Newbie needs help w/ Respironics S/T

-SWS wrote: @Sleepy55 & Snoredog- Mayo Clinic is usually on the leading edge of consensus changes in sleep medicine. And one of those consensus changes in recent years is that higher gaps between EPAP and IPAP are now more routinely employed:

This year's AASM PAP titration clinical guideline wrote: 4.3.1.6 The recommended minimum IPAP-EPAP differential is 4 cm H2O and the maximum IPAP-EPAP differential is 10 cm H2O (Consensus).

Notice 3 cm isn't even in the picture anymore? And notice 10 cm is now part of the recommended range? I was surprised when I first read that.

Hey I agree about the Mayo and the 4 cm, I've been quoting out of the latest Respironics literature, think that is what it says in Item 2 above if not mistaken.

I think Respironics was casually tossing out a 2-3 cm differential for comfort. 4 cm pressure support has been around for a long long time, even before these fancy dancy atamatic machines, it must work

Aha! So you were the one leading consensus medicine!

And to think that I tried to blame that on the Mayonnaise Clinic. Excellent place to have a BLT sandwich repaired if you ask me...

-SWS wrote:Aha! So you were the one leading consensus medicine!

And to think that I tried to blame that on the Mayonnaise Clinic. Excellent place to have a BLT sandwich repaired if you ask me...

No, I did my share of reading up but that was 18 months ago and I do place great faith in experimenting which is one reason I still own a Bipap S/T (exactly the same model as sleepy has).

Are you willing to participate in the thread on gaps that I kindly suggested we start - look you have already put forward one bit of info relevant to the topic.
If we have a specific topic around which we can focus I may hopefully get away from the feeling you are stalking me for a merry-go-round rather than a discussion on the available knowledge & info on gaps & their effects

DSM

Doug, I like your idea for a dedicated thread about IPAP/EPAP gaps. If possible let's wait until Bev gets squared away. My humorous comment above was about Snoredog perhaps having picked up on the 4 cm to 10 cm gap even before Mayo did.

No merry go round---everyone has an excellent discussion going IMO.

Banned wrote:Rise time is a comfort setting only. You should increase your Rise Time from your current setting to 3 (minimum). Inspiration Time should also be considered a comfort setting. Your Inspiration Time of 1.5 is in all likelihood too short. Especially with your current Backup Rate. You should increase your inspiration Time to 1.8 (minimum). Generally speaking, as you increase the Inspiration Time, you will find it more comfortable to increase the Rise Time. Your BPM should be set 2-3 BPM less than your resting (awake) BPM.

Banned

Banned, thanks for joining the thread and for the great explanation. I've begun to "tweak" both of these. I was noticing that the machine would stop blowing during inspiration before I finished breathing in.

Sleepy55

Snoredog wrote:I wouldn't raise anything until you KNOW what you are raising and what for.

Refer to the basics for bilevel therapy, these machines are no different;

IPAP handles Hypopnea and vibratory snore
EPAP handles Apnea and vibratory snore
CPAP handles both collectively.

IF apnea count is high, you increase EPAP,
IF Hypopnea count is high, you increase IPAP,
IF Vibratory Snore exists you may increase both,
IF you want to increase tidal volume you increase Pressure Support,

Snoredog, thanks for the info. Unfortunately, the Bipap S/T Encore Report does not provide a Hypopnea Count. Only shows Aver. Apnea Count, and I don't even know if it's referring only to OSA episodes or OSA and CSAs. If only I could get my hands on a copy of the clinical manual for the Bipap S/T (new gray model), I would get better insight into the machine and interpreting the Encore reports. I've searched high and low, even on Ebay, and no one seems to have a copy of the manual.

Progress Report: As of last night my settings are 16IPAP, 10EPAP, 8BPM, Insp Time 2.0, Rise Time 3. My Encore Report for last night says:
Average Apnea Count=140, Average Exhaled Tidal volume=510, Average Leak=40, Average % Patient Triggered Breaths=96, Average Peak Inspiratory Flow=40, Average Breath Rate=13, My oximeter shows 95% saturation. Raising my EPAP from 8 to 9, then to 10, did not decrease the Average Apnea Count. I will increase EPAP to 11 tonight and see if it does anything to my apnea count, but don't think I'll be able to increase higher than 11. Can someone please tell me what the Tidal Volume volume, Leak Rate and Inspiratory Flow mean in all this, and do my numbers look OK... Also, what should my goal be in reducing the Average Apnea Count? Zero?

Thanks again to everyone that has taken the time to provide advice, insight and even some humor

My Average Apnea Count was high when I used a Respironics AVAPS S/T machine. I never worried too much about it because I still felt good waking up and during the day. An S/T machine behaves more like a mechanical (NPPV) respirator, so I think in some perverse way, the apnea count may be a less relevant way to measure the success of your therapy. I went back to the ResMed Adapt SV because the AVAPS S/T could not mitigate my periodic breathing issue. If you are 5' 11" tall or less your Average Tidal Volume is fine. Your Average Leak of 40 is fine (27 is recommended). Try cranking your BPM up to 10. If that doesn't adversely effect your Patient Triggered breaths I would leave it at 10 BPM. The key question is, "Are you feeling better on the S/T than you did on CPAP?"

Trialing EPAP 11 is a good idea. I would also trial EPAP 11 in conjunction with IPAP 17. In general, I would not recommend an EPAP/ IPAP spread greater than 6 cmH20. But than again, I would not recommend an EPAP/IPAP spread of less than 6 cmH20 for anyone on a BiPAP device.

Banned

Banned,

Thanks for the info on tidal volume and leak rate. I do have some positive results from last night. I raised my EPAP to 11, leaving IPAP at 16 and BPM at 8. For the first time in my three weeks or so of tweaking, I finally saw a reduction of 50% in my Apnea Count! Here's all the numbers from the Encore Report:

Average Apnea Count=64 (Down from 140 the night before at EPAP 10 & down from 174 the night before that at EPAP 9), Average Exhaled Tidal volume=490, Average Leak=40, Average % Patient Triggered Breaths=97%, Average Peak Inspiratory Flow=40, Average Breath Rate=14, My oximeter shows 96% saturation.

I will raise EPAP tonight to 12, leaving all else alone for now, and see what my report looks like tomorrow. I'll raise my IPAP to 17 (or higher) only if I stop seeing a reduction in the apnea count by raising EPAP. Regarding backup rate, I started on my S/T with IPAP 16, EPAP 8 & BPM of 10. My patient triggered breaths varied between high 60% to low 80%. I raised BPM for one night to 12 and patient triggered breaths dropped to 67%. Dropping BPM to 8 has consistently raised my patient triggered breaths to as high as mid to high 90's. It could be, as previously suggested, that I don't even need a backup rate. When I'm done tweaking downward my apnea count, I'll turn off S/T for one night, turning my machine into a plain Bipap and see what the numbers look like.

Yes, I do feel better on the S/T than I did with my old bipap. I feel better in the A.M. and have less daytime sleepiness in the afternoons. I'm very excited about my progress, and owe it all to helpful people like you.

Happy Sleeping

Sleepy

Good going - you are making good progress & i shows. Don't worry too much about the patient triggered breaths - that is minor. You may well find turning off S/T mode makes little diff.

Keep up the good work.

DSM

Sleepy55 wrote: Average Apnea Count=64 (Down from 140 the night before at EPAP 10 & down from 174 the night before that at EPAP 9), Average Exhaled Tidal volume=490, Average Leak=40, Average % Patient Triggered Breaths=97%, Average Peak Inspiratory Flow=40, Average Breath Rate=14, My oximeter shows 96% saturation.

I will raise EPAP tonight to 12, leaving all else alone for now, and see what my report looks like tomorrow. I'll raise my IPAP to 17 (or higher) only if I stop seeing a reduction in the apnea count by raising EPAP. Regarding backup rate, I started on my S/T with IPAP 16, EPAP 8 & BPM of 10. My patient triggered breaths varied between high 60% to low 80%. I raised BPM for one night to 12 and patient triggered breaths dropped to 67%. Dropping BPM to 8 has consistently raised my patient triggered breaths to as high as mid to high 90's. It could be, as previously suggested, that I don't even need a backup rate. When I'm done tweaking downward my apnea count, I'll turn off S/T for one night, turning my machine into a plain Bipap and see what the numbers look like.

Yes, I do feel better on the S/T than I did with my old bipap. I feel better in the A.M. and have less daytime sleepiness in the afternoons. I'm very excited about my progress, and owe it all to helpful people like you.

Happy Sleeping

Average Apnea Count would INCLUDE both obstructive and central components. So once you find a downward trend stick with it. One of your target goals should be for the lowest Average Apnea Count, because if that number is lower or falling it means you are having fewer and fewer obstructive apnea and if there are any central apnea included they would be included in that same count. So the fewer of each you are having the better off you will be.

Patient Triggered Breaths is the "S" or spontaneous mode of the machine, (handles obstructive events and periodic breathing).
Machine Triggered Breaths is the backup "T" or timed mode of the machine (primarily handles central dysregulation).

Yahoo! After raising EPAP from 11 to 12 last night, my average total apnea count dropped significantly, from 64 to 38!
Here's the rest of my numbers from last night: Average Exhaled Tidal volume=480, Average Leak=45, Average % Patient Triggered Breaths=98%, Average Peak Inspiratory Flow=25, Average Breath Rate=14, My oximeter still showing about 96% saturation.

Even at EPAP of 12, my therapy is starting to feel like CPAP. As I breathe, I can't tell much difference in the pressures of the IPAP 16 and the EPAP 12. Nonetheless, tonight I'll raise EPAP to 13, leaving IPAP at 16 and BPM at 8. Hopefully the downward trend in apnea count will continue

P.S. Snoredog, thanks for the info re apnea count & S/T...

Anyone have the technician's manual for the Bipap S/T It's beginning to look like Respironic's best kept secret

Hey Sleepy,

Your doing so well on the S/T that I dragged my AVAPS out the closet, tonight. Think I'll crank it up and give it another spin approximating your settings. Maybe I can get my apnea count down with the AVAPS. I only have 47 hours on it. I'll set the AVAPS for S/T AVAPS Mode; EPAP 12; IPAP Min 17; IPAP Max 25; BPM 8; Inspiratory Time 2 sec; Rise time 4. The only difference between my AVAPS and your S/T machine is that I can also set the Tidal Volume, so I'll be setting the Tidal Volume to 620.

I run less than 1 AHI consistently using my ResMed Adapt SV, there is absolutely no EPAP/IPAP switching, and the Adapt SV is the cure for my periodic breathing. My periodic breathing issue can be a challenge using AVAPS, and the EPAP/IPAP switching sucks, however, I generally felt more refreshed in the morning with the tidal volume boost provided by the AVAPS machine.

So, thanks for the inspiration. I'll let you know how it goes.

You are welcome to the Provider Manual for the Respironics AVAPS machine if you PM me with your email address. It would be the same Provider Manual for your Respironics S/T, although the AVAPS manual would include the additional PC (Pressure Control) Mode and Tidal Volume setting that is available with the AVAPS machine.

Banned

Banned wrote:Hey Sleepy,

Your doing so well on the S/T that I dragged my AVAPS out the closet, tonight. Think I'll crank it up and give it another spin approximating your settings. Maybe I can get my apnea count down with the AVAPS. I only have 47 hours on it. I'll set the AVAPS for S/T AVAPS Mode; EPAP 12; IPAP Min 17; IPAP Max 25; BPM 8; Inspiratory Time 2 sec; Rise time 4. The only difference between my AVAPS and your S/T machine is that I can also set the Tidal Volume, so I'll be setting the Tidal Volume to 620.

I run less than 1 AHI consistently using my ResMed Adapt SV, there is absolutely no EPAP/IPAP switching, and the Adapt SV is the cure for my periodic breathing. My periodic breathing issue can be a challenge using AVAPS, and the EPAP/IPAP switching sucks, however, I generally felt more refreshed in the morning with the tidal volume boost provided by the AVAPS machine.

So, thanks for the inspiration. I'll let you know how it goes.

You are welcome to the Provider Manual for the Respironics AVAPS machine if you PM me with your email address. It would be the same Provider Manual for your Respironics S/T, although the AVAPS manual would include the additional PC (Pressure Control) Mode and Tidal Volume setting that is available with the AVAPS machine.

Banned

Sir Banned,

Go for it - just one point re similarity, the Bipap S/T has no IpapMax. Otherwise you can set it the same but to do so 100% you would have to set IpapMax to IpapMin. Also the unfortunate aspect of the S/T is that unlike the SV & AVAPS, it doesn't give any flags for AI HI or PB. Just averages AHI for the entire period. This is because it was specifically designed for CA sufferers with little or no OSA so the important data becomes rate, tidal flow & volume.

Cheers

Doug

Sleepy55 wrote:I raised my EPAP to 11, leaving IPAP at 16 and BPM at 8. For the first time in my three weeks or so of tweaking, I finally saw a reduction of 50% in my Apnea Count!

Very good!

Sleepy55 wrote:I will raise EPAP tonight to 12, leaving all else alone for now, and see what my report looks like tomorrow.

Will be interesting.

Sleepy55 wrote: It could be, as previously suggested, that I don't even need a backup rate.

Yup.

Sleepy55 wrote:When I'm done tweaking downward my apnea count, I'll turn off S/T for one night, turning my machine into a plain Bipap and see what the numbers look like.

I think that's a good idea.

Sleepy55 wrote:Yes, I do feel better on the S/T than I did with my old bipap. I feel better in the A.M. and have less daytime sleepiness in the afternoons.

I may be wrong, but I think it might not be the "S/T" factor that is giving you better results compared to your old bipap. I think raising the EPAP is what's doing that...plain and simple. I think it's the fact that you're working the EPAP up to where it actually is accomplishing what EPAP is supposed to do...prevent apneas.

If anything, I think the timed back up rate...that BPM setting... is just getting in your way. That is...if you don't have a significant "centrals" problem, which I still don't think your diagnostic and titration sleep studies would have missed if they really were there. But I could be wrong. I'm sure not a doctor!

When EPAP is high enough to keep the throat open enough that it's possible for you to actually get another breath started, that triggers the higher inhale pressure to keep your throat well and truly open for breathing in. Novel idea, isn't it? Actually being able to breathe while we sleep! Getting EPAP right is the most important setting, imho, when it comes to bilevel treatment.

If you still happen to have your old BiPAP Plus around, another interesting experiment would be to see if you just might feel the same good effects you're enjoying now (including O2 staying up) by using the old machine at, say IPAP 16 / EPAP 12 ( or IPAP 17/ EPAP 13) instead of the EPAP 8 it was set at before. If you try that, I'd turn on bi-flex at 3 or 2..whatever felt smooth to you.

Even better, but unfortunately you don't have one, would be trying a BiPAP Pro II (the old model) or M series BiPAP Auto set for bilevel mode using the new higher EPAP. With either of those machines, a download of the data with Encore Pro or Encore Viewer would show AHI data.

Sounds like you're doing very well, Sleepy55. You may have to change your nickname, soon!

Sleepy

RestedGal has nailed it well - have to agree completely.

Additional comments I would add include ...
> Bipap S/T does have adjustment for INSP that (IIRC) isn't available in the Bipap Pro so has that advantage
> Bipap Pro II adds detailed nightly data that the Bipap Pro & Bipap S/T doesn't offer
> Having a backup rate machine can be a psychological or even for some of us a physical plus - in my case nasal congestion caused me
to breathe slow & long through my nose & I ran one bilevel with S/T capability at a backup rate of 6BPM - it seemed to work well for me
& I was convinced it was helping me. I eventually learned to mouth breathe in a F/F mask when nasal congestion afflicted me & now find
I can use machines that used to give me trouble (e.g. Bipap Pro II switching to early when I had nasal congestion).

RestedGal's comment about the Bipap Auto (w Biflex) also matches my experience with one & I have no hesitation in recommending it.

DSM