ResMed VPAP Auto 25 Clinician's manual

ozij · Post by **ozij** » Sat Jun 20, 2009 2:04 am

You're saying that even now, despite the reduction in weight related obstructive events, you still feel much better on a machine that does ventilation.

O.

dsm · Post by **dsm** » Sat Jun 20, 2009 2:15 am

ozij wrote:You're saying that even now, despite the reduction in weight related obstructive events, you still feel much better on a machine that does ventilation.

O.

Given a choice of Bipap Auto vs Bipap SV - there is a no contest choice the SV
The daytime results are distinctly different from what the nightly data suggests.

If I go on a weeks holiday, I will use the Vantage S8 set in CPAP mode with EPR=3
But it is a poor substitute for the SV but does the job & I am always able to get
back to the prior good results after a couple of days on SV.

Ozij, after approx 5 years I am seeing results that really get my attention. To
get those results involves particular machine choices.

DSM

ozij · Post by **ozij** » Sat Jun 20, 2009 2:20 am

dsm wrote: Ozij, after approx 5 years I am seeing results that really get my attention. To
get those results involves particular machine choices.

DSM

I am very happy for you - and you are very fortunate to be able to do that.
O.

dsm · Post by **dsm** » Sat Jun 20, 2009 3:41 am

ozij wrote:You're saying that even now, despite the reduction in weight related obstructive events, you still feel much better on a machine that does ventilation.

O.

Ozij

To clarify this point. The SV does not *just* do Ventilation ! - that is a very wrong point to emphasize.

The Bipap SV does traditional bilevel+. If Epap is set correctly it is as good as the best bilevels. The
magic comes with the Ipap. That if set correctly in terms of epap-ipap gap is going to be as good as
the best bilevel but Ipap can be adjusted as much as 10 CMs within 3 breaths to smooth flow.

So once having a *best* bilevel setup, we have the SV algorithm that monitors Peak Flow (or in the case
of the Vpap SV, volume) and tracks to 90% of a 3-4 min moving window on either of these. This is the SV
magic, agreed, it was designed to smooth out irregular breathing BUT it seems that this smoothing is what
makes it 'magic' as far as my own therapy is concerned. So we have conventional pressure support for the
Epap component & we have conventional pressure support for the Ipap, then we *ADD* ventilation support
by way of SV. I am saying this makes a substantial difference. I am betting that in time others will realize
this too. My results aren't freak results nor figments of my imagination. The SV *IS A BILEVEL* but with
a fluctuating Ipap that can spin on a dime (3 Cms in 1 breath, up to 3 breaths). I see this happening
repeatedly in 18 months of data. But over the past 3 months or so the flying up of Ipap is reducing as I
get fitter & breathe better.

I would really love to see studies of OSA people who do OK or not so ok on Cpap/Apap & who don't have
*obvious* obesity related breathing issues (excessive weight & neck structure),nor other odd respiration
because, I am convinced that the results would be people who get far better daily results than they do
with their std cpap/apap setups. I would add Bilevels & Auto Bilevels into that mix.

I do think such studies will occur. cpap/apap therapy is not anywhere near its effectiveness yet & I
am in little doubt that there will be many more innovations & among them I see the SV as a shining
light of innovation (even if only parts of it make it into mainstream) for a significant segment of
cpap users.

DSM

rockhinkle · Post by **rockhinkle** » Sat Jun 20, 2009 5:19 am

jeff someone said i needed to come read your post. once again your knowledge of my field astounds me. great post!

Guest · Post by **Guest** » Sat Jun 20, 2009 5:28 am

dsm wrote:
ozij wrote:You're saying that even now, despite the reduction in weight related obstructive events, you still feel much better on a machine that does ventilation.

O.
Ozij

To clarify this point. The SV does not *just* do Ventilation ! - that is a very wrong point to emphasize.

The Bipap SV does traditional bilevel+. If Epap is set correctly it is as good as the best bilevels. The
magic comes with the Ipap. That if set correctly in terms of epap-ipap gap is going to be as good as
the best bilevel but Ipap can be adjusted as much as 10 CMs within 3 breaths to smooth flow.

So once having a *best* bilevel setup, we have the SV algorithm that monitors Peak Flow (or in the case
of the Vpap SV, volume) and tracks to 90% of a 3-4 min moving window on either of these. This is the SV
magic, agreed, it was designed to smooth out irregular breathing BUT it seems that this smoothing is what
makes it 'magic' as far as my own therapy is concerned. So we have conventional pressure support for the
Epap component & we have conventional pressure support for the Ipap, then we *ADD* ventilation support
by way of SV. I am saying this makes a substantial difference. I am betting that in time others will realize
this too. My results aren't freak results nor figments of my imagination. The SV *IS A BILEVEL* but with
a fluctuating Ipap that can spin on a dime (3 Cms in 1 breath, up to 3 breaths). I see this happening
repeatedly in 18 months of data. But over the past 3 months or so the flying up of Ipap is reducing as I
get fitter & breathe better.

I would really love to see studies of OSA people who do OK or not so ok on Cpap/Apap & who don't have
*obvious* obesity related breathing issues (excessive weight & neck structure),nor other odd respiration
because, I am convinced that the results would be people who get far better daily results than they do
with their std cpap/apap setups. I would add Bilevels & Auto Bilevels into that mix.

I do think such studies will occur. cpap/apap therapy is not anywhere near its effectiveness yet & I
am in little doubt that there will be many more innovations & among them I see the SV as a shining
light of innovation (even if only parts of it make it into mainstream) for a significant segment of
cpap users.

DSM

I believe you are talking about back up rate. normally we only add these to pt that exhibit CSA mixed with OSA. recently my medical director has had us add this ventilation to all BiPAP studies. Our compliance rates as well as our success rates on BiPAP have gone through the roof. If I have my way I will add this too every Bipap study I can in the future.

rested gal · Post by **rested gal** » Sat Jun 20, 2009 8:54 am

rockhinkle wrote:jeff someone said i needed to come read your post. once again your knowledge of my field astounds me. great post!

Right, rockhinkle! It was a great post that Jeff (jnk) wrote back on page 1!

Considering how much muddy water dsm's flailing around and self indulgent ramblings can track in (thank goodness people like -SWS and ozij are capable of, and willing to do, mop-up! LOL! ) perhaps it's time again to bring Jeff's excellent post back into the spotlight, as -SWS did on page 2.

The two machines Jeff was talking about are these two machines, when used in their autotitrating bilevel mode:

Respironics BiPAP Auto
ResMed VPAP Auto

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.

-SWS · Post by **-SWS** » Sat Jun 20, 2009 9:09 am

dsm wrote:To clarify this point. The SV does not *just* do Ventilation ! - that is a very wrong point to emphasize.

To clarify the above straw argument: nobody in this thread came close to saying the SV only ventilates. So I'm admittedly wondering who you're correcting when you address that "very wrong point" that absolutely no one expressed? We talked about EPAP and EEP being held constant to "stent" according to SV manufacturer requirements. But we we also talked about inadvertent "dynamic stenting" in this thread as well.

You drew this cough syrup analogy as if SV was nicely addressing OSA:

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.

And I pointed out that your cough-syrup logic failed to address the distinct possibility that beneficial "ventilation" may be occurring in your case as well:

-SWS wrote: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...

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.

Then I went on to present sound logic that IPAP-peak is very busy "ventilating" in your case, rather than purely "stenting" airway obstructions:

-SWS wrote: 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".

And since that extremely central point went unanswered, I repeated the same logic that highly dynamic IPAP-peak "ventilation" sure seems to be the salient pressure-treatment difference between those two machine platforms in your case, DSM:

-SWS wrote: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.

And rather than acknowledge just how busy IPAP-peak is in your case "ventilating" (because you really don't have a commensurate number of residual obstructions that can be "stented" at those base pressures)... you continued with the same vague observations of how nice it was to try a different machine and how much better SV makes you feel.

So then let's jointly argue those non-existent points of contention together:
1) "Just because auto BiLevel machines exist, that doesn't mean SV machines don't also serve a certain market or patient-population segment."
2) "DSM does feel better using a machine that can both stent and dynamically ventilate."
3) "The myth that SV machines only ventilate is very wrong."

Nobody here ever disputed the above three actively-defended points.

But let's be sure to leave this most central point unacknowledged:
1) "How about all that active IPAP-peak "ventilation" busily occurring on DSM's charts (when there can't possibly be that much residual obstruction to dynamically "stent" with all that IPAP-peak activity)?"

__________________________________________________________________________________________________________________________________

Here's some proposed logic, dsm:
If you feel a distinct beneficial difference between: 1) a machine that is designed to only stent, versus 2) a machine designed to both stent and dynamically ventilate... and you observe that same ventilation-capable machine very busy "ventilating" (when there just isn't that much residual obstruction to dynamically "stent" with IPAP-peak)... then how about a logical likelihood your salient treatment difference lies in "ventilation" of all things?

-SWS · Post by **-SWS** » Sat Jun 20, 2009 2:30 pm

Guest wrote: I believe you are talking about back up rate. normally we only add these to pt that exhibit CSA mixed with OSA. recently my medical director has had us add this ventilation to all BiPAP studies.

Guest, it sounds as if you are talking about including the BiLevel S/T titration protocol in PSG studies that would otherwise receive only the BiLevel S titration protocol. If so, I agree that you are talking about "back up rate" or the "timeliness of ventilation".

However, in the latter part of this thread, we have been primarily discussing "Proportional Assist Ventilation" (PAV) benefits provided by adaptive/auto Servo Ventilation type machines. Unlike backup rate, PAV is primarily a ventilatory issue of just how high or low IPAP will automatically range, to dynamically provide a targeted pressure support (PS) amplitude for each breath. Again, that amplitude-based PAV aspect of ventilation is really different than back-up rate, which addresses central breathing latency. But aside from PAV's dynamically-targeted per-breath PS amplitude deliveries, there are additional central latency benefits provided by the adaptive/auto Servo Ventilation type machines for patients who are centrally dysregulated---including backup rate.

Guest wrote:Our compliance rates as well as our success rates on BiPAP have gone through the roof. If I have my way I will add this too every Bipap study I can in the future.

If providing a back-up rate to otherwise spontaneous BiLevel treatment genuinely yields a "through the roof" difference, then I would strongly encourage your institution to document your treatment methodology and submit all those fantastic details for peer review---so that countless others may benefit. Good luck!

dsm · Post by **dsm** » Sun Jun 21, 2009 6:09 pm

-SWS wrote:
<snip>

__________________________________________________________________________________________________________________________________

Here's some proposed logic, dsm:
If you feel a distinct beneficial difference between: 1) a machine that is designed to only stent, versus 2) a machine designed to both stent and dynamically ventilate... and you observe that same ventilation-capable machine very busy "ventilating" (when there just isn't that much residual obstruction to dynamically "stent" with IPAP-peak)... then how about a logical likelihood your salient treatment difference lies in "ventilation" of all things?

SWS

Am with you on this but have to confess am grabbing time here in quick bursts & am pretty busy so yes I am not picking up all points you posted.

Yes your point is well taken. It is obvious that the Epap is taking care of stenting & also it is clear (& ozij, sorry I mis-read that point) that the fluctuating Ipap is ventilating & that is the heart of my belief that the SV is making a significant difference. This interaction is also colored by RGs unnecessary unpleasantness but that is RG these days & I will just have to ignore it. There is also hostile tone to your posts & I am sure I am not inviting that just making a case & looking to discuss it ?. My apologies if this observation is wrong.

But,
I have some additional thoughts as to what might make the difference if we hone in on the Bipap Auto vs the Bipap SV & that is, on regular occasions with
each machine, I get to a period between 3am & 5am where I will wake & realisze (with the SV) that it is ventilating heavily & I usually strech then roll over & go back to sleep - often I can see a big Ipap boost & assume that was likely the event but there is often no AI or HI tagged. With the Bipap Auto a similar experience is that I wake (say 3:30 am) feel a 'heaviness' stretch, get cramps, then eventually get back to sleep.

In comparing the two situations it is as if the SV has found a sudden change in target peak flow & has boosted Ipap & either that or the actual cause of the peak-flow drop, triggers the arousal - in the case of the Bipap Auto, same situation, but it is not able to react with a ventilation boost & then the cramps appear (there has to be a correlation between why cramps appear with one machine & not the other - there has to be a cpap related reason why these cramps appear at all - again in my very non-medical way I am assuming it is CO2 related ? ). These cramps occurring in this early morning period must be a known syndrome. Managing them has become an issue for me & the Bipap SV is the one machine I have that seems to do it.

I hope we can clear up any misunderstandings re the points you have & are making. I do need time to absorb some of the significance of a point. I come back to my point that the results I am seeing are becoming clearer with time & thus I have the confidence to explore them & to hone in on why an SV machine appears to do so much better (yes, for me) than an Auto.

DSM

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