ResMed VPAP Auto 25 Clinician's manual

jdm2857 · Post by **jdm2857** » Mon Jun 15, 2009 10:19 pm

Jeff,

If I understand you correctly, then I can visualize the Respironics dancers connected by a rope (which only limits how far apart they can get) and the ResMed dancers connected by a stick (which keeps them a fixed distance apart). And if that stick is the width of the dance floor, it keeps the dancers pinned against opposite walls all night.

Is that right?

dsm · Post by **dsm** » Tue Jun 16, 2009 4:31 am

jdm2857 wrote:Jeff,

If I understand you correctly, then I can visualize the Respironics dancers connected by a rope (which only limits how far apart they can get) and the ResMed dancers connected by a stick (which keeps them a fixed distance apart). And if that stick is the width of the dance floor, it keeps the dancers pinned against opposite walls all night.

Is that right?

(#2 - added 2 corrections subsequently pointed out to me)

If anyone applied it that way

(seems some do if they are thinking Bipap but apply that thinking to Vpap)

Here are a few words that I hope might (for some) clarify this difference. I am going to add dancing up the floor (higher pressures) & dancing down the floor (lower pressures) ...

The Bipap Auto starts off (no user input can set this ) with a minimum gap of 2 CMs between epap & ipap (lets call this 2 feet between the dancers named ipap & epap ) - as the night progresses, the epap dancer may try to move up the floor because epap feels uncomfortable down the floor thus pushing the partner (called ipap) at least 2 feet ahead any time epap dances up the floor. But ipap may dance up the floor & leave epap behind so the gap may widen beyond 2 feet (but there is that rope tying them together called Max PS (or max feet apart )) - If ipap dances so far from epap that the rope gets tight, ipap will drap epap along up the dance floor providing ipap doesn't hit the wall first in which case ipap can't go any higher up the floor.

Now with the Vpap dance again we have epap & ipap BUT, the rules of the dance are that these two will always stay a preset gap apart (this could be set to 3 CMs or 4 or whatever). There is also the max pressure (or distance up the floor ) that ipap can dance to (before hitting the limit set. Epap may dance up the hall but will always push ipap this preset gap ahead.

For Bipap machines the gap between epap & ipap varies as each pressure gets adjusted Independently (never less than 2 & never greater than PSMax (usually 8 CMs)).

For Vpap machines the gap between epap & ipap gets pre set & stays that way as long as epap can push or pull ipap within the boundaries of their dance area. They always stay the same distance apart vs Bipap where the gap varies depending on how epap & ipap each feel.

I just hope this addition doesn't mangle the whole dance routine

DSM

jnk · Post by **jnk** » Tue Jun 16, 2009 6:09 am

jdm2857 wrote:Jeff,

If I understand you correctly, then I can visualize the Respironics dancers connected by a rope (which only limits how far apart they can get) and the ResMed dancers connected by a stick (which keeps them a fixed distance apart). And if that stick is the width of the dance floor, it keeps the dancers pinned against opposite walls all night.

Is that right?

It sounds right to me, jdm2857.

And there is nothing wrong with keeping the dancers pinned, if that's what a person wants to do. Some like the feel of a ResMed autobilevel in auto mode (because of how Easy-Breathe feels) but don't want the pressures to move around at night. So to get straight bilevel while the machine is in VAuto mode, they purposely make the pressures stay the same by setting pressure support the exact distance between Min EPAP and Max IPAP. But if a person wants to use a ResMed autobilevel as an autobilevel, the stick has to be shorter than the walls or the pressures won't vary.

rested gal · Post by **rested gal** » Tue Jun 16, 2009 9:01 am

dsm wrote:I just hope this addition doesn't mangle the whole dance routine

DSM

Well, it did, imho. Mangle things considerably.

Jeff's explanation was clear. As was jdm2857's visualization comment.

There were several incorrect statements in your attempt, Doug...

For example:

At the end of your paragraph about "The Bipap Auto starts off ...."

dsm wrote:If ipap dances so far from epap that the rope gets tight, ipap stops moving up the dance floor (has hit max PS).

Wrong. Hitting "max PS" (max press sup) does not stop IPAP from continuing to go up if need be. If the difference between Max IPAP and Min EPAP setting is more than 8 cm H2O, IPAP can continue moving up higher than the max press sup setting on the Respironics BiPAP Auto is set for. In that case, IPAP doesn't stop there. It simply drags EPAP up, too.

dsm wrote:For Bipap machines the gap between epap & ipap varies as each is pressure gets adjusted INDEPENDantly (never less than 2 & never greater than PSMax (usually 10)).

Wrong (regarding the part of the statement I emphasized in red.) The most that the "max press sup" setting can be set at with the Respironics BiPAP Auto is 8 cm H2O. Not 10.

Too bad you didn't just let Jeff's wonderful explanations, and jdm2857's good comment stand. You just had to jump in with your usual "Hey, look, look...I'm a machine expert...I'll explain it!!" stuff that only muddies the water.

dsm · Post by **dsm** » Tue Jun 16, 2009 5:41 pm

rested gal wrote:
<snip>

Too bad you didn't just let Jeff's wonderful explanations, and jdm2857's good comment stand. You just had to jump in with your usual "Hey, look, look...I'm a machine expert...I'll explain it!!" stuff that only muddies the water.

Hmmmm,

What did you just jump in & do ???

DSM (you can be such a charmer )

dsm · Post by **dsm** » Tue Jun 16, 2009 10:31 pm

rested gal wrote:
<snip>

Wrong. Hitting "max PS" (max press sup) does not stop IPAP from continuing to go up if need be. If the difference between Max IPAP and Min EPAP setting is more than 8 cm H2O, IPAP can continue moving up higher than the max press sup setting on the Respironics BiPAP Auto is set for. In that case, IPAP doesn't stop there. It simply drags EPAP up, too.

<snip>

RG,

I agree that the 10 shd be 8 - now if you had asked me DSM didn't you really mean 8, I would have said 'yes of course'. As I have posted here several times over the years 8 is the max.

You mention in your reply that Ipap will keep going up after it hits the end of the maxPS gap & will drag Epap with it if there is room. Now this is of interest to me as, it is what I used to think happened at first but the more I worked with this machine the more I became convinced (perhaps wrongly) that Epap will hold Ipap back rather than Ipap drag Epap up. There are to me good therapy reasons why Epap would override Ipap so I am wondering where you got the info that says Ipap will keep rising & take Epap with it ?.

Here are the links to the various manuals, Ive looked for it but wasn't able to find it - based on the unusual 'tone' of your post I am certain you must be very confident of that detail & so am sure you can point us all to it.

Thanks kindly - DSM

http://bipapautomseries.respironics.com/
http://cpaphelp.internetage.ws/manuals/ ... Manual.pdf

http://cpaphelp.internetage.ws/manuals/ ... Manual.pdf

The Bipap Auto Rules:
==================

NOTE: The settings for Min EPAP, Max IPAP, and Max PS are highly interdependent.
Consider the range of allowable pressures as bounded at the top by the Max
IPAP setting and at the bottom by the Min EPAP setting. While setting up one
parameter, another may change according to the following set of rules:

• The device will not allow a Max PS setting outside the range of 3.0 to
8.0 cm H2O, and the device will prohibit other settings to ensure that
this rule is not violated.

• Within the range of 3.0 to 8.0 cm H2O, any setting can be chosen for
Max PS, but it is further subject to the following rule: The Max PS setting
cannot exceed Max IPAP setting minus Min EPAP setting.

• If the Min EPAP setting is incremented greater than Max IPAP setting
minus Max PS setting, it will force the Max PS to decrease. The Max PS
setting will only decrease down to the minimum setting of 3.0 cm H2O,
so Min EPAP setting cannot be incremented greater than Max IPAP
setting minus 3.0.

• If the Max IPAP setting is decremented less than Min EPAP setting plus
Max PS setting, it will force the Max PS to decrease. The Max PS setting
will only decrease down to the minimum setting of 3.0 cm H 2O, so
Max IPAP setting cannot be decremented less than Min EPAP setting
plus 3.0.

-SWS · Post by **-SWS** » Wed Jun 17, 2009 7:59 am

dsm wrote: I agree that the 10 shd be 8

Very glad to get that detail squared away...

dsm wrote:You mention in your reply that Ipap will keep going up after it hits the end of the maxPS gap & will drag Epap with it if there is room... it is what I used to think happened at first but the more I worked with this machine the more I became convinced (perhaps wrongly) that Epap will hold Ipap back rather than Ipap drag Epap up.

No, the algorithm behaves exactly as Rested Gal had mentioned, Doug.

Run the Respironics Auto Training Simulation to watch this algorithmic principle in effect that Rested Gal just accurately described. The Respironics training simulation employs a Max PS of 8. Thus repetitively simulate or click the FL and/or hypopnea event buttons, while using that training simulation, until IPAP and EPAP are exactly 8 cm apart (Max PS). However, be sure to avoid accidentally invoking the NRAH routine via excessive hypopnea runs. Then simulate or click either the hypopnea or FL event button to clearly watch the algorithm drag EPAP up exactly as Rested Gal had mentioned.

_____________________________________________________________________________________________________________________________________

I would also like to add my kudos to that wonderful and easy-to-digest description jnk provided on page one for newcomers and veterans alike. For auto BiLevel newcomers especially, here it is again:

jnk wrote:
Wuqing Wang wrote:the two machines are not in the same technical level.
I think you may misunderstand the differences between the two machines and how each machine must be set. They are both good autobilevels, but you can't set either of them up correctly by attempting to use the numbers that were used on the other brand of machine. You have to think about the numbers and translate them for how you want the other brand of machine to run.

As an illustration, think of inhale and exhale as being two dancers. On the Respironics dance floor in the Respironics world, the two dancers dance two different dances without caring what the other dancer is doing. You simply set the size of the dance floor and you tell the dancers the maximum distance they are allowed to get from each other during their separate dances (there is an automatic minimum to keep them from bumping into each other), and they each do their own thing. Sometimes they dance close to each other, and sometimes they dance far apart. That distance varies. On the other hand, on a ResMed dance floor in the ResMed world, the two dancers do the same dance and are always the exact same distance from each other, but they can still roam the full dance floor, as long as they do it together. So if you mistakenly set the fixed distance of the dancers to be the same size as the dance floor, you keep the dancers from moving at all.

In other words, for the Respironics machine, you set the maximum IPAP and minimum EPAP (the size of the dance floor), then you set the MAXIMUM pressure support, or maximum distance allowed between the two separate pressures (dancers). For the ResMed, you similarly set a maximum and minimum (the dance floor), but then you set the ACTUAL pressure support, the fixed distance (or, difference) between inhale pressure and exhale pressure for the night. On that machine, those two pressures increase and decrease TOGETHER, NOT SEPARATELY, moment to moment, during the night (since the two do the same dance together).

It seems that the person who set up your machine didn't understand that difference between the two machines and set up the ResMed as if it were a Respironics. That is incorrect. If you want the ResMed to run as an auto, make sure the pressure support number is a number LESS THAN the distance between Max IPAP and Min EPAP so the dancers have some room to move. If the machine isn't set up correctly, it is the person who set it up who has kept the machine from running as an auto. That is not a limitation of the machine; it is a limitation of the person who set it up. That person was confused. So don't blame ResMed.

As for which approach to autobilevel dancing is best, I don't know. I just know the two approaches are different and that before you set up one brand after using another brand, you had better learn something about dance floors and choreography in the other world and translate from one to the other, if you want to see a dance.

jeff, who set up his own autobilevel, but is a lousy dancer in real life if he doesn't have a guitar in his hands.

Nicely done, Jeff!

ozij · Post by **ozij** » Wed Jun 17, 2009 8:34 am

My apologies for responding without having read read the beginning of the thread, however, this, from the Respironics algorithm training program is highly relevant to the last interchange:

As the IPAP setting is raised, delta increases. If delta reaches the Max Delta setting, any further increases in IPAP force the EPAP setting to increase accordingly.

My underline. Precisely what has been pointed out by Rested Gal about the algorithms behavior.

O.

-SWS · Post by **-SWS** » Wed Jun 17, 2009 9:49 am

[quote="Conveying a manual section titled "Changing the Provider Mode Settings" dsm"]

The Bipap Auto Rules:
==================

...While setting up one parameter, another may change according to the following set of rules:

<remaining configuration rules for provider setup mode snipped>[/quote]
Those Respironics rules describe how the machine automatically maintains/adjusts settings as the clinician enters values into the machine during setup.

However, those Respironics provider-mode setup rules are not a description of the treatment algorithm.

dsm · Post by **dsm** » Wed Jun 17, 2009 3:44 pm

Thanks SWS & Ozij for clarifying that. I had posted that as how the Bipap Auto worked back in this post some time back.
viewtopic.php?f=1&t=18495&p=158796&hili ... gs#p158796 (here abouts)
#2 Be aware that in that description I mention a gap of 2 CMs between Epap & Ipap & that is based on using a dial manometer
to test the pressures & a gap of 2 is what I saw (irrespective of what the manual says).

But had also read that Epap must be raised very cautiously due to negative side effects (in the current Bipap prov manual).
I did then begin to change my mind to the Epap taking priority over Ipap for that reason. But I will accept that the simulator
is correct on this.

Cheers

DSM

jnk · Post by **jnk** » Wed Jun 17, 2009 5:33 pm

-SWS wrote:Nicely done, Jeff!

Thanks, -SWS! I'm sure I fudged a bit, technically, with my choice of words in the analogy, so thanks for going easy on me. I appreciate the encouragement and the way everyone has one another's back on this site. Good people here!

jeff

dsm · Post by **dsm** » Wed Jun 17, 2009 6:35 pm

-SWS wrote:[quote="Conveying a manual section titled "Changing the Provider Mode Settings" dsm"]

The Bipap Auto Rules:
==================

...While setting up one parameter, another may change according to the following set of rules:

<remaining configuration rules for provider setup mode snipped>

Those Respironics rules describe how the machine automatically maintains/adjusts settings as the clinician enters values into the machine during setup.

However, those Respironics provider-mode setup rules are not a description of the treatment algorithm.[/quote]

SWS,

As an aside, do you have any thoughts on why Ipap would override the Epap setting allowing for the potential for that to cause
'possibly' more serious side effects than the Ipap by being raised, is trying to resolve.

It does seem to me to be just a bit counter intuitive.

Cheers

DSM

jnk · Post by **jnk** » Wed Jun 17, 2009 7:18 pm

dsm wrote: . . . a bit counter intuitive. . . .

I am fascinated by Respironics' approach, but I find the whole approach counter-intuitive, myself. I would assume that constantly varying pressure support could throw off the body's breathing feedback loop for some people. I would think that it might make more sense to keep pressure support constant from that point of view. On the other hand, why raise EPAP every time IPAP needs to address an event if apneas are already handled? So I guess the other approach makes sense in its own way, too. All I know for sure is that I would love to try the Respironics BiPap Auto! Why couldn't I have been born rich instead of handsome?

dsm · Post by **dsm** » Wed Jun 17, 2009 8:01 pm

jnk wrote:
dsm wrote: . . . a bit counter intuitive. . . .
I am fascinated by Respironics' approach, but I find the whole approach counter-intuitive, myself. I would assume that constantly varying pressure support could throw off the body's breathing feedback loop for some people. I would think that it might make more sense to keep pressure support constant from that point of view. On the other hand, why raise EPAP every time IPAP needs to address an event if apneas are already handled? So I guess the other approach makes sense in its own way, too. All I know for sure is that I would love to try the Respironics BiPap Auto! Why couldn't I have been born rich instead of handsome?

JNK

I have to say that it is a very pleasant device to use. Gave me an excellent nights sleep, but also the pressures didn't wander very far, so I suspect that even for most people there isn't quite the dancing around we might imagine. It was a very bold initiative & I think quite clever.

I am normally a believer in fixed pressure gap & am not convinced auto ranging makes any really big improvement but after trying the Bipap Auto (with Biflex) and finding the low starting gap was not an issue, I was quite satisfied their technique works & works surprisingly well. I rate it as among Respironics very successful machines.

Here is a night's data I saved. Notice that 'only' the Ipap varied so clearly epap of 10 for me was very adequate. I would happily use it again.
http://www.internetage.ws/cpapdata/dsm- ... apauto.pdf

DSM

ozij · Post by **ozij** » Wed Jun 17, 2009 8:22 pm

dsm wrote:<snip>

But had also read that Epap must be raised very cautiously due to negative side effects (in the current Bipap prov manual).
I did then begin to change my mind to the Epap taking priority over Ipap for that reason. But I will accept that the simulator
is correct on this.

Cheers

DSM

That's very surprising. Could you perhaps tell us specifically which manual you got this warning from? As far as I know, provider manuals tell providers how to setup machines, based on doctors orders - they certainly do not assume the provider changes the pressure at will. I would be very surprised if the Respironics BipapAuto Manual had it any differently -

Edit: I've just skimmed through the Respironics BipapAuto Porvider's Manual link that you so kindly provided above (thank you!). I can't find that caution - could you point out for me where it mentions raising the EPAP very cautiosly?

O.

ResMed VPAP Auto 25 Clinician's manual

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