Newbie on AVAPS

Snoredog wrote:-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.

While not buying into the SD vs SWS comments, I am happy to comment on SD's points here and in essence what he is saying certainly matches what I see & understand.

I know SWS commented some days ago about the 'puff' as being a sampling of the type of apnea & more recently has said it is FOT or FOM, but since that first comment was made I have wondered about why they (Respironics) would add that into this machine. I tend to agree with SD who is saying that all apneas are treated as central & in my charts every time I see an apnea scored I can go right down to the patient triggered breaths line & see matching BPM activity initiated in response & agree that what SD says reflects what I see. Apneas are treated as central & treated by BPM adjustment, PB and fluctuating flow are treated by SV pressure support.

Just to add to the apnea issue, anytime I take an Spo2 reading for the night I usually see 10-12 spikes in pulse rate - I can now directly match these to scored apneas in the Respironics chart. Whilst I am no expert on what those PR spikes are (SAG please to contribute if you are willing) I am seeing them as regular arousals that I have been seeing in my SpO2 charts for years and that they reflect normal nocturnal movement. And as I believe we all agree, such arousals and movements will raise pulse rate, trigger deeper breathing and then ON A BIPAP SV score an apnea (a central) if the subsequent slowdown in breathing last for the duration set in the algorithm which in turn will do just as SD has said & activate the BPM rate adjustment algorithm (which depends on the BPM= setting).

Snoredog - that is IMHO, an altogether very well put summary.

DSM

Snoredog wrote:-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

Okay folks, and just what treatment do we think can be provided by one incredibly short puff of air? That short puff is described by both DSM and the patent description. And the patent description very explicitly describes that very short puff of air as "wave reflection". Not treatment. And not -SWS theory either.

Let's entertain Snoredog's insistence that the patent description is wrong about what short puffs are used for:

SO WHAT MIGHT THOSE MYSTERIOUS SHORT PUFFS BE?

DSM describes short puffs. And Respironics also describes one second puffs as being used specifically for "wave reflection". So what pray tell are these short puffs? Can they ventilate? No. Can they stent the airway open? No. So what the heck could they be? Snoredog knows perfectly well they can't be used for wave reflection exactly as Respiroinics says.... because it "isn't needing to do that" in his way of analyzing.

So what might those incredibly mysterious short puffs be? Darn! We're stumped now that we've dismissed that very explicit and clear Respironics explanation on Snoredog's advice...

Snoredog wrote:Sorry, but your patent describes an apparatus for PPAP and COPD patients to offer some relief to those patients over conventional CPAP

Yet more highly convenient selective reading, Snoredog? You seem to have rather conveniently missed all the patent embodiments in that description that are unique to CHF treatment---CHF treatment as in the BiPAP autoSV machine's initial and primary target population. I can see the Respironics scientists won't be catching up with you anytime soon either.

In the meantime Snoredog is gathering the REAL patent numbers for us... I'm sure the mystery of what those short puffs are REALLY used for will be described in those patents.

Snoredog & SWS,

I hope I may have some answers as this morning (just a few mins ago) I did some tests that I hope may shed some light on this FOT FOM issue & my conclusions swing back to SWS being on the money re the Respironics Bipap SV (we know the Vpap Adapt SV does) issues shorts puffs of air to try to determine if the obstruction is a block or a non-blocked event (a central).

I also can show AP scores from these tests on my last nights chart but it is what the machine actually did that swings me to SWS being right.

http://www.internetage.ws/cpapdata/dsm- ... 3nov08.pdf

See the 2 APs scored just as the night ends - also see the 'patient triggered breaths line & see that it shows quite strong activity in response. What happened was, I was thinking about how the BPM mechanism works & this issue of the machine scoring APs which some of us have said must be centrals as far as the machine is concerned. It occurred to me that if I was the designer I would not want to be bursting the sleeper with cycling while bumping up 2 CMs per cycle if it was a genuine obstructive apnea & not an assumed central.

My test was to do the usual PB thing by increasing my breathing steadily, taking a last deeper breath then breathing out (the machine does seem to know if you exhaled ) then holding my breath - almost as soon as I breathed out I felt a short 'puff' of air burst, then was sure I got a second slightly stronger one, I started breathing again, the machine didn't seem to go into its cycling routine, but the machine seemed to resume its normal ventilation. I tried this sequence again shortly after and again on exhale the machine did a puff of air - on a third go I held my breath firmly & was surprised to get a very strong 'burst' of pressure (not a puff) & had little option but to breathe as air began squeaking out the mask.

Now to be fair these are my 1st impressions & I would want to be able to repeat these tests but the data from them is there in the chart.

DSM

Well, if the puffs are too short to either: 1) ventilate the lungs or 2) stent the upper airway, then by default Respironics just might be describing them accurately in their patent description.

Regardless, it's been a very interesting and fun inquiry IMO. Thanks, Doug.

-SWS wrote:

Snoredog wrote:-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

Okay folks, and just what treatment do we think can be provided by one incredibly short puff of air? That short puff is described by both DSM and the patent description. And the patent description very explicitly describes that very short puff of air as "wave reflection". Not treatment. And not -SWS theory either.

Let's entertain Snoredog's insistence that the patent description is wrong about what short puffs are used for:

SO WHAT MIGHT THOSE MYSTERIOUS SHORT PUFFS BE?

DSM describes short puffs. And Respironics also describes one second puffs as being used specifically for "wave reflection". So what pray tell are these short puffs? Can they ventilate? No. Can they stent the airway open? No. So what the heck could they be? Snoredog knows perfectly well they can't be used for wave reflection exactly as Respiroinics says.... because it "isn't needing to do that" in his way of analyzing.

So what might those incredibly mysterious short puffs be? Darn! We're stumped now that we've dismissed that very explicit and clear Respironics explanation on Snoredog's advice...

Snoredog wrote:Sorry, but your patent describes an apparatus for PPAP and COPD patients to offer some relief to those patients over conventional CPAP

Yet more highly convenient selective reading, Snoredog? You seem to have rather conveniently missed all the patent embodiments in that description that are unique to CHF treatment---CHF treatment as in the BiPAP autoSV machine's initial and primary target population. I can see the Respironics scientists won't be catching up with you anytime soon either.

In the meantime Snoredog is gathering the REAL patent numbers for us... I'm sure the mystery of what those short puffs are REALLY used for will be described in those patents.

No No No let's go back to the specific section in the Patent US7296573B2 where it says this patent covers the apparatus known as the Adapt SV.

Snoredog loves to entertain but he isn't searching for any patents, why should he? you claim to already have it right in front of you, so does Snoredog, he says prove it.

Very simple question, show me where in the patent you gave it says this apparatus is for the Adapt SV?

We all should have the Patent in front of us by now and we can all follow along, just Google that Patent number.

Tell everyone how this Patent covers the Adapt SV and not the Gray model, Bipap S/T, AVAPS?

I have the patent right in front of me, tell me the section number and I will go right to it and I will come back here and say:

gee "I was wrong".

But before I can do that, you need to answer the f**king question, what in the Patent YOU gave says this patent is even for the Adapt SV?

So don't change the subject, so you can only come back later and edit out all your posts.

Because right now you are trying to match up a repeated claim you have made about this machine and no one ever challenges -SWS on what he says. I am challenging you right now, what in that Patent you gave me above specifically indicates this patent you are trying to cover your ass with on FOM is for the Adapt SV?

What are you going by? Digital Auto Track? Nearly all of Respironics later generation machines have that carried over from the Parent Patent. Biflex? Aflex? Cflex? I didn't know this machine used any one of those technologies or that it was the preferred machine for COPD patients. We learn something new every day.

I don't give a dam what the Resmed Adapt SV uses, so don't confuse the issue with that machine.

well well well dsm said.... well you are the one that backed him up on it so you are just as wrong as he is, if that is proven to be the fact. He already admitted the FOT he was thinking about came from the Resmed Adapt SV, you then backed him up with the a description found in some patent with no means to incorporate it into this machines operational function, a apparatus description supposedly used in the Adapt SV machine. So I ask again,

1. Show us where in this patent where it is you came to the conclusion it specifically pertained to Adapt SV?

My PDF search doesn't appear to be working, just give us the section or paragraph, that should be easy you found the paragraph above describing it has this feature.

2. Show us where this "puff" of air is superimposed over breathing acting as an oscillation technique where this machine can somehow measure that bounce back effect to determine if the airway is open/closed.

I know damn well it is not using FOT and superimposing a 1-5hz oscillation signal over breathing and measuring that. Maybe you need to look in the Remstar Auto patent for it? You see I'm not looking for it because well I didn't make the claim, you are backing up someone else's claim with data of your own, I'm only asking for more of that said data.

But the first order of business is identifying the patent you are using for you data is even for the Adapt SV machine.

Because if it isn't for this Adapt SV machine, then your data isn't valid and well you are misleading a lot of people with incorrect data claiming it as fact. Now everything I have described to date is my theory based on information gained from published Respironics materials from the mfg. that I have found to date, not from the algorithmic level the functional level.

So you are quoting what you think is fact from the algorithmic level yet you side-stepping the question on if the data you are looking at in making that fact is even for the Adapt SV and not some other machine. Because if you cannot identify that part it does not good asking you on the below:

Since you are the expert on FOM and have data to back it up, please explain:

1. Tell us what using that FOT or FOM method is going to accomplish on this machine.
2. Tell us WHY we need to differentiate these two types of events?
3. Tell us WHERE and WHEN this puff of air supposedly occurs?
4. Tell us how the machine will measure and use this result to make a decision.
5. And once the decision is made, how it will be used in the function of this machine.

Now if a patient is going to have an apnea, it should appear after the end of the last exhale in the pause and time when Rise time should start. If there is no Inspiration due to an apnea of either type, the length of time from Inspiration to Inspiration will be greatly extended. Now putting a puff in there does what?

Of course you know that when you detect the airway is closed and it is an obstructive apnea, I'm only going to ask you next what you are going to do with it? hopefully you will have an answer for that too.

But right now all we have is your suggested Patent you can't show where it is for this machine and a puff of air.

Snoredog

Now I'm confused. I thought we were talking about the Bipap Auto SV & 'puffs' of air that look like FOM. Not the Vpap Adapt SV.

I thought we agreed that the Vpap Adapt SV does use FOM & Resmed have a patent on the technique but it is also normal for Resmed and Respironics to cross license some of their technologies & algorithms (they do it more than we might think).

So back to 'puffs of air' on the Bipap Auto SV.

DSM

Snoredog, either the short puffs are happening or they are not. Neither you nor I can measure what the BiPAP autoSV machine is doing since we don't have one. If the short puffs aren't happening, then Respiroinics is clearly not using their patent-protected version of one-second 2cm wave reflection. Period. If those short puffs are happening then they simply can't be used to: 1) ventilate the lungs, or 2) stent open the upper airway. Period.

Rather, those short puffs must be occurring for that very same reason Respironics says that they employ short puffs:

Describing 1-second 2cm puffs Respironics 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).

Again, if the short puffs are not happening, then forget all about the differentiation via wave reflection that Respironcis has patent protected above---which they can use in any machine they choose. The don't have to break out the words "BiPAP autoSV". In fact the manufacturers almost never place PAP models anywhere in the patent descriptions, since they tend to protect multiple embodiments in each description. After all, each patent description is nothing more than legal protection----good luck finding exclusive low-level design documents for anything in the patent archives. If the short puffs are happening as Doug describes, then there's not much else Respironics can do with short puffs other than what they have patent protected.

So Doug, are those short puffs long enough to either ventilate the lungs or stent open the upper airway? Thanks for the clarification.

SWS

The puffs are clearly 'probes' - they are much shorter than 1 second more like 100 millisecs but they may vary in length if repeated. As to pressure, I would guess the initial one is 2 CMs or so, later ones seem at a higher pressure. I will do some further trials.

Given that Respironics can do such probing I am satisfied now that it is exactly what they are doing on the Bipap Auto SV. As I said earlier, on reflection I *can* see that they would want to make sure they were not about to apply the pressure ramping cycling (2 CMs per cycle) to an obstructive apnea & doing those puffs is a very sound way to go about determining that it is a central and thus can be dealt with using the current active BPM (BPM=number or BPM=auto) algorithm to deal with it as a central. We all agree that the Bipap Auto SV treats central apneas using the current active BPM algorithm.

DSM

And what else are short puffs or probes used for if not event differentiation exactly as Respironics describes?

Alright, I would like to hear at least three more pages of argumentative denial from Snoredog regarding just how those short puffs are an absolute impossibility because he knows perfectly well how the autoSV machine REALLY operates.

<more argumentative tail chasing will shortly ensue that I won't be participating in>

-SWS wrote:Snoredog, either the short puffs are happening or they are not. Neither you nor I can measure what the BiPAP autoSV machine is doing since we don't have one. If the short puffs aren't happening, then Respiroinics is clearly not using their patent-protected version of one-second 2cm wave reflection. Period. If those short puffs are happening then they simply can't be used to: 1) ventilate the lungs, or 2) stent open the upper airway. Period.

you still didn't answer the Patent question. I'm not saying the puff doesn't exist. Since when is a puff seen associated with a bi-level machine seen as unusual.

How do you know that puff is not from the machine going into backup mode?
How do you know that puff is simply not the machine cycling from EPAP to IPAP?

For any "puff" to be used as a FOT oscillation signal for FOM, it would have to deliver that puff after last Inhalation and at the pause at the end of Exhale where EPAP is. If it dropped below EPAP, PPAP if used would have to add it's gain there as Rise time would begin which is the noisiest part of respiration. At the bottom EPAP is static here, no evidence pressure is going to zero or even below EPAP, if it was PPAP would kick in with Gain and bring that back up. That might be helpful with someone who has COPD.

FOT/FOM is like radar you send the signal out and measure the response back, if low or no return signal the airway is open if high it is closed and obstructive.

So now you have determined an event is obstructive, now what are you going to do with it?

-SWS wrote:And what else are short puffs or probes used for if not event differentiation exactly as Respironics describes?

Alright, I would like to hear at least three more pages of argumentative denial from Snoredog regarding just how those short puffs are an absolute impossibility because he knows perfectly well how the autoSV machine REALLY operates.

<more argumentative tail chasing will shortly ensue that I won't be participating in>

You can't leave. If you leave people are going to come by here and ask:

Where's -SWS?

and you KNOW what I will say, he left cause he got tired of being wrong all the time,

I give you the chance to substantiate your position and show where you are not wrong and you can't do it.

your data is invalid.

Me thinks THIS Patent US 200702212224AI Entitled Ventilatory Control System does a hellva lot better job in describing the patented technology used on the Adapt SV:
http://www.google.com/patents?id=zd6hAA ... on#PPA1,M1

Look at paragraph {0062} and {0063} and Fig. 6, believe your "puff" is seen as item 17 after item 22 has elapsed.

Sorry, but it is a "timed" event not a FOM method.

Snoredog wrote: Since when is a puff seen associated with a bi-level machine seen as unusual.

Come on, Snoredog. Those autoSV pressure probes Doug describes are nothing like any of his other BiLevel machines. Otherwise he would have been the first to acknowledge that.

Snoredog wrote: For any "puff" to be used as a FOT oscillation signal for FOM, it would have to deliver that puff after last Inhalation and at the pause at the end of Exhale where EPAP is.

That is clearly wrong. Why on earth probe a normal respiration phase as you just described? The purpose of the probe would be to sense whether the apnea was a closed or open airway apnea.

Anyway, it's clear that Doug is describing pressure probes that are unique to his SV machines and very different than all of Doug's conventional BiLevel machines. Those pressure probes can't ventilate lungs and they can't stent the upper airway open. The only other possible purpose would be to literally stimulate the upper airway nerves---and Respironics describes using short pressure bursts to differentiate airway closures instead.

Snoredog wrote:Me thinks THIS Patent US 200702212224AI Entitled Ventilatory Control System does a hellva lot better job in describing the patented technology used on the Adapt SV

Actually patent 6539940 is the primary BiPAP autoSV patent description. However, Respironics can employ any of their legally patent protected embodiments in any machine or combination of machines they choose. If they are performing pressure probes as Doug describes, then it really doesn't matter what document Respironics decides to legally protect that particular feature or embodiment in. The various autoSV features are undoubtedly spread out among several patent protected documents. You keep looking for a grand unified low-level autoSV design document, and that kind of situation is never the case.

I'm done arguing about this... A pressure probe is a pressure probe. Doug's description of unique short pressure bursts is good enough for me.

ozij wrote:

-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.

Try 20060070624.

If BPAP AutoSV did employ Forced Oscillation Technique, then wouldn't the whole NR methodolgy be instantly obsolete and disappear? And in it's place a line that sez "Centrals"?

SAG

StillAnotherGuest wrote: Try 20060070624.

If BPAP AutoSV did employ Forced Oscillation Technique, then wouldn't the whole NR methodolgy be instantly obsolete and disappear? And in it's place a line that sez "Centrals"?

SAG

Sure wish it would because NRAH don't work worth a darn! I think the technology we see utilized in a product is more a result of patent infringement avoidance than what works best.

I'm sorry, FOT just didn't make any sense to me, I think Weinmman has that market cornered don't they.

StillAnotherGuest wrote:

ozij wrote:

-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.

Try 20060070624.

If BPAP AutoSV did employ Forced Oscillation Technique, then wouldn't the whole NR methodolgy be instantly obsolete and disappear? And in it's place a line that sez "Centrals"?

SAG

Actually patent 6539940 and others are listed right in the 2007 User Guide. This is the BiPAP autoSV where the NR algorithm literally does not apply regarding both event detection and the very short per-breath time frames involved.

Differentiation via wave reflection might be algorithmically useful at best. But what would the specificity/sensitivity be? Alright. So design techniques need only to lend an advantage to be employed. They don't have to be highly specific or sensitive enough to yield clinical scoring, simply because they are employed.

And just what might Respironics be doing with those very short bursts of air anyway, if not differentiating?