CPAPtalk.com

ozij wrote:

In any ASV technology, therefore, all of the obstructive events must be manually titrated out. The apneas, absolutely. Theoretically, ASV technology will attack hypopnea, but why spend 4 times the money on something that doesn't do the job as well (because ASV technology never completely matches spontaneous breaths, it always undershoots to avoid the hyperventilation that perpetuates "central dysregulation").

Thanks for "undooming" us!

Am I right inassuming you really mean "all of the obstructive events must be manually titrated out. The obstructive apneas, absolutely" in that sentence?

O.

According to both SV manufacturers, manually eliminating obstructions is required. Algorithmically, the two-fold rationale has to do with: 1) the fact that both machines deliver automatically-adjusting IPAP pressures to specifically target flow----and 2) the fact that a central event at any given measured underflow value will require an entirely different IPAPpeak pressure to resolve than an equivalent obstructive event at that same underflow value. Essentially the SV algorithms need to calculate each IPAPpeak pressure target using exclusively central-event pressure extrapolations. If the titrating clinician leaves too many residual obstructive events, either SV algorithm will have an undetermined and very difficult mix of both central and obstructive IPAP pressure extrapolations to make. The SV algorithms just aren't equipped to handle that IPAP work-load ambiguity efficiently.

With that said, it's unrealistic to expect that any SV patient will experience absolutely no obstructive events---even after titration by a highly skilled clinician. On that basis the BiPAP autoSV algorithm will attempt to differentiate how "heavy" or "light" an apneic/hypopneic event happens to be by utilizing a very quick 2cmH2O puff of air (forced oscillation technique or FOT). While that technique is undoubtedly helpful toward extrapolating a required IPAPpeak value, it's apparently not specific enough to clinically differentiate obstructive events from central events. That differentiating lack of specificity/sensitivity is presumably why the events are not clinically differentiated on the autoSV Encore Pro reports.

Regardless of those algorithmic attempts to differentiate toward IPAPpeak pressure extrapolations, Respironics very clearly asks that obstructive events be manually titrated away by the clinician. And in my way of analyzing, that requirement probably speaks of this forced oscillation technique's inefficiency at central versus obstructive event differentiation.

Whew! See this is what I mean, I go away for 12 hours and the thread has grown by 10 pages
The posts aren't really over my head, but they are very, let's say dense, (full of acronyms and references etc) and I really haven't taken the time to sit and pour over each post. And therefore I lose the reasoning behind the arguments very easily (I'm hoping to learn via osmosis instead of reading). So I'll stop whining now and spend the weekend studying each and every word of all of these posts.

p.s.

StillAnotherGuest wrote:
Meanwhile, I will try to re-summarize my points:

The only way to be reasonably sure (and not 100%, either) that your one-channel (airflow) device (xPAP machine) is seeing a central apnea is to employ a technology that can "look down" the open, unobstructed airway and identify it as such. And the only technology that is able to do that is ballistocardiography (the search for cardiac pulsations in GK420E) or forced oscillation technique (send out a pressure pulse and watch its behavior, looking for resistance in the oscillation as seen in SomnoStar). Any other machine cannot make this differentiation, all they see is a straight line.

Here, let me use someone else's words in describing your summary above:

absolutely and unequivocally false.

To add to that, I totally disagree, seems you have been reading way too many German magazines! FOT is not even a consideration here, that technique is simply too slow. In fact this machine does NOT have to have technology to differentiate the central event, in fact it is not even expecting the need to differentiate. All it has to sense is inspiration and since it targets the half-breath it only needs less than 3 seconds to determine that, in fact it will target and find it in as little as 1.5 seconds of inspiration if it detects flattening.

No airflow is NO airflow. If the event has NO airflow machine is NOT going to sense inspiration to even trigger PS, it has up to 3 seconds to decide and determine that.

Obstructive apnea is eliminated by EPAP.
Obstructive apnea is eliminated by EPAP.
Obstructive apnea is eliminated by EPAP.

What is left? Unstable breathing and Centrals. Put yourself in the shoes of the machine, a obstructive hypopnea is coming in, it senses flattening on that hypopnea and increases PS to eliminate it. Treated Hypopnea is NOT going to show up on the Therapy Flag graph (TFG). You will see PS increase and NO event tic for that Hypopnea on TFG. Events shown on TFG are events it could NOT resolve, they are residual events. Object of this game is NO tics on the TFG.

Obstructive Hypopnea is eliminated by Pressure Support.
Obstructive Hypopnea is eliminated by Pressure Support.
Obstructive Hypopnea is eliminated by Pressure Support.

Obstructive Hypopnea is always eliminated by Pressure Support, if it doesn't, EPAP is NOT high enough. If I cannot eliminate it within 3 seconds, I'm going to BPM mode.

However, you are correct, machine is ONLY going to respond with PS if it sees a partial inspiration. When machine does NOT see Inspiration when it "expects" to see one it assumes it is a central. It is simply a matter of "what are you looking for here?" I'm looking for inspiration, I know what the last 4 minutes have been with breathing, they are bound to have taken a breath or two in the last 4 minutes.

Fact is, if I'm the machine and I don't see 1.5 seconds of Inspiration when I'm expecting to see it, that event has to be a central, I don't apply PS to pump that breath up, in fact I don't apply PS at all, I go to what my BPM directive is set for. If BPM=Off, I do nothing and pick up on the next breath, if BPM=Fixed, I now follow the instruction set for fixed using those values (follow titration protocol for establishing those), if BPM=Auto, I use spontaneous sample settings incorporated into the algorithm.

StillAnotherGuest wrote: In any ASV technology, therefore, all of the obstructive events must be manually titrated out. The apneas, absolutely. Theoretically, ASV technology will attack hypopnea, but why spend 4 times the money on something that doesn't do the job as well (because ASV technology never completely matches spontaneous breaths, it always undershoots to avoid the hyperventilation that perpetuates "central dysregulation").

I agree, all obstructive events must be manually titrated out, think I said that. Remember me asking -SWS if that included Hypopnea in the earlier pages of this thread? Think he said yes, I didn't want to push the wrong buzzer but I knew otherwise. Pressure Support of IPAP is going to eliminate any obstructive hypopnea, you do NOT have to titrate those out, but it helps if you can kill any with EPAP.

StillAnotherGuest wrote: If you arbitrarily stick in a backup rate in someone that does not have central apnea, you run the risk of hyperventilation and causing "central dysregulation". This is possible to do in pretty much everybody.

I agree you can induce central dysregulation it in pretty much anybody, think I already indicated that in my first response to that theory. But I think you -SWS and dsm need to get out the book again and read how this machine responds with its back-up mode, because neither one of you guys have gotten it right to date, I've only tried to get that point across in 3 threads a half dozen times.

It is right in the logic of its titration protocol that -SWS tried to discount in the beginning of Bev's thread, oh we had a good argument about it, he still didn't win in changing the logic behind the Respironics Titration Protocol, its there for a reason. I already said Respironics was stupid for calling it BPM, all that does is confuse people like you.

StillAnotherGuest wrote: The breath rate is determined by an IPAP event. That makes this statement

I agree, its all about Inspiration, no argument there.

StillAnotherGuest wrote:

Snoredog wrote:If that hypopnea was central, there is NO inspiration, machine won't see that partial inspiration

absolutely and unequivocally false.

Once a machine senses any inspiration, the rate is calculated.

Where's SAG?
Ah he left because he got tired of being wrong all the time

I think you need to re-read what I wrote above again. Think I also said that any Hypopnea that shows up on the Therapy Flag Graph will be a Central one as obstructive hypopnea will be eliminated by IPAP pressure support. There won't be any residual obstructive Hypopnea listed on the Therapy Flag Graph, if there is, your EPAP is not high enough and/or IPAP working was bumping into IPAP Max.

How long does a hypopnea duration have to be?
How long does it take this machine to determine inspiration is NOT going to meet its target? I'll answer that for you, in as little as 1.5 seconds or as soon as it sees "flattening" it applies PS (can be seen in funny little cartoon in the brochure and the book).

Okay kids, How long does it take for this machine to determine the event seen is a central event?

StillAnotherGuest wrote: This poster explained this inability of event differentiation without realizing it:

Snoredog wrote:How does it know it is central? Both events if they occur are displayed the same on the Therapy Flag graph, the only way you know which the machine "seen" is by its response, that being from the report was going to BPM mode seen as a dip on the Patient Triggered Breathing graph.

Snoredog wrote:Respironics wouldn't ask you as part of its titration protocol to input the CPAP pressure that eliminated all obstructive events if it meant otherwise. Since EPAP pressure is static on this machine, you better input the pressure that eliminates all obstructive events. So this means this machine is NOT going to respond to frank obstructive apnea period.

Snoredog wrote:if the machine detects an event resembling an apnea, that apnea has to be either obstructive or central or a combination of both. Since this machine only offers CPAP as baseline support and does NOT have the ability to adjust and respond on the fly therefor machine treats that event as a central by switching to BPM mode.

But in the case of obstruction the underlying issue is treated symptomatically and therefore inadequately.

SAG

Oh I realized it, I figured if I wrote it at a 5th grade level, it might sink in with some. Yep it seems I have to repeat things here a half dozen times before Cousin itt gets it. So on this machine you can toss out your cardiac oscillation technique, your FOT theories because this machine doesn't need either one a simple pressure sensor on a single circuit is all that is needed.

Respironics could do a whole lot better job if they would better explain what is actually seen on this machine's reports. On that Therapy Flag Graph, events seen are residual events they are NOT events the machine resolved. They are events the machine did NOT resolve. IF PB flag shows up, SV did NOT prevent PB, that says you need to fix settings so it can resolve PB. When AP shows up that is Apnea Periods the machine could NOT resolve. Have too many "AP"'s and you may have to think twice about that BPM=Auto. 100% Patient Triggered Breathing and no Therapy flags is the goal on this machine.

If we look at dsm's 11/19 report, he has zero HI therapy flags, that means the SV completely eliminated his obstructive hypopnea with Pressure support found in the Min to Max range set. He had about a half dozen AP's, those are central apnea. Those are probably transitional staging centrals so there is nothing that needs to be done about those, nor is there anything you can do about them.

Hell if your thinking is wrong about this machine there will be a lot of them ending up in the dumpster. Who's fault is that?

Snoredog wrote:To add to that, I totally disagree, seems you have been reading way too many German magazines! FOT is not even a consideration here, that technique is simply too slow. In fact this machine does NOT have to have technology to differentiate the central event, in fact it is not even expecting the need to differentiate. All it has to sense is inspiration and since it targets the half-breath it only needs less than 3 seconds to determine that, in fact it will target and find it in as little as 1.5 seconds of inspiration if it detects flattening.

No airflow is NO airflow. If the event has NO airflow machine is NOT going to sense inspiration to even trigger PS, it has up to 3 seconds to decide and determine that.

Those very quick 2cmH2O puffs of air described in the patent description and by this message board's autoSV users disagree with your statement above. Please see my description two posts up regarding why obstructive zero-airflow and central zero-airflow are different regarding IPAPpeak workload. Regardless, obstructive and central events---including both hypopnea types will both occur in the real world despite requiring different IPAPpeak extrapolations. Hence the 2cmH2O FOT technique that I have summarized two posts above.

Also, since the machine specifically targets peak flow, it cannot rely only on a pressure sensor as you suggest. Great discussion...

-SWS wrote:

Snoredog wrote:To add to that, I totally disagree, seems you have been reading way too many German magazines! FOT is not even a consideration here, that technique is simply too slow. In fact this machine does NOT have to have technology to differentiate the central event, in fact it is not even expecting the need to differentiate. All it has to sense is inspiration and since it targets the half-breath it only needs less than 3 seconds to determine that, in fact it will target and find it in as little as 1.5 seconds of inspiration if it detects flattening.

No airflow is NO airflow. If the event has NO airflow machine is NOT going to sense inspiration to even trigger PS, it has up to 3 seconds to decide and determine that.

Those very quick 2cmH2O puffs of air described in the patent description and by this message board's autoSV users disagree with your statement above. Please see my description two posts up regarding why obstructive zero-airflow and central zero-airflow are different regarding IPAPpeak workload. Regardless, obstructive and central events---including both hypopnea types will both occur in the real world despite requiring different IPAPpeak extrapolations. Hence the 2cmH2O FOT technique that I have summarized two posts above.

Also, since the machine specifically targets peak flow, it cannot rely only on a pressure sensor as you suggest. Great discussion...

Like Users on this board have never been wrong before (I'm not picking on you dsm, you can be assured of that).

Can you please provide the document number and/or filename you are looking at on the Adapt SV Patent so I can read that description for myself? The part where it describes FOT would be nice.

However, If you are reading from the Remstar Auto Patent, then well don't bother. Having assisted in the authoring of more than 30 patents myself, I know that what you put in a Patent Application doesn't necessarily mean it makes it's way into the final product. I think Digital Auto trak came over from that machine, that and CPAP and well maybe the plastic case. Oh yeah and Ramp.

But if you have the doc number on one specifically for the Resp Adapt SV, I would like to read it and see for myself how it is incorporated into the SV algorithm because it is really NOT needed, I'm not looking for the results it would return.

Now if you are describing that from the Remstar Auto Patent, well then let's talk about the little chairs found on Bev's Aflex reports because that is the only thing remotely resembling FOT but again, that is NOT the Adapt SV in the immediate discussion.

This machine is NOT looking for obstructive events. It is only looking at that peak inspiration flow and determining if it is meeting its target.

It does NOT matter what the event is, if inspiration is expected that is what it looks for. Once inspiration is detected it then looks to see if it is meeting its target, if not, it makes sure it does by adding PS to extend the Inspiration. It is NOT going to puff half-way through that inspiration cycle then monitor what happens on the down side, ain't gonna happen.

Any time you cycle from IPAP to EPAP or EPAP to IPAP at a different pressure you are going to get a "puff". Just because you get a "puff" doesn't mean it is FOT, unless you mean Flawed Obsolete Theory

Come on -SWS, this machine is NOT looking for obstructive events, nor was it ever designed to. Sure it is going to get them, if they are hypopnea those are zapped away with IPAP working pressure all part of that peak targeting, that is why residual obstructive hypopnea rarely exist on this machine if the Min to Max range is wide enough to allow it to resolve it.

Any rouge obstructive apnea will be treated the same as a central apnea, if that causes the machine to go into BPM mode, no big deal, but it CANNOT do anything with a obstructive apnea period. If you cannot DO anything about obstructive apnea, then why wasted circuit time looking for it? Doesn't make any sense to use it.

I'm only looking to control:

Periodic Breathing
Central Dysregulation

Obstructive Hypopnea is the only treatable obstructive event this machine can treat. It does that with the SAME IPAP working pressure it uses to control Periodic Breathing.

Snoredog wrote:Come on -SWS, this machine is NOT looking for obstructive events, nor was it ever designed to.... <unabated yadi yadi yada>

Respironics Patent 7296573 wrote:The invention further includes a method for determining if the airway is open (central apnea) or obstructed (obstructive apnea) during an apnea. Once an apnea of significant duration is detected the system, under the direction of CPU 70, automatically increases Gamlnsp by 2 cm H2O, waits approximately 1 second and decreases the pressure back to the original value. If there is a significant change in flow during this pressure change, the system concludes that the airway is open (central apnea). If there is no significant change in flow the system determines that the airway is obstructed (obstructive apnea). The system will continue to monitor each apnea for its entire duration at periodic intervals to determine the nature of the apnea. In accordance with a preferred embodiment, the PPAP apparatus 10" controls are automatically adjusted as follows. In the event of a hypopnea, Gain&^ is increased by 2 cm/liter/second. In the event of an obstructive apnea, Pbase is increased by 1 cm H2O. The device will continue to increase Pbase as long as an obstructive apnea of significant duration is detected.... <even more yadi yadi yada than Snoredog's>

-SWS wrote:

Snoredog wrote:Come on -SWS, this machine is NOT looking for obstructive events, nor was it ever designed to.... <unabated yadi yadi yada>

Respironics Patent 7296573 wrote:The invention further includes a method for determining if the airway is open (central apnea) or obstructed (obstructive apnea) during an apnea. Once an apnea of significant duration is detected the system, under the direction of CPU 70, automatically increases Gamlnsp by 2 cm H2O, waits approximately 1 second and decreases the pressure back to the original value. If there is a significant change in flow during this pressure change, the system concludes that the airway is open (central apnea). If there is no significant change in flow the system determines that the airway is obstructed (obstructive apnea). The system will continue to monitor each apnea for its entire duration at periodic intervals to determine the nature of the apnea. In accordance with a preferred embodiment, the PPAP apparatus 10" controls are automatically adjusted as follows. In the event of a hypopnea, Gain&^ is increased by 2 cm/liter/second. In the event of an obstructive apnea, Pbase is increased by 1 cm H2O. The device will continue to increase Pbase as long as an obstructive apnea of significant duration is detected.... <even more yadi yadi yada than Snoredog's>

Thanks, that is what I was looking for, I will look it up and read the rest. But the above appears to be what it does AFTER it detects the apnea. If said apnea is of "significant duration", how long is that? 10 seconds? if shorter its a Hypopnea. Remember this machine is capable of targeting peak half way, if Inspiration maximum allowed time is 3 seconds, that is far short of apnea of significant duration. If apnea is No airflow....

but I'll read what it says and respond back, thanks for the Patent #.

Doug, can you tell if, indeed, there is a one second 2cm puff? I agree that everything in the patent descriptions do not go into these machines. Thanks, my friend!

Banned, I hope we didn't hijack your thread too much. At least there are some valuable ideas and information getting thrown back and forth IMHO.

Snoredog wrote:Like Users on this board have never been wrong before...

Well, that's an important point that I honestly think we need to emphasize again and again around here. I know I'm going to be wrong VERY often... I just never know specifically which items I'm going to be wrong about.

And it's tough---very tough---not to be what I call a "hard opinionater". The outspoken folks on this message board, myself included, tend to be that way. We know that we're that way. But I'm afraid newcomers will interpret our hard opinions as fact. Anyway, back to the great discussion! Just a word of caution for new readers that this thread and most are largely opinion.

But I also want to say that I appreciate SAG's professional opinions and presence here in no small way. I can't say that enough.

-SWS wrote: Banned, I hope we didn't hijack your thread too much. At least there are some valuable ideas and information getting thrown back and forth IMHO.

No problem,
I like learning more about the SV, here.
Re-affirms giving it up the SV for AVAPS.

-SWS wrote: But I also want to say that I appreciate SAG's professional opinions and presence here in no small way. I can't say that enough.

Agreed. Thanks Snoredog, dsm, SWS, and everybody!
Should I change my name to Curly?

StillAnotherGuest wrote: Theoretically, ASV technology will attack hypopnea, but why spend 4 times the money on something that doesn't do the job as well (because ASV technology never completely matches spontaneous breaths, it always undershoots to avoid the hyperventilation that perpetuates "central dysregulation").

Why spend 4 times the money when you can spend only 3 times the money to cure VB/PB and the technology will always match spontaneous breaths?

Banned

-SWS wrote:Doug, can you tell if, indeed, there is a one second 2cm puff? I agree that everything in the patent descriptions do not go into these machines. Thanks, my friend!

Banned, I hope we didn't hijack your thread too much. At least there are some valuable ideas and information getting thrown back and forth IMHO.

Snoredog wrote:Like Users on this board have never been wrong before...

Well, that's an important point that I honestly think we need to emphasize again and again around here. I know I'm going to be wrong VERY often... I just never know specifically which items I'm going to be wrong about.

And it's tough---very tough---not to be what I call a "hard opinionater". The outspoken folks on this message board, myself included, tend to be that way. We know that we're that way. But I'm afraid newcomers will interpret our hard opinions as fact. Anyway, back to the great discussion! Just a word of caution for new readers that this thread and most are largely opinion.

But I also want to say that I appreciate SAG's professional opinions and presence here in no small way. I can't say that enough.

So far I'm only on section 13 of the of the Presently Preferred Embodiment and well I read really really slow and if there are not pictures I have to read it a couple times. This CIP sure talks alot about COPD, PPAP, and Gain, Gain, Gain, Gain which tells me this technology could be applied to any machine Respironics has ever made going back to 1996 and if you include Servo descriptions it goes back the "iron lung" of 1964. How long has the Adapt SV been out? this CIP is dated Nov 2007, and my reading so far could as easily apply to the Gray machine, the Bipap S/T, Bipap Auto, even Aflex to the brand new AVAPS, but that could change in the next paragraph, but I'm a bit perplexed about Gain "Esp", I can see Gain "Insp", looking for pictures.... Who said this CIP was for the SV??

I'll keep looking...

Snoredog wrote:So far I'm only on section 13 of the of the Presently Preferred Embodiment and well I read really really slow and if there are not pictures I have to read it a couple times. This CIP sure talks alot about COPD, PPAP, and Gain, Gain, Gain, Gain which tells me this technology could be applied to any machine Respironics has ever made going back to 1996 and if you include Servo descriptions it goes back the "iron lung" of 1964.

Well, having extensive patent experience, you realize the "background of the invention", such as the "iron lung" speaks only of the historical background leading up to the invention. Right?

Snoredog wrote:How long has the Adapt SV been out? this CIP is dated Nov 2007

And having that same extensive patent experience, you saw in the very first sentence that this patent number was a continuation of several earlier patent numbers, right? Make up your mind. Is it too old because it mentions a 1964 iron lung, or is it too new because it's a recently spawned Nov 2007 patent? You can't have it both ways. It's either too old or too new---but it can't be both!

Snoredog wrote:Who said this CIP was for the SV??

Ooops! I stand corrected. Above, you so very adamantly stated what was and wasn't happening in the autoSV, that you obviously know the REAL patent number. May we have it please? BTW, here's an interesting one that gets applied to an already-existing PAV/PPAP design: 6532956 (time based parameter variations, which are those 1cm or 2cm incrementing/decrementing steps that DSM video recorded---specifically d1, d2, d3).

Snoredog wrote:and my reading so far could as easily apply to the Gray machine, the Bipap S/T, Bipap Auto, even Aflex to the brand new AVAPS..

And I'm sure you saw that the patent description's most salient aspect is proportional delivery. None of the machines you just mentioned, with the exception of AVAPS, uses proportional delivery.

Snoredog wrote:I'll keep looking...

Based on your incredibly biased readings so far, don't even bother...

-SWS wrote:
<snip>

With that said, it's unrealistic to expect that any SV patient will experience absolutely no obstructive events---even after titration by a highly skilled clinician. On that basis the BiPAP autoSV algorithm will attempt to differentiate how "heavy" or "light" an apneic/hypopneic event happens to be by utilizing a very quick 2cmH2O puff of air (forced oscillation technique or FOT). While that technique is undoubtedly helpful toward extrapolating a required IPAPpeak value, it's apparently not specific enough to clinically differentiate obstructive events from central events. That differentiating lack of specificity/sensitivity is presumably why the events are not clinically differentiated on the autoSV Encore Pro reports.


<snip>

SWS,

I am interested in the 'puff' comments because as previously discussed I have experienced that effect (on both the Vpap Adapt and the Bipap SV). I have been able to find some info on it in regard to Resmed's machines but nothing re FOT on the Respironics Bipap SV. Am wondering why they have made any comments anywhere re this. Any links ? -

The puff does seem to be the same in that it feels like a gentle puff or burst of air - quite gentle but very noticeable.
I always though FOT was a burst of oscillations (kind of like a very low frequency tone).

I guess I am asking if it is FOT (burst of oscillating air ) or just a single 'puff'.

DSM

#2 Just read all the following posts - lordy this thread has been active and all with fascinating info. Will read further then add another post in response to SWS's request but, I may have already answered it.

Doug

dsm wrote:I guess I am asking if it is FOT (burst of oscillating air ) or just a single 'puff'.

In any event it's certainly wave reflection, Doug. But now that you mention it, when only one cycle or pulse is administered I'm not so sure the medical industry really calls it "forced oscillation technique". So your point is well taken in my opinion.

The Respironics patent description refers to it as "wave reflection". And IIRC the Resmed patent description refers to theirs as "forced oscillation method". However, on this message board we have informally been referring to all of the above as FOT. I suppose we could more accurately refer to the general case as "wave reflection". Anyway, that 2cm 1 second puff I have quoted in the patent text below is the wave reflection used by Respirionics to very roughly differentiate central from obstructive events.

Thanks for the information, Doug.

Respironics Patent 7296573 wrote:The invention further includes a method for determining if the airway is open (central apnea) or obstructed (obstructive apnea) during an apnea. Once an apnea of significant duration is detected the system, under the direction of CPU 70, automatically increases Gamlnsp by 2 cm H2O, waits approximately 1 second and decreases the pressure back to the original value. If there is a significant change in flow...

(additional patent text quoted several posts above)

-SWS I am NOT going to continue to chase your theory on FOT or FOM because I know it isn't needing to do that as stated previously. Sorry, but your patent describes an apparatus for PPAP and COPD patients to offer some relief to those patients over conventional CPAP. Adapt SV isn't the ideal machine for COPD patients, the Bipap S/T is according to Respironics marketing materials for COPD overlap. It is your suggestion of it using FOM which caused us to want to chase down that theory. Sorry there is no evidence to support your FOM theory, so I'm going to assume the Respironics Adapt SV does NOT have FOM or FOT.

Besides, SAG did NOT say the Adapt SV specifically uses FOT or FOM either, he said:

StillAnotherGuest wrote:
Meanwhile, I will try to re-summarize my points:

The only way to be reasonably sure (and not 100%, either) that your one-channel (airflow) device (xPAP machine) is seeing a central apnea is to employ a technology that can "look down" the open, unobstructed airway and identify it as such. And the only technology that is able to do that is ballistocardiography (the search for cardiac pulsations in GK420E) or forced oscillation technique (send out a pressure pulse and watch its behavior, looking for resistance in the oscillation as seen in SomnoStar). Any other machine cannot make this differentiation, all they see is a straight line.

In any ASV technology, therefore, all of the obstructive events must be manually titrated out. The apneas, absolutely. Theoretically, ASV technology will attack hypopnea, but why spend 4 times the money on something that doesn't do the job as well (because ASV technology never completely matches spontaneous breaths, it always undershoots to avoid the hyperventilation that perpetuates "central dysregulation").

But in the case of obstruction the underlying issue is treated symptomatically and therefore inadequately.

SAG

And I'll re-summarize mine:

Now, I agree with what SAG says above, however even SAG admits you MUST manually titrate out the obstructive events,
"The apneas, absolutely."

I think I said pretty much the same thing above in my descriptions. SO, I think I also said

1. Obstructive apneas are assumed to be eliminated with manual titration. Those are eliminated on this machine using EPAP pressure which is Fixed as the baseline CPAP support.

-Obstructive Apnea are gone, manually titrated out as SAG suggests

2. With Obstructive Apnea gone, you can still have residual obstructive Hypopnea. Since IPAP pressure is what eliminates these, they will be eliminated with any increase in IPAP working pressure support. Didn't I say that already? Actually I think I said they "should" be killed within the first 3 seconds of their existence, as they will be targeted as Inspiration like any other inspiration breath. If that Hypopnea demonstrates any flattening it will be eliminated within 1.5 seconds.

-Obstructive Hypopnea are now gone, taken care of by IPAP Pressure Support

With ALL obstructive SDB now taken care off, what is left for the machine to correct?

From the Marketing Materials description, it says machine corrects:

-Periodic Breathing
-Central Dysregulation

For those that don't know what Periodic Breathing is, look it up, its described in the sales brochure and has pictures to show what it is, and HOW it corrects it.

Do I need to repeat that again here? All the machine is going to do is target that same inspiration and increase IPAP working pressure to bring those peak volumes up to expected levels.

Now let's not split hairs here, it is described as about as clearly as it possibly can be in the Sales brochure for the machine on how it resolves PB, I've already explained it a half dozen times.

Now the last remaining part and what SAG appears to be questioning is Central Dysregulation. Every possible
document you can find on the Adapt SV says centrals are eliminated with BPM or backup mode. The options
for that are:

BPM=Off
BPM=Fixed (4 to 30 BPM, IT=x.x, RT=)
BPM=Auto

Now SAG has a problem inducing a "Fixed" BPM rate into the backup mode despite it being standard Respironics Titration Protocol for this machine. On page 3 of that same titration guide at the top it says "Document RR". That means document the Respiratory Rate from manual titration.

Now SAG thinks we need to differentiate central apnea from obstructive apnea. I say we do NOT. Just as I described again above and he agrees with, Obstructive apnea is taken care of with manual titration. What other kind of apnea is left REMAINING if the OBSTRUCTIVE apnea are gone?

Now WHY do I need to continue to look for Obstructive apnea with FOT, FOM, 420e cardiac oscillations or look down someone's throat to see if the airway is open?

Fact is I don't, they are GONE

You guys can take that FOT, FOM theory and file it under FOS because it is not on this machine. I'd rather see us delve into the BPM mode so there is a general consensus on how that works, I'm tired of explaining it over and over.

The logic behind BPM should be easily understood by following the titration guide flow-chart. As a tech, I'm really surprised SAG is questioning me about it, afterall, they produced the damn thing for his benefit.

-SWS wrote: Above, you so very adamantly stated what was and wasn't happening in the autoSV, that you obviously know the REAL patent number. May we have it please?

O.