Using a Bipap Auto SV and using a Vpap Adapt SV

Doug, I just added this comment to the above post:

I see where VPAP S/T gave you plenty of timed back up breaths, but at the expense of inducing excessive BPM.

Rhetorical pondering: if BiPAP AutoSV backs you up at the rate of 68 per hour (without inducing excessive breath rates), might it also prevent arousals commensurate with that backup rate? Dunno.

There are also some treatment discrepancies I noticed between the Encore charts and the Power Point presentation, regarding when responsive PS increases occur. Regardless, I think the BiPAP autoSV may very well be preventing hypopneas via fluctuating PS that the AutoSet Vantage is designed to allow. However, that should be of lesser symptomatic significance to a purely OSA patient.

An interesting treatment/SDB puzzle for us to decipher... That's for sure!
.

Interestingly, After using the Vpap IIIs I always felt a bit 'hyper' very similar to what I felt on the 3rd night with the Vpap Adapt SV.

By 'hyper' I mean - same shallow sleep & lots of arousals but would get up early without any difficulty. There was also a feeling that at some time (after a few days of it) I might want to just go sleep without a machine.

I once described this 'hyper' feeling as being like a supercharged kitty - that is when you rub a cats fur until its eyes spin & it is ready to fly

DSM

I might add that the PB330 compared to the VPAP IIIs was to me a similar difference as to the Bipap SV to the Vpap Adapt SV.

The PB330 seemed a lot 'tamer' - none of that 'hyper' feeling.

D

-SWS wrote:
<snip>

Even OSA-targeted BiLevel does not rely on timed backup rates. Rather OSA-targeted BiLevel is purely spontaneous. You, my friend, rely on a timed backup:

Average Breaths Per Minute=14.1
Average Patient Triggered Breaths: 99.2%
Therefore Average Breaths Per Hour=846
Therefore Average Machine-Triggered Breaths Per Hour=68

Now bear in mind that if those were apneas being responded to that would be a residual AI of 68 (residual only after IPAP/EPAP or even CPAP finishes addressing vanilla OSA via ordinary airway inflation). But with that vanilla OSA diagnosis your doctor gave you and that vanilla OSA static pressure he prescribed to inflate your airway, you should really be good with the above vanilla EPAP=11 and IPAP-min=14 to address those vanilla obstructions, right? So what residual AHI did your doctor achieve with his static vanilla pressure? And what was his prescribed vanilla pressure for a guy who needs a timed backup at the not-so-OSA-vanilla rate of 68 breaths per hour?

<snip>

SWS,

I don't believe that chart shows I rely on timed mode. All it is saying is that the Bipap SV tracks me on average at 14 BPM and if my breathing varies outside its target (which certainly is going to be close to 14 BPM) it will flag the need to bring me back to the target as per its algorithm.

I used to run 6 BPM on the PB330 and the VPAP III. I derived that rate based on how long it took me to breathe through my nose when it was a bit congested.

So all the 'patient triggered breath' data is saying is that the Bipap SV keeps my BPM tidy and that is merely 'very nice' versus 'needing it'.

I do have some SpO2 data from when I 1st went on the Bipap SV and published it at the start of this thread. That SpO2 data is consistently the best I had ever recorded (note - 'consistently'). It is very even and shows a very nice straight line whereas on my other machines SpO2 does wander a bit more. Also pulse rate is far more steady with the Bipap SV. It too seems to be a remarkable steady line compared to any other chart I look at.

This Bipap SV seems to keep everything tidy - this machine is just very good. I am willing to bet that many other people trying it would see similar smoothing of SpO2 and pulse and their AHI plus more restful sleep (assuming they do a proper bilevel titration before setting it up & provided they keep IpapMax no more that 7 - 10 CMs above IpapMin.

DSM

#2 on re looking at that SpO2 & pulse data I think it is faultless - so smoooth.

Some SpO2 links whilst on the Bipap SV

http://www.internetage.com/cpapdata/dsm ... pr08-2.jpg

http://www.internetage.com/cpapdata/dsm ... pr08-2.jpg

http://www.internetage.com/cpapdata/dsm ... pr08-2.jpg


The above coresponding Bipap SV Data can be located at

http://www.internetage.com/cpapdata

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CPAPopedia Keywords Contained In This Post (Click For Definition): bipap, Titration, CPAP, AHI

-SWS wrote:Should most vanilla OSA cases respond better to SV? If not, which ones will and which ones won't? What might any treatment discrepancies among the vanilla OSA crowd say about the various treatment platforms? What might it say about diagnostic methods? About SDB confounding factors in pathophysiology? About contemporary SDB epidemiology?

The people best served by SV therapy would be the vanilla OSA crowd with periodic respiratory controller disorder. SWS and dsm have both suggested that some forms of PRCD will likely not be picked up in a sleep lab. eg. Paroxysmal Nocturnal Dyspnea (cardiac asthma).

I would not survive using my Vantage as a travel/backup machine. Hence, I picked up the 'enhanced' Adapt SV, and use the 'original' Adapt SV for travel/backup.

I find the new enhanced version of the Adapt SV to be operationally smoother than the previous model. It feels like breath-rate tracking is quicker and more finely tuned. There is no EEP/IPAP swithing as in the previous model. It would not be unreasonable to assume that ResMed updated the Adapt SV algorithm while also increasing the pressure. And, it is quiet! At higher pressure levels I do not even hear those faint chirps.

My old CPAP study suggested a baseline pressure around 14cmH2O with optimal REM sleep and more Centrals observed at 17cmH2O. Since the enhanced Adapt SV allows for increased pressure I now find that I get deeper and more satisfying sleep at EEP 11 + MinPS 6 = (IPAP) 17.

I think dsm, or anyone, would like the the enhanced Adapt SV. In the future, I do look forward to a trial with the BiPAP Auto SV.

Banned

I don't believe that chart shows I rely on timed mode. All it is saying is that the Bipap SV tracks me on average at 14 BPM and if my breathing varies outside its target (which certainly is going to be close to 14 BPM) it will flag the need to bring me back to the target as per its algorithm.

...So all the 'patient triggered breath' data is saying is that the Bipap SV keeps my BPM tidy and that is merely 'very nice' versus 'needing it'.

I agree, Doug. And I think your sleep doctor's RX was correct by today's standards as well.

Your results make me wonder what about the BiPAP autoSV is important to your sleep. Around 40-to-70 times per hour that machine will "tidy up" your breath rate for you. It will automatically manage to keep your breath rate close to an ordinary 14 or 15 BPM. That, of course, is something the OSA-targeted platforms would never even therapeutically attempt.

Is that tidying up or consolidation somehow key for you? If so how might your sleep architecture and/or arousal rate reflect that presumably beneficial respiratory compensation? How might cyclic alternating pattern or CAP reflect those presumably beneficial changes for you as well?


But I truly am glad it seems to work well for you! Absolutely!!

Banned wrote:

-SWS wrote:Should most vanilla OSA cases respond better to SV? If not, which ones will and which ones won't? What might any treatment discrepancies among the vanilla OSA crowd say about the various treatment platforms? What might it say about diagnostic methods? About SDB confounding factors in pathophysiology? About contemporary SDB epidemiology?

The people best served by SV therapy would be the vanilla OSA crowd with periodic respiratory controller disorder.

So in essence there should be some central raspberry or central chocolate swirl thrown in with that vanilla OSA to meet the manufacturers' design intent. If you have a little central swirl thrown in with your vanilla OSA, then these machines are targeted for you. If you have a lot of central swirl thrown in with your vanilla OSA, then these machines are targeted for you as well. If you have vanilla OSA only, with no central swirls thrown in, then the manufacturers currently do not target you with these SV designs.

Specifically these SV designs are both targeting respiratory controller gain issues, with the obstructive SDB component manually addressed with the fixed-pressure equivalents of CPAP (Respironics only) or IPAP/EPAP (Respironics or Resmed) used as minimum inflationary pressures.

Treatment Summary: Got obstructions? Then inflate the upper airway to get rid of any airway narrowing. Got central issues? Then ventilate the airway via timely and proportional "mechanical unloading" with any obstructions already out of the way.

Banned wrote: It would not be unreasonable to assume that ResMed updated the Adapt SV algorithm while also increasing the pressure.

I agree!

Banned wrote: And, it is quiet! At higher pressure levels I do not even hear those faint chirps.

So they removed the hamster? .

-SWS wrote:

I don't believe that chart shows I rely on timed mode. All it is saying is that the Bipap SV tracks me on average at 14 BPM and if my breathing varies outside its target (which certainly is going to be close to 14 BPM) it will flag the need to bring me back to the target as per its algorithm.

...So all the 'patient triggered breath' data is saying is that the Bipap SV keeps my BPM tidy and that is merely 'very nice' versus 'needing it'.

I agree, Doug. And I think your sleep doctor's RX was correct by today's standards as well.

Your results make me wonder what about the BiPAP autoSV is important to your sleep. Around 40-to-70 times per hour that machine will "tidy up" your breath rate for you. It will automatically manage to keep your breath rate close to an ordinary 14 or 15 BPM. That, of course, is something the OSA-targeted platforms would never even therapeutically attempt.

Is that tidying up or consolidation somehow key for you? If so how might your sleep architecture and/or arousal rate reflect that presumably beneficial respiratory compensation? How might cyclic alternating pattern or CAP reflect those presumably beneficial changes for you as well?


But I truly am glad it seems to work well for you! Absolutely!!

dsm wrote:In summary, these machines do appear to be very capable of addressing a wider range of SDB than we are told they are designed for. My next bet is that we will see 'tri-level' machines marketed as top level solutions to the vanilla OSA market and with an added emphasis on cleaning up residual events, smoothing out SpO2 & pulse & breathing & providing sounder sleep.

So in summary we have:

1) both manufacturers algorithmically addressing respiratory controller gain problems,

2) both manufacturers saying SV is not targeted for simple OSA

3) Fifteen years of this modality with not even a single scientific study hinting that this is a superior OSA treatment method, and

4) Because you and Banned have breathed into this machine and slept well you think this is a great OSA treatment method?

As an SV opinion that works just fine for me, although I admit to disagreeing with that conclusion. As a sound methodology to support the conclusion that all manufacturers and all independent researchers have completely missed a superior OSA treatment method for fifteen years.... I'm thinking this conclusion may need some more work---with or without the aid of vanilla-conclusion-based epidemiology.

-SWS wrote:

dsm wrote:In summary, these machines do appear to be very capable of addressing a wider range of SDB than we are told they are designed for. My next bet is that we will see 'tri-level' machines marketed as top level solutions to the vanilla OSA market and with an added emphasis on cleaning up residual events, smoothing out SpO2 & pulse & breathing & providing sounder sleep.

So in summary we have:

1) both manufacturers algorithmically addressing respiratory controller gain problems,

2) both manufacturers saying SV is not targeted for simple OSA

3) Fifteen years of this modality with not even a single scientific study hinting that this is a superior OSA treatment method, and

4) Because you and Banned have breathed into this machine and slept well you think this is a great OSA treatment method?

As an SV opinion that works just fine for me, although I admit to disagreeing with that conclusion. As a sound methodology to support the conclusion that all manufacturers and all independent researchers have completely missed a superior OSA treatment method for fifteen years.... I'm thinking this conclusion may need some more work---with or without the aid of vanilla-conclusion-based epidemiology.

SWS

Your logic at times loses me

1) Can and does a Bilevel address OSA ?

2) Is the SV design a Bilevel with an added mechanism called PS and some algorithms for tracking air flow and breathing rate ?

Respironics tell us it is gets titrated like a bilevel and addresses primary OSA and secondary centrals and irregular breathing.

I don't understand why you keep ignoring/distorting this fact ?

We have both repeated ad nauseum that we agree that the SV was not designed for simple OSA - BUT it was designed to address OSA plus ! - exactly as stated in Respironics marketing material !.

DSM



SLIDE #1



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SLIDE #3


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

dsm wrote: SWS Your logic at times loses me

Friend, I am truly flattered! I feel as if I just single-handedly contrived Zeno's Sleep Disordered Breathing Paradoxes for you!

But I agree that we have slightly different logical interpretations of precisely what that Respironics marketing literature implies:

Respironics BiPAP AutoSV Presentation wrote:Indications for Use- To provide non-invasive ventilatory support to patients for the primary treatment of Obstructive Sleep Disordered Breathing with secondary Central Sleep Apnea and/or Cheyne Stokes Respiration (CSR).

dsm wrote:the SV... it was designed to address OSA plus !

Respironics' statement explicitly says that this machine is intended to treat a compounded condition: a primary breathing condition compounded with a secondary breathing condition---and that they will use a compounded treatment approach (which I have expounded on in great detail rather than ignore).

However, your logic takes that Respironics explicit wording and decouples that compounded condition. You proceed to assert that if this machine can treat a compounded primary and secondary breathing condition, that it can surely treat the primary condition alone! That may be a true statement, and probably is. But what are the ramifications and dynamics regarding disturbance-related pathophysiology---regarding say a 1 or 2 second pressure increase on the order of 8 or 10 cm in response to heavy occlusion? And why did Respironics completely drop their OSA intent for this PAV technology back in 1994?.

Back to logic, my friend. Here's where your logic starts plugging in inferences. Once you have decoupled the machine's design intent from treating a compounded condition to optionally treating only the primary condition, you imply that the primary condition will somehow be treated with increased OSA benefits. You then infer that OSA gets "tidied up".

Hmmm... So airway inflation somehow doesn't work for the OSA platforms that successfully treat OSA for so many? So is 15 cm inflationary pressure somehow more or less inflationary pressure on any given xPAP platform for vanilla obstructions? Which standard vanilla obstructions couldn't your sleep doc "tidy up" with spontaneous BiLevel and why? And why is it that your "vanilla OSA" can only receive proper OSA inflation with a machine that backs your breaths up at the occurrence rate of 40 to 70 breaths per hour?

So does OSA really get "tidied up" here where all the other machines have failed to inflate? So what is really getting "tidied up" here? After all, aside from those 40 to 70 backup breaths you receive per hour, how can you know when you get "OSA tidied up" and when you get "respiratory controller tidied up"---let alone by a machine that is designed to tidy up respiratory controller gain?

dsm wrote:Respironics tell us it is gets titrated like a bilevel and addresses primary OSA and secondary centrals and irregular breathing.

I don't understand why you keep ignoring/distorting this fact ?

I'm not distorting anything that I am aware of, Doug. The Respironics statement says that it will treat a compounded condition and that is what I have been adhering to all along. But to say that the SV is good to treat standalone OSA distorts Respironics words---despite probably being true. However, to say or imply that SV will treat obstructions better via "tidying up OSA" remains to be substantiated by evidence-based medicine.

In fact, Respironics claimed just that in a 1994 patent, and then dropped OSA from PAV altogether! To this day Respironics essentially says "Hey! Get any obstruction stented and out of the way first, so that PAV can be used to compensate respiratory controller gain problems". So far nobody's claiming PAV tidies up OSA other than Respironics in 1994 (claim dropped) and DSM in 2008 (claim still avidly contended).

Regardless of our different interpretations: Cheers, my friend!
.

This post is in good humor it is more of a parable than
anything

DSM

***********************************************

Once upon a time there were companies that manufactured
both spades and shovels.

Their marketing literature advised the buyers to use the
spade for digging holes in their garden and to use the
shovel for moving dirt from one place to another.

It was generally accepted that this was the best use for
each tool. But, it was also common knowledge that either
tool could do both jobs even if not as efficiently as the
prefered tool.

Then one day two of these companys released a 'super shovel'.

This variation on the older tool, used newly developed
technologies that made the shovel stronger and lighter than
either of the other two tools. Also the designers reduced
the curve at the front edge and flattened the shape to half
what it had been before and narrowed it by an inch each side.

This new super shovel was an oustanding improvement over the
earlier design. Then someone noticed he could dig holes better
than he could with the older design spade.

This person did several trials & found that in most cases
the new shovel out performed both the older tools.

But when he published his findings, someone pointed out that
the new tool was still called a shovel & should not be used
as a spade.

The conversations went something like this ....


OPP: If you want to primarily dig holes you should buy a
metal plate tipped, flat ended, short handled, 'D' shape gripped,
manual earth - extraction tool'. (otherwise called as a spade).

SUP: But why ? - this (admittedly more expensive) new super
shovel seems more than capable of doing both jobs and does
them better than either of the prior models.

OPP: This new tool is a soft round nosed, metal tipped, long
handled, zero 'D' gripped, manual earth shifting tool' and
this new version is still only designed to move earth not dig
holes. The overall design is very old and has not changed in
centuries so how can you claim to that it is better at digging
holes.

SUP: This new 'shovel' is just a tool but look at the modern design,
look at the shape, look at the results from trialling it for both
types of task.

OPP: But!, the manufacturer designed it to shift earth.

SUP: But this new shovel digs holes better than a spade does in most
instances.

OPP: Who are you to question a marketing brochure.

SUP: What do we use tools for ?, I have just found a much better tool
for digging holes as well as shifting dirt. It works well and can be
demonstrated to do the best job I could hope for. Don't
demonstrated results count here ?

OPP: But you should only use the tool the manufacturers tells you to
and also because you aren't insured to use the new super shovel as a spade

etc: etc: etc: etc: etc: etc:

If they dig deep enough they'll discover it's turtles all the way down, Doug. Then they'll be justified in using the adaptive servo turtle extractor instead.


I'd also like to take this opportunity to express that your debating skills have increased a good fifty-fold... ever since you started compensating that respiratory controller!

SWS,

I believe there is more to the spade story (apart from calling a spade a spade ) - that 'new shovel' is so versatile I believe it can also be used to chop wood. Something to do with a technological advance in the metals its shape the edge & the stroke

D

So far we have race cars veering off roads, holes being dug with shovels, and SDB diagnoses à la vanilla extract: science by logic and metaphors rather than methodology. The problem with science by logic and metaphors is that it has a rich history of yielding "irrefutable fact" that turns out to be false. So I'll take your word for it that you sleep better with the BiPAP autoSV.

But how do you have the slightest clue that SV is "tidying up" your obstructions as opposed to doing exactly what it was designed for, let alone at the measured backup rate of 40 to 70 times per hour?

And how to you propose to generalize any one or two uncontrolled experiments across an entire pathologically diverse patient population?
.

Sorry, I couldn't resist! LOL Yeah, this is a link to click, doubling as my comment.