ResMed VPAP Auto 25 Clinician's manual

dsm wrote:I guess by saying raising Epap when the data doesn't show a need seems a bit 'counter-intuitive' I am saying so from the mindset of someone who has become convinced that the Servo Ventilation approach of adjusting only Ipap & leaving Epap alone, seems to have made a world of difference to my therapy... for me the SV has been an incredible discovery...I have almost 18 months nightly data from both SVs & can see an improving pattern that is pretty linear.... but the results for me speak for themselves.

Above you are very clearly describing your own SV results, Doug. Your initial statement is what threw me off. When I read it, I thought you were trying to generalize that moving EPAP along with IPAP made no sense across the OSA patient population:

-SWS wrote:

dsm wrote:To be honest, after much thought today re Ipap dragging Epap up, I just can't see the sense of doing so.

In other words, when this situation happens both IPAP and EPAP move in tandem to all supported types of obstructive sleep events.

Moving EPAP in tandem with IPAP is really the hallmark of Resmed's auto BiLevel design. So that aspect of BiLevel treatment, which you find counterintuitive, clearly makes a great deal of sense to Resmed and all those OSA patients who reap great benefits from that auto BiLevel design.

But if I read your original statement in the context of what just so happens to work best for you, then your statement makes better sense. But your scope of observation does not support any population-wide efficacy assessments about moving EPAP in tandem with IPAP---or even SV modality. There are already plenty of clinical and even message-board anecdotes about SV modality not always working so well.

SWS

I am wondering if the reason for my such positive SV result is an age vs obesity issue.

Tricky area to discuss, but there has to be an explanation for why I get such continuously good results. Also, every
time I hear someone saying or asking why their cpap therapy was not working after a few months I wonder if I am
hearing my own story.

It seems to me that there may well be a division in the ranks of us OSA sufferers - and am wondering if SV is going
to work better for this segment like me. My sleep studies are little different from many other peoples (bar those with
a significant obesity factor & neck structure factor).

So, just because Resmed & Respironics sell Bilevel Autos, doesn't mean that SV isn't a better approach for a segment
of users. I am sure there is still a lot of learning going on by these companies and their researchers. I just can't avoid
seeing the good results I have honed in on over the past years.

Cheers

DSM

dsm wrote: So, just because Resmed & Respironics sell Bilevel Autos, doesn't mean that SV isn't a better approach for a segment
of users.

That is a knife that can cut both ways, namely:

Just because Resmed & Respironics sell SV machines, doesn't mean that Bilevel Autos aren't a better approach for a segment of users.
Or:
Just because some patients do well on Bilevel Autos doesn't that SV isn't a better approach for other people.

etc.

Okay, this thread has veered from ResMed VPAP Auto configuration issues for newcomers, to a comment that raising EPAP along with IPAP makes no sense to:

dsm wrote:So, just because Resmed & Respironics sell Bilevel Autos, doesn't mean that SV isn't a better approach for a segment of users.

As if anybody ever sat on the other untenable side of that statement. Yes, there is an indisputable "segment". Why else would that highly targeted SV platform be manufactured?

However, there's really no tenable logic in taking an unexplored and inherently nebulous medical statement like that, and then extending it into highly specific targeted etiologies that have no supporting empiricism or methodology. It's not as if the manufacturers and especially independent researchers just so happen to have amazingly forgotten to consider SV modality in relation to the various non-targeted SDB etiologies.

If there were clear winning combinations---such as SV and UARS, for instance---the UARS researchers would have written a white paper by now and the manufacturers would have hailed the breakthrough. Again, it's not as if the manufacturers and researchers collectively forgot to consider SV in relation to all the common SDB etiologies. That "V" in "SV" stands for "ventilation". And ventilation protocols in general are used to address: 1) hyperventilation, 2) hypoventilation, and 3) central dysregulation.

Here IPAP fluctuates so dynamically because it is performing "ventilation" rather than merely "stenting". Both SV manufacturers discussed in this thread want EPAP or EEP sitting constant because that pressure addresses the obstructive component, which those machine models cannot accurately differentiate. So the EPAP or EEP needs to be a constant "stent" for obstruction so that IPAP can dynamically "ventilate" on an as-needed basis for centrally-dysregulated patients according to all the research and marketing literature from the manufacturers and independents.

So is there anybody on this message board who thinks the manufacturers and independent researchers have not yet tried SV on OSA patients? And if the results were so promising, where is that single text hint in the annals of independent medical literature or even manufacturer marketing literature?

SWS

I fear you are missing my point. If I take a cough medicine and discover it has a remarkable effect on my long suffering sinuses, & despite the labels on the bottle, over time continue to find the side benefit shows a notably remarkable improvement. Then it is worth looking into despite the common position it was only to fix my cough.

I fear I keep hearing a message that says "DSM, you aren't reading the label !!!. That SV machine is for CSR, CompSA, MixedSA & CA !!!, you can't claim to be an OSA patient & be getting 'better' benefits from it that you claim unless you are one of those categories (which I am not according to 3 sleep studies over 12 years). Steve, I am saying I think the SV machine may, for a segment of OSA sufferers, be a better mousetrap. But as mentioned, it is still such early days for SV and for OSA in general.

& Ozij, absolutely it cuts both ways. But I am looking at hard & fast results gathered over a few years & proving to be fairly consistent. I am in NO doubt that a segment of OSA people wuill benefit from Auto algorithms - what we might be debating is where that split occurs & I am saying I think it may be closer to the middle than anyone realizes. I sure believe it is a point worth my further investigation.

DSM

dsm wrote: I fear you are missing my point. If I take a cough medicine and discover it has a remarkable effect on my long suffering sinuses, & despite the labels on the bottle, over time continue to find the side benefit shows a notably remarkable improvement. Then it is worth looking into despite the common position it was only to fix my cough.

I didn't miss your point. Your point is based on this etiological assumption: that you fail to benefit from "ventilation"---while purely reaping the assumed benefit of timely "stenting" instead.

That stands fine as both assumption and opinion. However, present your SV conclusion based on that inadequately-proven assumption to a scientific committee for peer review and I absolutely guarantee that's the last time that committee will ever see you. But that kind of comment flies just fine on message boards.

If you benefit from "ventilation", then you fit the target population for SV. Conversely, if you're reaping purely dynamic "stenting" benefits on SV, then you haven't proven it either. And once again, we're still short of substance to push the application of SV onto any specific etiology other than those proven by the SV manufacturers and independent researchers---who happen to rely on methodology and empiricism rather than metaphors and syllogisms.

-SWS wrote:

dsm wrote: I fear you are missing my point. If I take a cough medicine and discover it has a remarkable effect on my long suffering sinuses, & despite the labels on the bottle, over time continue to find the side benefit shows a notably remarkable improvement. Then it is worth looking into despite the common position it was only to fix my cough.

I didn't miss your point. Your point is based on this etiological assumption: that you fail to benefit from "ventilation"---while purely reaping the assumed benefit of timely "stenting" instead.

That stands fine as both assumption and opinion. However, present your SV conclusion based on that inadequately-proven assumption to a scientific committee for peer review and I absolutely guarantee that's the last time that committee will ever see you. But that kind of comment flies just fine on message boards.

If you benefit from "ventilation", then you fit the target population for SV. Conversely, if you're reaping purely dynamic "stenting" benefits on SV, then you haven't proven it.

SWS

Why do so many people (incl myself) start cpap therapy & find it fades after a few months ? - this is clearly a vexing issue for many people coming to these boards. Also it doesn't seem to matter be it cpap or auto. & Yes the same question can be applied to SV users, except SV is still new & despite it being an exclusive CSR/CA device 8 years ago, today it has been expanded to CompSA & MixedSA.

That scientific panel has to be somewhat in the past based on the usual caution taken in medical circles. But OSA/CA etc: is still bleeding edge.

As for dynamic stenting from SV - who can say why there is this difference in results (Bipap Auto vs Bipap SV) except that for me it is there & real & happening & repeatable.

Is it possible that a failure of Auto algorithms lies in the reality that whilst they are meant to be pre-emptive, they are in use mostly reactive & that reactivity is a let down to a significant segment of users *some* of who might benefit from a volume tracked therapy once their OSA has been covered with an effective Epap. ?

DSM

dsm wrote: Why do so many people (incl myself) start cpap therapy & find it fades after a few months ? - this is clearly a vexing issue for many people coming to these boards.

An entire variety of reasons and even comorbidities seem probable to me. Riverdreamer, JoyD., and I are currently collaborating on that same general topic toward some future write-ups. We hope to get others involved in those threads and articles as well.

dsm wrote:As for dynamic stenting from SV - who can say why there is this difference in results (Bipap Auto vs Bipap SV) except that for me it is there & real & happening & repeatable.

Dynamic stenting as the salient treatment difference does not seem likely, based on your auto BiPAP charts in this thread. At those base BiLevel pressures, and with those graphed results, there aren't many residual obstructive events for the SV to tackle. Are there?

And yet, set your BiPAP AutoSV with those same base pressures, and your machine's IPAP spends a lot of time very actively going up and down. But there aren't many residual obstructive events at those base BiPAP pressures using the other machine. Right? That's clearly plenty of IPAP-peak "ventilation" occurring versus "dynamic stenting".

dsm wrote: & Ozij, absolutely it cuts both ways. But I am looking at hard & fast results gathered over a few years & proving to be fairly consistent. I am in NO doubt that a segment of OSA people wuill benefit from Auto algorithms - what we might be debating is where that split occurs & I am saying I think it may be closer to the middle than anyone realizes. I sure believe it is a point worth my further investigation.
DSM

Your hard and fast data, reliable and valid as it may be, is based on a single case. Perhaps on a singular case. There in no basis for saying your case of one applies the whole population.
It is always easy to say something "may" happen - that hypothetical statement however is not proof of anything.
Generalizations about populations have to be based on representative samples of what is being observed. I do not consider you a representative sample of the population in general - and you have certainly not carried out the kind of comparative population investigations carried out by the people who are selling the machines.

Proper further investigation of the generlizability of your results means you need access to a sleep lab, access to a population that will be randomly divided between a treatment group and a control group, professionals who will score the PSGs. Furthermore, the study would have to be a double blind one: where neither patient nor data scorer know which machine was used. Such research needs funding - and to the best of my knowledge you are not a sleep professional with the funds for that - therefore I honesty fail to see how you can carry on the further investigations pertaining to the rest of the population.

However, perhaps you only meant your further investigation of what previous research has show on the subject - after all, studying what has gone on before is an important part of serious investigation.

There is a major difference between empiricism and debate. The question of how fitting SV may be to people with OSA or UARS is an empirical one.

dsm wrote:That scientific panel has to be somewhat in the past based on the usual caution taken in medical circles. But OSA/CA etc: is still bleeding edge.

No, even today they don't go for cough-syrup drawn conclusions like that. They prefer empiricism, but they also expect to see sound logic when conjecture is involved.

I honestly don't think the logic you present in this thread is either convincing or sound toward SV conclusions. But it works fine for off-the-cuff speculation or just pondering IMHO. And that's what message boards are about sometimes.

ozij wrote:The question of how fitting SV may be to people with OSA or UARS is an empirical one.

I couldn't agree more.

Ozij

I don't disagree at all. But when change happens it usually starts with one then a few them more examples.

If my OSA were abnormal I could understand regarding my experience as possibly unique. I am making the
case that I am not unique. I can't see any data in my sleep studies that makes my OSA different from the norm.

But, cpap & apap were failing me - SV isn't - all I am doing is asking the obvious questions & pushing the issue.

I will again come back to the *fact* that 5-6 years ago people argued forcefully that anyone with vanilla OSA
who chose to use a Bilevel was ignoring the 'rule' that cpap treated OSA & Bilevel treated COPD. But today
with the price down & the fact that people are less blind to just how good Bilevel is, we see Bilevel as the
prominent form of OSA therapy. I am of the opinion the same thing is repeating itself again today. The
rule says cpap, auto & bilevel auto & anyone who argues for SV is ignoring the rule - despite any results that
back this up.

I am raising the issue that from what I can see & have experienced, that SV may well be a better treatment
for a significant segment of OSA sufferers. All I hear is no that can't be. I think it can.

DSM

-SWS wrote:

dsm wrote:That scientific panel has to be somewhat in the past based on the usual caution taken in medical circles. But OSA/CA etc: is still bleeding edge.

No, even today they don't go for cough-syrup drawn conclusions like that. They prefer empiricism, but they also expect to see sound logic when conjecture is involved.

I honestly don't think the logic you present in this thread is either convincing or sound toward SV conclusions. But it works fine for off-the-cuff speculation or just pondering IMHO. And that's what message boards are about sometimes.

ozij wrote:The question of how fitting SV may be to people with OSA or UARS is an empirical one.

I couldn't agree more.

Yes I will agree with Ozij's point re SV & UARS - qualified by what a broad specrum of conditions the syndrome covers.

My 'speculation' is truly that - and based on nearly 5 years of trying all therapy types & today am very very satisfied with the outcome.

DSM

dsm wrote:My 'speculation' is truly that - and based on nearly 5 years of trying all therapy types & today am very very satisfied with the outcome.

If you feel better, then that's no speculation.

But what do you think of that bold text I have above that deduces IPAP-peak is very busy "ventilating" rather than "stenting" residual obstructions at those same base pressures that you posted in this thread?

Based on that busy IPAP-peak, I'll speculate you feel better on SV because you are receiving so much active "ventilation" by IPAP-peak for lack of residual obstructions to be addressed by IPAP-peak. And that's what SV is designed to do: very actively ventilate.

Here are some things I remember your saying about yourself, dsm:
Your breathing is extremely shallow.
You practice(d) slow breathing - even very slow - related, IIRC to diving and yoga.
You've got nasal problems bat enough to make you doctor suggest surgery.

I do not consider any of the above "the norm".

And you've found a specific machine that gives you good therapy.
O.

ozij wrote:Here are some things I remember your saying about yourself, dsm:
Your breathing is extremely shallow.
You practice(d) slow breathing - even very slow - related, IIRC to diving and yoga.
You've got nasal problems bat enough to make you doctor suggest surgery.

I do not consider any of the above "the norm".

And you've found a specific machine that gives you good therapy.
O.

Ozij,

Part of that goes back 4-5 years when I 1st started on therapy.

But, having got down to cycling 25 kms per day & lost 17 KG in the past 8 months + 2 years use of nasonex, I can tell you my breathing
is pretty damned good now & most of my progress in all spheres came after swapping to SV. The doc really only wants to remove tonsils
& polyps - I am satisfied with the turbinates being tamed with nasonex.

No, I don't believe I am that much different to anyone else - but as can be seen from the accumulated data - loosing weight GREATLY
reduced the nightly AHI scores !!!. Today they average less than 0.5 & mostly hypops which in turn are probably from the few times I
turn over in the night.

So where does this end ? - I am satisfied with my therapy & will stay with that magic machine. I do though wonder how long it will be
before some form of SV gets incorporated into the leading edge cpap machines. I am NOT convinced that the typical AUTO algorithms
be it A10 or Resp, will go down in Cpap history as the big advance some thought it would be. On paper it looked wonderful.

DSM