New to this- Husband vpap III 5 days but not taking breaths

Banned · Post by **Banned** » Tue Mar 04, 2008 7:27 pm

With respect to the ResMed Adapt SV: EEP is adjustable from 4cmH2O to 10cmH2O. EEP, in layman's terms, would be the exhale pressure. It is easier to exhale against the Adapt SVs default EEP of 10cmH2O than say an adjusted EEP of 8cmH2O. On the Inspiration side of the equation there is MIN PS and MAX PS. MIN PS is adjustable from 3cmH2O to 6cmH2O in .2 increments. The Adapt SVs default MIN PS is 3cmH2O. The combination of EEP + MIN PS is the starting Inspiration Pressure (From the patient's prescription). You never adjust MAX PS because MIN PS automatically sets MAX PS. In Casiesea's husbands case he needs an Inspiration Pressure of 10cmH2O. He has only two choices, that would be 6-4 (which is his script) or 7-3. 7-3 offers a more natural breathing space because the expiration pressure is lighter than 6-4 (i.e. It is easier to exhale). Tne Adapt SV's proximal sensor tube at the mask samples EEP. There is only one mask that is fully compatible with the Adapt SVs Air delivery system (hose and Proximal Senso Tube), That would be the Quattro FF.

Cheers,

-SWS · Post by **-SWS** » Tue Mar 04, 2008 7:30 pm

Banned wrote:It is easier to exhale against the Adapt SVs default EEP of 10cmH2O than say an adjusted EEP of 8cmH2O.

That experience you are reporting is contrary to what most users seem to report.

And that implies either atypical expiratory physiology or atypical perception. And to suggest that others not go lower than an EEP of 9cm or 10cm (which you find comfortable) suggests that everyone should set their ASV therapy to your own atypical experience.

Handing out universal advice based on your own physiology or perception is not sound advice IMO. I would think an EEP default of 10 should fit many users. But 9 or 10 as universal advice?

Banned, I guess I'm questioning the basis of your projections when you hand out those statements. Are they based in logic, personal experience (which cannot be universalized), empiricism, manufacturer research, or... precisely what are those statements based in?

StillAnotherGuest · Post by **StillAnotherGuest** » Tue Mar 04, 2008 7:46 pm

-SWS wrote:
Banned wrote:It is easier to exhale against the Adapt SVs default EEP of 10cmH2O than say an adjusted EEP of 8cmH2O.
Right. That experience you are reporting is contrary to what most users seem to report.

And that implies either atypical expiratory physiology or atypical perception. And to suggest that others not go lower than an EEP of 9cm or 10cm (which you find comfortable) suggests that everyone should set their ASV therapy to your own atypical experience.

Handing out universal advice based on your own physiology or perception is not sound advice IMO. I would think an EEP default of 10 should fit many users. But 9 or 10 as universal advice?

Well, not for nothing, but the AdaptSV EEP default is 5 cmH20.

SAG

-SWS · Post by **-SWS** » Tue Mar 04, 2008 7:52 pm

Thought Banned said EEP was defaulted at 10cm... which gets me to wanting to repeat my addendum question to Banned---who discourages ASV users from setting an EEP lower than 9 or 10 cm:

-SWS wrote:Banned, I guess I'm questioning the basis of your projections when you hand out those statements. Are they based in logic, personal experience (which cannot be universalized), empiricism, manufacturer research, or... precisely what are those statements based in?

Banned, where are these ASV therapy decrees coming from? Personal experience?

dsm · Post by **dsm** » Tue Mar 04, 2008 8:03 pm

-SWS wrote:
dsm wrote: The mechanics of EEP are basically similar to epap, but using a different label (as explained in an earlier post here).
The mechanics of EEP are virtually identical to that of a standing wave in physics.

EEP is a static-pressure component upon which alternating pressure variations are superimposed. EEP is a purely static-pressure component and is functionally identical to that of static-pressure CPAP. Both of those static pressure components (EEP and CPAP) are used to address the obstructive component of SDB.

Note that EEP is the same pressure constant regardless of respiratory phase (inspiration or expiration), and that pressure constants are used to address obstructions in the cases of ASV and CPAP. In both cases they inflate the airway with static pressure to clear obstructions (which tend to occur during both expiratory end-phase and inspiration).

Banned · Post by **Banned** » Tue Mar 04, 2008 9:40 pm

-SWS wrote:Thought Banned said EEP was defaulted at 10cm... which gets me to wanting to repeat my addendum question to Banned---who discourages ASV users from setting an EEP lower than 9 or 10 cm:

SWS,

Discouraging users from using an EEP lower than 9 or 10cmH2O would of course be a fallacy. I believe the time I said that I was thinking about my own case and people who might be using higher inspiration pressures, at least 13cmH2O, and above. Casesea's husband and others who use lower pressures will of course need to use lower EEP and MIN PS. I did not mean to slight those people at lower inspiration pressures. My general point was, the higher EEP you use, the easier it is to exhale. Hence the more natural breathing. I personally do not use an EEP of 10cmH2O, because for me, it is more comfortable to have some slight degree of back pressure on the exhale.

Cheers,

dsm · Post by **dsm** » Tue Mar 04, 2008 10:10 pm

Banned wrote:
-SWS wrote:Thought Banned said EEP was defaulted at 10cm... which gets me to wanting to repeat my addendum question to Banned---who discourages ASV users from setting an EEP lower than 9 or 10 cm:
SWS,

Discouraging users from using an EEP lower than 9 or 10cmH2O would of course be a fallacy. I believe the time I said that I was thinking about my own case and people who might be using higher inspiration pressures, at least 13cmH2O, and above. Casesea's husband and others who use lower pressures will of course need to use lower EEP and MIN PS. I did not mean to slight those people at lower inspiration pressures. My general point was, the higher EEP you use, the easier it is to exhale. Hence the more natural breathing. I personally do not use an EEP of 10cmH2O, because for me, it is more comfortable to have some slight degree of back pressure on the exhale.

Cheers,

Banned,

I think that confusion has arisen because your posts generally imply that 10 CMS EEP is easier to breathe out against than 5 CMS EEP.

What most of us can't see, is how 10 CMS of EEP can be easier than 5 CMS of EEP.

You mention that 9 CMS EEP provides more back pressure than 10 CMS EEP but again this seems to be the reverse of what EEP stands for.

EEP 9 CMS will start the machine with a lower exhale pressure than EEP 10. The expectation is that the user when breathing out, will always find 9 CMS easier to breathe against than 10 CMS.

Can you see the problem ?

Cheers

DSMl

-SWS · Post by **-SWS** » Tue Mar 04, 2008 10:16 pm

Doug, there are five graphs on page 2 of the following ASV Fact Sheet:
http://www.resmed.com/en-us/products/fl ... _sheet.pdf

Take a look at the second graph on page two. That graph shows a transition from stable patient breathing (not requiring PS adjustment) to central apnea/hypopnea (requiring adaptive PS).

These ASV factory default settings are demonstrated in that second graph on page 2:
EEP=5cm, PSmin=3cm, PSmax=10cm

CASE ONE: STABLE BREATHING
Based on the above factory defaults you see IPAP/EPAP cycling as follows during stable breathing:
8/5, 8/5, 8/5, 8/5, etc.

You can alternately express the above IPAP/EPAP cycling as:
(EEP+PSmin)/EEP, (EEP+PSmin)/EEP, (EEP+PSmin)/EEP, etc.

The above two say the same thing, and they represent what happens during stable breathing when adaptive PS adjustment is not required.

CASE TWO: CENTRAL APNEA/HYPOPNEA OCCURS (REQUIRING ADAPTIVE PS)
So look at what happens when central apnea/hypopnea is detected and PSmax is eventually delivered by the ASV (please refer to that same graph):
15/5, 15/5, 15/5, 15/5, etc.

PSmax is finally delivered in this case so now the IPAP/EPAP cycling must be expressed by these values:
(EEP+PSmax)/EEP, (EEP+PSmax)/EEP, (EEP+PSmax)/EEP, etc.

Notes-
-1- IPAP adaptively fluctuates according to PSmin and PSmax settings
-2- EPAP stays constant according to EEP setting
-3- IPAP fluctuates adaptively, but does not necessarily reach PSmax
-4- Delivered PS will never be less than 3cm
-5- EEP + PSmax will never exceed 20cm
-6- PSmax minus PSmin must always be greater than or equal to 5cm
-7- That EEP of 5cm can be manually increased to address greater obstructive components (as a static-pressure bias)
-8- That Adaptively fluctuating PS is what stabilizes central dysregulation
-9- Once central dysregulation has been eliminated, "Case One" (described above) resumes

Banned · Post by **Banned** » Tue Mar 04, 2008 10:25 pm

dsm wrote: SWS,

We have the likelihood of miss communication on my point being made re EEP function.

I was speculating that although EEP (like epap) can be set to say 5 CMS and PSmin can be set to add say 4 CMS to provide a minimum ipap of 5+4=9 CMS, and PSmax can allow the machine's minimum ipap to roam beyond 9 and up to 9+5=14) - that the machine being a servo ventilator will actually 'move' up and down in pressure, with each breathing cycle as the sleeper breathes in and out and that these pressures may together 'roam' up and down (but that the PSmin will be maintained as a gap between exhale & inhale).

The machine may not go as low as the EEP setting and may not go as high as the PSmax but will normally operate in between these pressures while holding a inhale exhale gap set to PSmin. Versus, a standard Bilevel that will arbitarily go between epap and ipap.

Now this observation is merely me attempting to work out just how this machine operates. I am still working on a model for how the Bipap SV operates. I think it is going to be very similar except that I believe the Bipap SV doesn't hold to a PSmin (fixed gap) but gain I am speculating on this.

Cheers

DSM

PS I do think banned may not realise his explanation of breathing out against EEP10 vs breathing out against an EEP of 5 is back to front. It is an easy warp to get into

D

#2
I guess the nub of my speculation boils down to "does the adapt SV do its thing while always maintaining an inhale/exhale gap as set by PSmin" ?

I don't know the answer but am guessing this is how it works.

dsm would be correct. Once the EEP is set, it will remain a constant throughout Adapt SV therapy. EEP will not change until it is manually dialed-in, again. Using dsm's example of 9+5=14 will give an inspiration pressure that will never fall below 14cmH2O. "The machine being a servo ventilator will actually 'roam' up and down between 14cmH2O and the MAX PS (which as you remember was automatically set when MIN PS was dialed-in, generally 5cmH2O above MIN PS). So, back to dsm's example of 9+5=14, EEP would always be a constant at 9cmH2O and inspiration pressure would fluctuate between 14cmH2O and 19cmH2O depending on servo-ventilation requirements on a breath-by-breath basis.

I've been using the Adapt SV for 6 months so all of what I have to say is through my own experience. Having never been tirated on an Adapt SV, obtaining the Clinician's Manual with my Adapt SV was essential. The Adapt SV is a deceptively simple and amazing machine. Theoretically the current Adapt SV has an inspiration range limit of 7cmH2O (4+3 =7) to 16cmH2O (10+6=16), not including MAX PS. The Adapt SV 'Enhanced' will raise the inspiration pressure range to compete with the Respironics BiPAP ASV. The 'Enhanced', being marketed as a 'diagnostic' machine will also have user friendly software.

Cheers

dsm · Post by **dsm** » Tue Mar 04, 2008 10:55 pm

Banned wrote:
dsm wrote: SWS,

We have the likelihood of miss communication on my point being made re EEP function.

I was speculating that although EEP (like epap) can be set to say 5 CMS and PSmin can be set to add say 4 CMS to provide a minimum ipap of 5+4=9 CMS, and PSmax can allow the machine's minimum ipap to roam beyond 9 and up to 9+5=14) - that the machine being a servo ventilator will actually 'move' up and down in pressure, with each breathing cycle as the sleeper breathes in and out and that these pressures may together 'roam' up and down (but that the PSmin will be maintained as a gap between exhale & inhale).

The machine may not go as low as the EEP setting and may not go as high as the PSmax but will normally operate in between these pressures while holding a inhale exhale gap set to PSmin. Versus, a standard Bilevel that will arbitarily go between epap and ipap.

Now this observation is merely me attempting to work out just how this machine operates. I am still working on a model for how the Bipap SV operates. I think it is going to be very similar except that I believe the Bipap SV doesn't hold to a PSmin (fixed gap) but gain I am speculating on this.

Cheers

DSM

PS I do think banned may not realise his explanation of breathing out against EEP10 vs breathing out against an EEP of 5 is back to front. It is an easy warp to get into

D

#2
I guess the nub of my speculation boils down to "does the adapt SV do its thing while always maintaining an inhale/exhale gap as set by PSmin" ?

I don't know the answer but am guessing this is how it works.
dsm would be correct. Once the EEP is set, it will remain a constant throughout Adapt SV therapy. EEP will not change until it is manually dialed-in, again. Using dsm's example of 9+5=14 will give an inspiration pressure that will never fall below 14cmH2O. "The machine being a servo ventilator will actually 'roam' up and down between 14cmH2O and the MAX PS (which as you remember was automatically set when MIN PS was dialed-in, generally 5cmH2O above MIN PS). So, back to dsm's example of 9+5=14, EEP would always be a constant at 9cmH2O and inspiration pressure would fluctuate between 14cmH2O and 19cmH2O depending on servo-ventilation requirements on a breath-by-breath basis.

I've been using the Adapt SV for 6 months so all of what I have to say is through my own experience. Having never been tirated on an Adapt SV, obtaining the Clinician's Manual with my Adapt SV was essential. The Adapt SV is a deceptively simple and amazing machine. Theoretically the current Adapt SV has an inspiration range limit of 7cmH2O (4+3 =7) to 16cmH2O (10+6=16), not including MAX PS. The Adapt SV 'Enhanced' will raise the inspiration pressure range to compete with the Respironics BiPAP ASV. The 'Enhanced', being marketed as a 'diagnostic' machine will also have user friendly software.

Cheers

Banned · Post by **Banned** » Tue Mar 04, 2008 10:56 pm

dsm wrote: Banned,

I think that confusion has arisen because your posts generally imply that 10 CMS EEP is easier to breathe out against than 5 CMS EEP.

What most of us can't see, is how 10 CMS of EEP can be easier than 5 CMS of EEP.

You mention that 9 CMS EEP provides more back pressure than 10 CMS EEP but again this seems to be the reverse of what EEP stands for.

EEP 9 CMS will start the machine with a lower exhale pressure than EEP 10. The expectation is that the user when breathing out, will always find 9 CMS easier to breathe against than 10 CMS.

Can you see the problem ?

Cheers

DSMl

In the Adapt SV, an EEP of 10cmH2O is one heck of allot easier to exhale against than an EEP of 5cmH2O. EEP 5 would make me choke! Even on my old Vantage S8 it was easier to exhale against EPR 3 than it was EPR 1. Not that EEP equals EPR. Even with my ancient Respironics C-Flex wasn't C-Flex 3 easier to exhale against than C-Flex 1?

SAG would be correct. Factory default EEP would be 5 (Not 10, as I stated) in the Adapt SV.

Banned

dsm · Post by **dsm** » Tue Mar 04, 2008 11:27 pm

Further thoughts

The Vpap Malibu and the Vpap Auto both (I believe) do what I said about raising inhale & exhale pressures by the same amount in response to 'situations'.

So if that is true, what makes the Vpap SV different. What I believe the difference is, is that the Vpap SV can do it many times faster & by using the mask sensing air line is effectively more a high performance tuned system than the other two Bilevel Autos. Also, they (I believe) provide traditional bilevel relief, without tracking to a breathing rate & volume pattern but have an auto adjusting capability.

The Vpap SV is not only much faster at responding but tracks to 90% of past volume & rate and can because of this, switch from passive to active ventilation on the fly - I don't believe the other two models can.

DSM

Banned · Post by **Banned** » Tue Mar 04, 2008 11:38 pm

Ok dsm, I sort of see what you are saying. I'm sure within the guts and the algorithms of the Adapt SV the EEP is going crazy and not staying constant. i have no idea what happens internal to the machine. What I do see on the outside of the machine (in the LCD) is that the EEP setting stays constant while the Inspiration pressure roams (and sometimes roams wildly) from the set inspiration pressure of EEP+MIN PS to EEP+MAX PS, if you will, on a breath-by breath basis. Whatever it does it freakin' works great.

Hey, I about fell out of my chair today. I was cruising the forum and I tripped across some guy from northern California who actually said, "I LOVE MY RESPIRONICS BiPAP ASV." Go figure..

And yes, the Adapt SV adjusts automatically (quickly and accurately) to your breath flow rate.

Banned

_________________

CPAPopedia Keywords Contained In This Post (Click For Definition): respironics, bipap

-SWS · Post by **-SWS** » Tue Mar 04, 2008 11:43 pm

Banned, would you also mind commenting on these two additional proposed clarifications:

Banned wrote:MAX PS is automatically set by MIN PS and will always be 5cmH2O higher than MIN PS.

The ASV User Manual wrote:Max PS minus Min PS is greater than or equal to 5 at all times

Thus First Proposed Clarification: the ASV design allows for MAX PS to be more than 5cm higher than MIN PS

Banned wrote:You never adjust MAX PS because MIN PS automatically sets MAX PS.

By contrast to the above statement the ASV user manual allows for MAX PS to be manually adjusted between the values of 8cm and 16 cm (with a default value of 10 cm). The ASV manual also goes on to explain that MIN PS automatically adjusts MAX PS whenever it needs to meet these two requirements:

The ASV User Manual wrote: "Max PS minus Min PS is greater than or equal to 5 at all times" [requirement one],

"EEP + MAX PS will not exceed 20cm" [requirement two],

"To satisfy these limits setting Min PS automatically adjusts Max PS" [driven by the above two requirements]

Second Proposed Clarification: MAX PS can be user-adjusted between 8cm and 16cm. However the set-up menu will automatically intercede and adjust MAX PS, but only if the above two requirements are not met by the user during manual set up.

Thanks.

dsm · Post by **dsm** » Tue Mar 04, 2008 11:49 pm

-SWS wrote:Banned, would you also mind commenting on these two additional proposed clarifications:

Banned wrote:MAX PS is automatically set by MIN PS and will always be 5cmH2O higher than MIN PS.

The ASV User Manual wrote:Max PS minus Min PS is greater than or equal to 5 at all times
Thus First Proposed Clarification: the ASV design allows for MAX PS to be more than 5cm higher than MIN PS

Banned wrote:You never adjust MAX PS because MIN PS automatically sets MAX PS.
By contrast to the above statement the ASV user manual allows for MAX PS to be manually adjusted between the values of 8cm and 16 cm (with a default value of 10 cm). The ASV manual also goes on to explain that MIN PS automatically adjusts MAX PS whenever it needs to meet these two requirements:
The ASV User Manual wrote: "Max PS minus Min PS is greater than or equal to 5 at all times" [requirement one],

"EEP + MAX PS will not exceed 20cm" [requirement two],

"To satisfy these limits setting Min PS automatically adjusts Max PS" [driven by the above two requirements]
Second Proposed Clarification: MAX PS can be user-adjusted between 8cm and 16cm, however the set-up menu will automatically intercede if the above two requirements are not met.

Thanks.

SWS,

Thanks for that. Also it seems from what Banned is saying, that EEP doesn't roam with PSmin.

I can't imagine though that EEP will stay say at 4CMS (if that was its initial setting) if PS has gone up to PSmax. That just doesn't make sense to my picture of how the machine works.

Any thoughts ?

Thanks

DSM

New to this- Husband vpap III 5 days but not taking breaths

Greetings From Mr. Glib

Proposed Clarifications

Re: Proposed Clarifications