by post nasal drainage and/or acid reflux disease. There are specialists, such as the researchers at Beth Israel, who actually specialize in vocal chord-based apneas.

Long story short: if I were in your shoes I would be very interested in correlating my AHI flare-ups to either post nasal drainage problems, acid reflux flare ups, or both. Most hoseheads do not experience such episodic AHI flare-ups. For those who do, it might not be such a bad idea to attempt to correlate AHI flare-ups with equally episodic trigger conditions or disorders. Moderate AHI variation from night to night is probably normal for many of us. But highly episodic AHI variation with radical swings in AHI is not typical. Just my opinion.

The port on the side of the Adapt SV VPAP is a Pressure Sensor Tube.
The air tubing has a small line clipped to the main air tube between the mask and the flow generator. The line has a Luer connector to mate with the machine, this is what you see in the photo. The other end has a Proximal cuff to measure pressure at the mask interface.

The machine requires a Learning function to be run every time the tube or humidifer or mask connection is altered. The machine appears to determine a baseline before the patient places the mask on his or her face.

The machine does operate relatively quietly. I've used it for about 5 nights.

Lubman wrote:The port on the side of the Adapt SV VPAP is a Pressure Sensor Tube.
The air tubing has a small line clipped to the main air tube between the mask and the flow generator. The line has a Luer connector to mate with the machine, this is what you see in the photo. The other end has a Proximal cuff to measure pressure at the mask interface.

The machine requires a Learning function to be run every time the tube or humidifer or mask connection is altered. The machine appears to determine a baseline before the patient places the mask on his or her face.

The machine does operate relatively quietly. I've used it for about 5 nights.

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Hi Lubman,

As you can imagine, there are many of us dying to hear about how effective the machine appears to be.

Some aspects that aren't fully clear are ...
- Is there just the one model ? (Vpap Adapt)
- Are you using it because of CS / CHF ?
- How do you find the machine's ability to switch from passive to active ventilation, affects you ? (is it noticeable or barely perceptible ?)

Hope you are finding it a big improvement !

Cheers

DSM

So good to hear from someone who is using this machine, as I am scheduled for a titration with it in a few days.
Lubman, do you have any advice or suggestions for when I am in the study?

I am so relieved to hear it is quiet. The VPAP III that I have had for a year is so noisy

Hi to freqseeker
I have spent some time simply catching up on this thread.
I'm an engineer like DSM and would love to PM with a side technical discussion.

First some background - I have idiopathic CSA, no HF issues, no other health problems. My CSA event is repetitive say 4 or 5 breaths occur and the pattern regularly repeats.

My lab test was the first one in this state - the lab has done considerably more tests since then. My DME has about 9 machines out in the field.

My lab test results were mixed and no clear cut solution was identified. So I asked to have it for a 3 month trial.
It arrived last Tuesday.

Some initial thoughts and I promise in the next few evenings to give you more details:

a) The machine does a good job of handling leaks if you have a full face mask from ResMed and in my opinion aren't an unusual shaped face.
The machine algorithm understands the 4 or 5 Res Med masks and you do select the mask type in set up.

The Res Med rep who conducted my test said that the FF mask would seal best if it was not synched down tight. I admit now that I have some experience with it - he is right. It seals much like a vacuum if set properly.

Yes it can leak, especially if you move a lot or are not a supine sleeper or
have other issues.

b) The machine tells you the degree of mask leak and does read out some
basic data.

c) The machine should be turned on and left completely alone for 30 seconds from start up. Then once the humidifier and any additional O2 lines are connected, one runs a "learn circuit" with the mask off and unobstructed. Once can see the machine drive higher and higher pressures through the tubing setup and mask. I assume it compensates for anything unusual in the setup -- this made me think at first that DSM and others were right in that the ASV was managing the CO2 buildup.

d) I rerun the learning circuit every night and I take off the air tube and the pressure line with the luer connector and hang it up.

e) Even the humidifier used is important, I think the ASV will only work with the 2 Res Med humidifiers - more on this later.

f) I have been reading the original papers and the manuals, plus talking to the participants in the 2 Res Med DME training courses (which my MD invited me to attend and ResMed said no !)

g) The default EEP recommended is 5, literature implies that for mixed one might try EEP=8. However the sleep lab said that they are starting to see results for some with lower EEP settings such as 3 or 4. Some people had dramatic results using the machine.

h) I did Tue night on Respironics BiPap at 11/6 with 2 ltr O2 and recorded the data. i did last night on the ASV with EEP=5 after acquiring a ResLink module. In my opinion, one must have either the ResLink module to store detailed data from the machine or have the ResScan software directly conectedd to the machine to get more than the standard reult values out of the device.

Tonight I will go into more details - I am already needing to leave for work.

Lubman

Lubman wrote:I assume it compensates for anything unusual in the setup -- this made me think at first that DSM and others were right in that the ASV was managing the CO2 buildup.

Early in this thread I made the assumption that CO2 was actively managed by this machine. That erroneous assumption was based on phase-crucial CO2 supplementation in the mask (either passive rebreathing or active ancillary machine-based modulation) as the only previously-known PAP-related mediation techniques for hypocapnic central apneas (as in the CSDB phenotype). However, DSM posted a diagram of the impellers and internal machine layout, and we very soon came to realize the VPAP Adapt-SV does not passively manage CO2 rebreathing; nor does it appear to actively machine-modulate CO2 in any crucial or appreciable manner.

In my way of analyzing, adaptive servo's alternate mediatory approach in the transient time domain, and the resulting efficacy, may thus have extremely important etiological implications regarding the very "front end" of CSDB's pathophysiology.

Lubman wrote:The default EEP recommended is 5, literature implies that for mixed one might try EEP=8. However the sleep lab said that they are starting to see results for some with lower EEP settings such as 3 or 4. Some people had dramatic results using the machine.

I guess I'm not surprised to hear this. The CSDB patients with hypocapnic central apneas seem to experience either CSA onset or significant CSA increases once traditional PAP is applied. The CSDB study by Gilmartin, et al suggested that doctors use the lowest feasible positive air pressure to manage obstructive apneas in these patients (see excerpt below; please note the underlined emphasis is mine). Dramatic differences between an EEP of 5 cm compared to an EEP of 3 cm or 4 cm imply a certain static-pressure-related maladjusted threshold for these patients. I personally suspect that stretch receptors are neurologically factoring into subsequent maladjustment of several neural-plasticity-based resulting physiologic mechanisms: a defensively elevated CO2-based inspiratory trigger, as well as an equally defensive vocal-chord-based airway closure.

Geoffrey S Gilmartin; Robert W Daly; Robert J Thomas wrote:"Avoiding Pressure Toxicity
Patients with complex disease are sensitive to positive airway pressure, and usually flow limitation cannot be eliminated without worsening periodic breathing or inducing central apneas. An immediate worsening with bilevel ventilation may be seen, consistent with an effect of induced hypocapnia on the peripheral chemoreceptors. One approach is 'permissive flow limitation' - allowing some obstruction to persist and thus avoiding the worsening of control dysfunction."

We very much look forward to your own comments and interpretive results. Good luck!

SWS - I find your insights and understanding quite interesting. Maybe you can help as i dig deeper into this.

i would love to see the design website diagram, which was taken down.
It would add to my understanding. Maybe a patent search is in order!

First some VPAP Adapt SV details:

- The machine has ASV and CPAP modes
- It monitors average minute vent. in three minute windows
- Machine default EEP = 5 cm and it is adjustable
- Minimum pressure setting default = 3 cm; maximum default setting = 10
- it is my understanding the machine has a backup rate of 15 BPM

- Machine asks which of 4 ResMed masks you are using
full face, Vista, Ultra or Activa
- Internal to the flow generator it stores 5 days of detailed data and 365 days of summary data.

- Without either a cable and ResScan software or ResLink, all one can get from the machine displays is

-- Leak in L/minute at the 95th percentile
-- Average pressure
-- Tidal Volume in ml (5 and 95 %ile)
-- Minute Ventilation in L/min (5 and 95 %ile)
-- ResMed manual only recommends the Humidaire 2i or Humidaire to be used with machine if humidification is used.


The port on the machine that was mentioned early in this excellent and long set of posts is for a pressure line, which is clipped to the main air hose and is coupled as near as practical to the mask in a proximal cuff

-------------------------
---- I have short cycle Cheyene stokes resp + mixed apneas.
So for me I am very interested in the studies dealing with non HF cases.
Can you provide references?

I have the Gilmartin paper and several others, including what I assume was the initial study done early in this decade at Alfred Hospital in Melbourne.

How similar is the ASV approach to that taken by Dr. Younis, who was working with C02 levels and centrals. I think one of his papers indicated he was in Toronto, but I will have to go to my desktop machine and check the stored PDFs. We will save that for another day.

How would you suggest I try to find a helpful setting?
My plan right now is to compare detailed data from ResLink with data from my respironics BiPap Pro 2 set at 11/6 -- both used with supplmental O2.

I am someone who does not tolerate high pressures well at all.

Lubman

Hi Lubman,

As you can imagine, there are many of us dying to hear about how effective the machine appears to be.

Some aspects that aren't fully clear are ...
- Is there just the one model ? (Vpap Adapt)
- Are you using it because of CS / CHF ?
- How do you find the machine's ability to switch from passive to active ventilation, affects you ? (is it noticeable or barely perceptible ?)

Hope you are finding it a big improvement !

Cheers

DSM


Let me specifically respond to DSM's questions

As far as i know the only model is the VPAP Adapt SV
I do not have CHF. I have short cycle CSR w/ mixed apneas
The switch from passive to active does not necessarily affect me, but I do use Lunesta or Ambien CR to aid in sleep consolidation.
I have managed to wake up after 3 or 4 hours after using EEPs of 5, 4 and 6
and other nights I have slept until early morning hours.

I just wish i still didn't feel tired or my concentration was better - that tells me I haven't hit upon the right settings yet assuming this algorithm is for me.

What more can someone tell us about the Respironics HeartPap model - although that is fodder for a new thread.

Lubman

My mask fit is excellent with leak rates in the low to mid teens/min and the lowest I have seen is 7 leaks/min.


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