ResMed S8 AutoSet Vantage (slight rant - request for info)

socknitster wrote:I've watched/read this thread with interest as I'm very interested in this machine.

I really feel sorry for the newbie poster who inadvertantly got him or herself in the middle of a sniper battle.

Socknitster,

This newbie's not taking any offense. I'm good at dodging "sniper" fire, and I appreciate a vigorous debate. (Though, I can't speak for other newbies).

Although I admit I was a little surprised by the passions this post aroused.

BTW: The J.A. stands for John A. Taylor--So I'm a he. And the A. remains a secret (I've only divulged that to Rested Girl, and I'm hoping that she tapes her lips shut ). It's a great middle name, but not one I publicly bat about. Childhood trauma I guess

Anyway, I appreciate all the support, and the debate, and I'm sure that if it turns out that I like the Vantage, I'll be just as passionate about my machine.

Because of course, in my opinion, whatever machine I have will be the best.

[quote="itchysmom"]Snoredog, I value your advice and knowledge but you are wrong on many points.

For one thing, Rested Gal and several others on this forum PM'd me to tell me how to manipulate the settings. I changed the pressure, the C-Flex was ON.

I'm a registered nurse and have been for most of my adult life. I work in critical care MANY of our patients are on CPAP/BIPAP. I'm not an idiot, I know how to get the information I need to manipulate the settings. If RG hadn't given the instructions to me, a couple of the RT's I work with were going to change the settings for me anyway.

Also, although I have been on xPAP for only about 6 weeks, that does not diminish my experience thus for nor my OPINION about the machine I am using.

Ummmm...perhaps you need to go back over the posts Snoredog.

First of all, I never even addressed EPR in my posts other to say that I don't use that feature because I use my machine in Auto mode at all times.

All I said was that when I decided to go with the S8 my biggest concern was that it DID NOT HAVE the Aflex/Cflex option that the Respironics machine has.

What I have found, IN MY PERSONAL EXPERIENCE, is that I am not missing the Aflex/Cflex or ERP because I have absolutely NO difficulty breathing against the pressure and in fact my breathing is so easy that I sometimes wake up in the morning thinking that the machine has stopped working.

It is very quiet, very easy to breath with, very user friendly and I like it very much.

That is just MY OPINION, take it FWIW. I was just trying to support the OP. I don't think this board should be a "brand war". Each individual person should be able to come here, ask questions, get information and make decisions based on what is best for them, not what is popular. JMHO.

Snoredog wrote:I never said you were an idiot, you did.

Snoredog, you are truly my hero.

Such vile and invective, such ranting and cheap shots, such brute force hijacking of a discussion to have a whine on a favourite topic!

All I can say is WOW!

Keep up the good work... rude science will never catch up to you!

WOOF WOOF!

snoredog wrote:Show us where it works in Auto mode? don't show me a Malibu that is a Bilevel machine and not a CPAP auto because now you are comparing apples to oranges.

Well, the equivalent comparison if you want to look at AFlex would be Malibu, cause AFlex, when you think about it, can be categorized as "bilevel" as well (although again, using terms like "CPAP" and "bilevel" no longer suffice to describe these modalities).

Anyway, as soon as AFlex sees events, its response is to provide inspiratory support:



Comparing this to Malibu:



the difference between the ResMed and Respironics Expiratory Relief (ER) adjuncts can be noted in the periods immediately prior to inspiration, where the difference can basically be summed as as being Respironics ER occurs only during active exhalation, whereas ResMed ER is generally maintained up to the succeeding inhalation.

socknitster wrote:Also, I don't understand what you are saying about the exhale relief cutting off when some "acronym I forgot because it means nothing to me" happens. Please elaborate for those of us not in the know.

This concept was originally noted by the revolutionary sleep forum poster Sleepy "Che Guevera" Dave 2 years ago elsewhere, where he observed

sleepydave wrote:Had an appointment with my Resmed rep today, and he brought along an S8 Elite with EPR, their answer to the Respironics CFlex.
I had about an hour to try a few things and do some pressure readings to get a rough idea how it works. I didn't get all the information to do a good head to head comparison, but hopefully I should be able to get either a diagnostic unit which will allow for better waveform analysis or at least a prolonged loaner so I can set up my own transducers. At any rate, I wanted to at least get back with some preliminary information.
From a straight put-it-on-how's-it-feel, I absolutely must say this thing is phenomenal. I ran it at 5, 10, 15, and 20 cmH2O, it was very comfortable throughout, and none of the glitches associated with CFlex at the high pressures. We're really talking night and day here.
The EPR is maintained virtually to the point of inhalation. Doing this really addresses high pressure problems in a big way.
I did inquire as to the trigger that terminates the EPR function, the rep didn't know but said he'd get back to me.
Since the model I tested did not have outputs to monitor the transducer activity, I used a nasal pressure transducer to gather waveform information, but couldn't set up a second unit to monitor the actual CPAP pressure at critical moments, and I think that has to be looked at closely, because there may be a couple of potential issues.
Here's the waveform I generated at 20 cmH2O:



The first two arrows represent the termination of EPR (the first tiny waveform), and you can see how close they are to inspiration. This suggests that the trigger might be inspiratory flow, which could create a problem if you're trying to inspire from a sub-therapeutic pressure level. Or, it could be a very low expiratory flow rate. Try as I might, I could not verify this either way, so we'll have to wait for the manufacturer's response. But you really need to be at therapeutic CPAP level prior to inspiration, so we'll have to look at this carefully.
The second two arrows show where the EPR did not terminate, and inspiration occurred at well under therapeutic levels. I was able to generate this situation at all pressure levels. The obvious problem here would be if the EPR level was below the apnea threshold, therapy would not be effective. Again, I don't know why this occurred, and passed this information along to the rep.
This situation might be overcome by raising the baseline CPAP slightly, but the point is that using this EPR might change your CPAP requirements slightly.
I should also point out that there is a time function for EPR, if no breath is detected after a period of time, EPR is immediately suspended, so it seems that only a single breath would miss detection.
These issues aside, and I'm not yet sure if they are in fact issues, I can say that I was thoroughly impressed with the feel of this modality. It's definitely worth a look.
sleepydave

Any concerns offered were theoretical in nature, I don't know if any of them ever came to fruition.

That would be academic anyway in that now you have the ResMed ER adjunct available in Auto.
SAG

StillAnotherGuest wrote:

snoredog wrote:Show us where it works in Auto mode? don't show me a Malibu that is a Bilevel machine and not a CPAP auto because now you are comparing apples to oranges.

Well, the equivalent comparison if you want to look at AFlex would be Malibu, cause AFlex, when you think about it, can be categorized as "bilevel" as well (although again, using terms like "CPAP" and "bilevel" no longer suffice to describe these modalities).

Anyway, as soon as AFlex sees events, its response is to provide inspiratory support:



Comparing this to Malibu:



the difference between the ResMed and Respironics Expiratory Relief (ER) adjuncts can be noted in the periods immediately prior to inspiration, where the difference can basically be summed as as being Respironics ER occurs only during active exhalation, whereas ResMed ER is generally maintained up to the succeeding inhalation.

socknitster wrote:Also, I don't understand what you are saying about the exhale relief cutting off when some "acronym I forgot because it means nothing to me" happens. Please elaborate for those of us not in the know.

This concept was originally noted by the revolutionary sleep forum poster Sleepy "Che Guevera" Dave 2 years ago elsewhere, where he observed

sleepydave wrote:Had an appointment with my Resmed rep today, and he brought along an S8 Elite with EPR, their answer to the Respironics CFlex.
I had about an hour to try a few things and do some pressure readings to get a rough idea how it works. I didn't get all the information to do a good head to head comparison, but hopefully I should be able to get either a diagnostic unit which will allow for better waveform analysis or at least a prolonged loaner so I can set up my own transducers. At any rate, I wanted to at least get back with some preliminary information.
From a straight put-it-on-how's-it-feel, I absolutely must say this thing is phenomenal. I ran it at 5, 10, 15, and 20 cmH2O, it was very comfortable throughout, and none of the glitches associated with CFlex at the high pressures. We're really talking night and day here.
The EPR is maintained virtually to the point of inhalation. Doing this really addresses high pressure problems in a big way.
I did inquire as to the trigger that terminates the EPR function, the rep didn't know but said he'd get back to me.
Since the model I tested did not have outputs to monitor the transducer activity, I used a nasal pressure transducer to gather waveform information, but couldn't set up a second unit to monitor the actual CPAP pressure at critical moments, and I think that has to be looked at closely, because there may be a couple of potential issues.
Here's the waveform I generated at 20 cmH2O:



The first two arrows represent the termination of EPR (the first tiny waveform), and you can see how close they are to inspiration. This suggests that the trigger might be inspiratory flow, which could create a problem if you're trying to inspire from a sub-therapeutic pressure level. Or, it could be a very low expiratory flow rate. Try as I might, I could not verify this either way, so we'll have to wait for the manufacturer's response. But you really need to be at therapeutic CPAP level prior to inspiration, so we'll have to look at this carefully.
The second two arrows show where the EPR did not terminate, and inspiration occurred at well under therapeutic levels. I was able to generate this situation at all pressure levels. The obvious problem here would be if the EPR level was below the apnea threshold, therapy would not be effective. Again, I don't know why this occurred, and passed this information along to the rep.
This situation might be overcome by raising the baseline CPAP slightly, but the point is that using this EPR might change your CPAP requirements slightly.
I should also point out that there is a time function for EPR, if no breath is detected after a period of time, EPR is immediately suspended, so it seems that only a single breath would miss detection.
These issues aside, and I'm not yet sure if they are in fact issues, I can say that I was thoroughly impressed with the feel of this modality. It's definitely worth a look.
sleepydave

Any concerns offered were theoretical in nature, I don't know if any of them ever came to fruition.

That would be academic anyway in that now you have the ResMed ER adjunct available in Auto.
SAG

StillAnotherGuest wrote: Well, the equivalent comparison if you want to look at AFlex would be Malibu, cause AFlex, when you think about it, can be categorized as "bilevel" as well (although again, using terms like "CPAP" and "bilevel" no longer suffice to describe these modalities).

Actually you should be comparing apples to apples, you are comparing apples to oranges. You compared EPR to AFLEX when the discussion was EPR to CFlex huge difference, one works in Auto mode the other still doesn't. So you bring in a Bipap Auto and compare now a CPAP feature AFlex to a Bilevel Auto?

Technically, AFlex is NOT classified as a Bilevel machine. The Malibu clearly is.

How is that a similar comparison even to the S8?

If you are going to do that comparison, you need to compare oranges to oranges and that would be the Remstar Bipap Auto w/BiFlex to the Resmed Malibu EPR, now you have an oranges to oranges machine comparison.

But that is okay, the bottom of that AFlex waveform is Cflex, above that support line is AFlex, it simply has the built-in minimum 2 cm pressure support found on their Bipap Auto. I'm not even going to attempt to explain BiFlex to them.

You guys clearly have a lot more background information on how these things work. I still am having trouble understanding the full details but I get the gist.

I truly appreciate the work it took to bring up all the info.

And I also appreciate the return to "spirited discussion" which is a definite improvement and much more interesting to read.

I agree with Snoredog to some degree, but also agree that the lines between these different types of machines are starting to blur. There are some grey areas here now. Some of the new machines are starting to act more and more like bilevels that is for sure. But of course they aren't true bilevels at all to someone who really needs the full 4 cm spread between exhale and inhale, like I used to.

jen

Some simple comments on BiLevel function & Exhale Relief function. (#2 - this post has actually turned into a bit of a history lesson - just rolled out that way)

If we start with CPAP of which the 1st commercial machine was (IIRC) a Sullivan model (later renamed Resmed). But the first exhale relief introduced was the Respironics BiLevel. They coined the name (trade marked) BiPap and very quickly after that Healthdyne came out with a BiLevel (aptly called a BiLevel). Then came (IIRC0 The Sullivam and the early Puritan Bennett plus some other BiLevels).

BiLevels were very very expensive and thus were only made available to people with COPD or other lung problems. In the early days they still had not come up with a CPAP / BiPAP that could deal with centrals.

Next Resmed came up with an advanced concept for adjusting the pressure automatically (The Autoset). The purpose here was to keep the machine at as low a pressure as needed as this helped keep away from pressures that had too many negative side effects.

At approx the same time Respironics added timed mode to their BiPap (this was still the big square box model). This became known as the BiPap S/T (Synchronous and Timed), this machine was then applied to people with centrals.

The Sullivan BiLevel & the Puritan Bennett BiLevels also added timed mode.

All BiLevels then began to add ways to adjust the rise & fall time (the speed with which the machine went from Epap to Ipap (rise) & Ipap to Epap (fall). In particular, people were finding that it was a strain on them and disruptive to sleep if the risetime transition from Breath-out to Breath-in happened too quickly.

Healthdyne and Respironics also entered the market with Autos (this period was the late 1990s).

Then Respironics adopted the approach of using software to determine the difference between leaks and breathing - this algorithm was in the feature they call Auto-Trak. The other vendors took the approach of mainaining leak rate tables in the software inside the machines to determine what was leak vs breathing. The Auto-trak approach offers more flexibility because it can adapt to different masks but the Resmed / Puritan Bennett approach was much more accurate but does require the machine to be set for the correct mask. Resmed added an Auto-trak equivalent but called it V-Synch.

Leak vs breathing accuracy is really important in a BiLevel because of the need to get the Ipap to Epap to Ipap transitions correct. A machine that has difficulty detecting slow breathing vs a leak will get its timing wrong.

Then Respironics introduced an innovation into its Cpap and Auto models & called it C-Flex, it was an extension of the Auto-trak algorithm & so on top of the machine being an Auto (which gives relief by keeping pressures as low as it can based on the settings) there was this exhale relief that could be set to 3 different settings.

At this same time Resmed and Puritan Bennett began adding more adjustments to their BiLevels as many more side effects were emerging.

One significant problem was that if the Ipap pressure was higher than it needed to be and the gap to Epap was too great, people could begin to hyper-ventilate & that disrupted sleep. Respironics BiPap machines had less rise/fall adjustments that the other brads but solved that issue by adding the Bi-Flex feature. BiFlex provides a dip to the Ipap & Epap pressures as the users transitions from one mode to the other. This kept their machines simple & easier to adjust by non-technical users. For example, it takes some expertise to set up a BiLevel & the PB330 is a classic example of that complexity.

Respironics then came out with an innovative Auto BiLevel that sought to keep the gap to a minimum (2 CMS) and to adjust the Ipap and Epap independently. This idea was very innovative for the time but there is insufficient research to know if this has improved use of BiLevels or created some new issues.

Resmed then took the concept of a BiLevel, came up with what they considered optimum rise time & created EPR. EPR offered the equivalent of a BiLevel that could be adjusted for a 1, 2 or 3 CMS Ipap to Epap gap. This is very adequate for the non COPD user.

Respironics continued their innovation by adding another feature to their Auto called A-Flex. This feature took the basic C-Flex function (exhalation relief) and extended the pressure control into the breath-in part of the cycle. This solved an issue with C-Flex where as C-Flex ends, there is a sudden rush of air as full pressure resumed. This rush if C-Flex was set high (3) could cause mouth popping (pops of air escaping) or bubles going into the stomach (aerophagia). A-Flex was intended to solve that. It also acts as a sort of a BiLevel in that the machine keeps the A-Flex min max pressure gap to max 2 CMS.

As has been happening lately, the next generation of Servo Ventilation machines appeared 1st with the Resmed Vpap Adapt and now the Bipap SV.

These machines push the technology to new limits but already are showing they can provide results that are the best hoped for. They provide the best type of relief to people on CPAP therapy but because they are still in their early days are mainly being supplied to people with disorders such as Cheynes-Stokes breathing or Central-Apnea or Complex-Apnea

But make no mistake, the SV type machines are the future & as costs come down expect to see our garden variety CPAPs looking more like them.

For me, I admire the innovation of all the companies involved. There are some very dedicated & smart people working hard to make our lives better.

DSM

PS Anyone please feel free to correct any point - it is a lot of history & may be out of seq or important bits left out or given a wrong emphasis.

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CPAPopedia Keywords Contained In This Post (Click For Definition): respironics, resmed, bipap, Puritan Bennett, C-FLEX, CPAP, auto

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CPAPopedia Keywords Contained In This Post (Click For Definition): respironics, resmed, bipap, Puritan Bennett, C-FLEX, CPAP, auto

Snoredog wrote:I'm not even going to attempt to explain BiFlex to them

Bi-Flex "softens" airflow at inhalation and exhalation, making breathing more natural and comfortable for patients. In Bi-Flex mode, patient-adjustable pressure relief is provided at the critical stages:

A. EPAP to IPAP
B. IPAP to EPAP
C. During exhalation

SAG