ResMed VPAP Machine Family Tree

dsm wrote:

-SWS wrote:

DSM wrote:Just to restate what makes the AVAPS different ... AVAPS offers the same features as a timed bilevel but includes a pressure support algorithm that can rapidly adjust ipap (breath-by-breath).

Doug, many thanks for that summary. As it turns out, the AVAPS doesn't rapidly adjust IPAP like the SV machines. Rather, Respironics claims an IPAP adjustment rate of only 0.5 to 1 cm per minute.

AVAPS Web Site wrote:The algorithm calculates the change in pressure needed to achieve the target tidal volume then slowly increases or decreases the IPAP pressure to achieve the proper pressure support.
________________________

...the algorithm slowly increases or decreases inspiratory pressure for each breath (0.5 to 1 cm H2O/min) in order to achieve the preset tidal volume.

<snip>
SWS Thanks for that correction. I had always assumed the adjustment was quick. So much to learn

DSM

I find that a lot of my learning happens when I read - including reading companies' description of their technology - as for instance, Respironics' description of the way AVAPS responds. Actually, reading source materials (e.g. the AVAPS web site) keeps me from some of the wrong assumptions I might make otherwise. Well said, dsm: "So much to learn" .

O.

Went to see the doc. He read the report and said definitely BiPAP. I asked for copies of the PSG and the CPAP titration and said they would mail them to me as soon as one of the two docs who are sleep specialists review the report and sign off. I asked about BIPAP AVAPS and he was amenable because the titration showed (he said) 121 CSAs. I asked him about OSAs and he couldn't find a listing for OSAs. The 121 apneas went down to 20 with a bi-level pressure of 21/16 (what does that mean?") and lots of hypopneas (30 was a number but I don't know if it was before or after.)

We talked about FSHMD and sleep apnea and he said basically, the brain wasn't sending a signal to the diaphragm or the signal was too weak. He agreed that long term it would be better to have the volume support. I then talked to the RT who couldn't find a set of OSA/CSA numbers. I gave him the machine name and he said as soon as they have sign-off from the sleep specialty doc they would order the machine.

So, I called the DME and asked if they had any and was told they don't deal with that machine but if it was ordered she would try to get me to someone who does.

Oh well, more hurdles.

rogelah wrote: bi-level pressure of 21/16 (what does that mean?")

That would mean 21 cm H2O of pressure for inhale, 16 cm for exhale. That 5 cm of difference would be the amount of pressure support.

It's a rare machine, so I wouldn't consider that a hurdle.

Depending on the experience of the pulmonologist, it might not hurt for a cardiologist to see your study results, too, imo.

After meandering through the myriad of Medicare documentation, I found one called L5023 for Restrictive Thoracic Disorders that covers progressive neuromuscular disease. It allows the doctor to prescribe a BIPAP with timed backup or without as his choice.

It also covers severe COPD and CSA where centrals and hypopneas are 50% or more of the total apneas.

The RT from the pulmonology department called to say that the BIPAP titration had been read by one of the two sleep specialists and he was concerned that my total apneas had gone up from 60 from the PSG to 119 during the BIPAP titration. He said they want to do a VPAP titration to determine things like EEP, IPAP (sub max), IPAP (sub min) and EPAP. I asked if this would include titration for tidal volume (target). I also asked if they had Auto SV in mind. He said that the RT at the sleep lab had made such a notation but the sleep specialist had crossed it off.

At this point can someone please elucidate me as to what they might be doing besides handling this whole thing badly? For me, going to the sleep lab is not a problem. But, I am in a wheelchair and use a hydraulic lift to get in and out of bed. Even if I schlepped the lift with me there is insufficient space in the bedroom to use it. It takes two RTs to manhandle me; a situation that is not high on my list of exciting things.

Rogelah, do you have the option of another or other sleep labs? It may be that it is time to lay your cards on the table and flat tell them how you feel about this situation and what you learned

Medicare documentation, I found one called L5023 for Restrictive Thoracic Disorders that covers progressive neuromuscular disease. It allows the doctor to prescribe a BIPAP with timed backup or without as his choice.

It also covers severe COPD and CSA where centrals and hypopneas are 50% or more of the total apneas.

You don't want to get that good sleep tech in trouble BUT since it was the pulmonary department's RT who told you

that the RT at the sleep lab had made such a notation but the sleep specialist had crossed it off.

I would be sorely tempted to bring THAT up too.

Your experience just reinforces my personal opinion that the RPSGTs are the true heroes of sleep medicine (and they are the ones who are NOT considered "medical" personnel - SNORT!). These sleep doctors really don't seem to have a good handle on reading PSGs, like they gorge to get the certification and then purge everything they studied to get that certification. What the hay, let the RPSGTs do the scoring and then just initial the results. There ARE exceptions, of course. But ....

By the way, I'd be inclined to diplomatically lay all this on the sleep lab MANAGER thereby allowing the sleep doctor to "save some face" yet let the sleep lab manager get it across to the doctor that he needs to shape up and be more diligent regarding your care and maybe even actually give some credence to the RPSGTs PSG experience. The doctors don't do the PSGs, the RPSGTs do.

I have run into this problem before and I am not shy about speaking my mind. As I have related previously, although FSHMD is the third most common muscular dystrophy, Duchenne is number one, I am usually the first MD patient my doctors have seen. Add to that, the pulmonologist I see, while being the department head, is not a sleep specialist. I have asked that the sleep specialist call me when he reviews my VPAP titration and explain to me what it tells him and what he recommends. If necessary, I will educate him too. Who knows, I may get an education. I'll keep my mind open to his results until I hear them.

rogelah wrote: The RT from the pulmonology department called to say that the BIPAP titration had been read by one of the two sleep specialists and he was concerned that my total apneas had gone up from 60 from the PSG to 119 during the BIPAP titration. He said they want to do a VPAP titration to determine things like EEP, IPAP (sub max), IPAP (sub min) and EPAP. I asked if this would include titration for tidal volume (target). I also asked if they had Auto SV in mind. He said that the RT at the sleep lab had made such a notation but the sleep specialist had crossed it off.

At this point can someone please elucidate me as to what they might be doing besides handling this whole thing badly? For me, going to the sleep lab is not a problem. But, I am in a wheelchair and use a hydraulic lift to get in and out of bed. Even if I schlepped the lift with me there is insufficient space in the bedroom to use it. It takes two RTs to manhandle me; a situation that is not high on my list of exciting things.

rogelah,

I think in your case (like so many of our cases) you are being experimented on because the situation isn't really straight forward. The experimentation part is a fact of life, the frustration to you is also. At least by making the people involved aware that you are researching this yourself, it should help both them and you discuss what is being done.

The two aspects of this you need to hone in on (if you haven't already) are 1) the need for volume ventilation vs 2) the benefits of pressure ventilation.

On the surface of it (qualified by my non medical background) it seems some form of volume ventilation (where the machine has a target tidal volume set) is the likely outcome.

PS Both Resmed and Respironics have a range of ventilators that can be set to volume modes
BUT it is not clear to me if the Resmed units are avail in the USA. (Elisee xxx, VS III, VS Ultra)

Resmed (See Pressure & Volume Ventilators) = http://www.resmed.com/au/products/venti ... clinicians

Respironics (Home Ventilation) = http://homeventilationfamily.respironics.com/
Respironics (Clinic Ventilation) = http://plv102.respironics.com/

DSM

rogelah wrote: . . . asked if they had Auto SV in mind. He said that the RT at the sleep lab had made such a notation but the sleep specialist had crossed it off . . .

I may be confused, but I believe the machine ozij and -SWS was referring to was the BiPAP AVAPS by Respironics, right?

jnk wrote:

rogelah wrote: . . . asked if they had Auto SV in mind. He said that the RT at the sleep lab had made such a notation but the sleep specialist had crossed it off . . .

I may be confused, but I believe the machine ozij and -SWS was referring to was the BiPAP AVAPS by Respironics, right?

No JNK you are not confused. I understand that the consensus here at cpaptalk is that AVAPS with ite hybrid-volume ventilation 'may' be a smarter choice than a Vpap Adapt SV or a Bipap Auto SV.

What I understand Rogelah is telling us is there are multiple opinions among the people dealing with him. The sleep specialist appears to share our thinking & struck off the Bipap Auto SV.

DSM

#2
My guess is that either this http://www.resmed.com/au/products/elise ... clinicians
or this, http://bipapavaps.respironics.com/
will do the job.

But am no respiratory expert by any measure.

D

rogelah wrote:At this point can someone please elucidate me as to what they might be doing besides handling this whole thing badly?

Sorry about all that difficulty, rogelah. That is frustrating! But I'm not so sure that your clinicians are handling the situation badly. Rather, your case entails a more complicated etiology than usual. And unfortunately that is going to take much more work on your part and the clinicians' part to methodically arrive at an optimum pressure/volume RX.

If you had vanilla OSA, and nothing more, then you really should expect to be in and out of the PSG in only one or two visits (split night study versus dedicated titration night). The fact that your central apnea component elevated with BiLevel presents a modality and titration challenge. And that's undoubtedly why the RT at the sleep clinic initially thought of Adapt SV. However, the fact that you seemed to require a high EPAP or EEP additionally suggests the possibility of significant mass that needs to be stented. Then central timing and volume insufficiency likely enter the picture because of your neuromuscular disease. And if significant obesity is also present, an additional tendency toward hypoventilation can occur for that reason as well---more so in cases of neuromuscular dyscontrol or weakening.

Some etiologic components can fare better with low pressures while others fare better with high pressures. Similarly, coexisting etiologic components can literally compete for a favored or specific treatment modality as well. Therein lies the crux of your somewhat unique titration challenge: clinicians must now present your physiology with a much more robust variety of pressure-and-volume treatment protocols and challenges. That methodical trial-and-error clinical process is necessary toward finding out exactly which treatment modality, target volume, and pressure(s) are optimal for your particular dynamic constellation of respiratory issues. Unfortunately, that methodical trial-and-error clinical procedure can take multiple visits to the lab in some of the more complicated cases such as yours. At least that is my understanding.

I would strongly suggest that you give the clinicians the necessary opportunity to continue pinning down that optimal RX. I think it will pay dividends in the long run. Hang in there!

Thanks SWS. While the sleep lab is part of the pulmonary department, the sleep lab is in a nearby motel (which makes it conducive to sleeping comfortably). The sleep lab is manned by RRTs who have other jobs as RRTs and provide the coverage at night for the studies. The RRT who reviews test results and is a full-time employee and IMO ferries the results to the pulmonary department for subsequent review by one of the two sleep specialist doctors (one of whom is the director of te sleep lab). The specialist decides what comes next. If another test/titration is needed a secretary/scheduler calls. If an xPAP is the result, the prescription is given to another RRT who sends it to the DME.

The scheduler has the same mantra regardless of reason for the test..."I need to schedule a followup in 6 weeks and be sure to bring your machine." There are some things that IMO could be better (like replacing Sgt. Schultz, the gatekeeper/scheduler with a kinder, gentler personality.)

What has been missing to me is a smoother flow. IMO, I am constantly being confronted by Sgt. Schultz demanding a detailed explanation of why I need to talk to my doctor, the RRT, etc.

In any event, I am again scheduled for this coming Monday night. By the time this is all over I may have enough materal o write a book called Confessions of A Sleep Lab Zombie.

A highly disjointed process for sure, rogelah. And bribing Sgt. Schultz with desert probably won't help this time.

This message board has proven, time and again, that a well-informed patient can be a highly effective self-advocate or case manager. Unfortunately your case will take some methodical clinical trial-and-error, and that over-compartmentalization is frustrating just to read about. So I can only manage a vague inkling of how much it might very understandably annoy you. I would definitely try to get rational feedback to them, hoping they can somehow better integrate their intraorganizational processes.

It's bad enough when the right hand doesn't know what the left hand is doing... but you seem to be dealing with a dysfunctional organizational octopus there.

I returned from the VPAP titration and promptly fell asleep for 5 horus. Must have been the RT's parting comment,"He wasn't impressed by the ResMed Adapt SV's performance. This is the same RT who told me at 10 pm that this was the machine that would finally tell them what pressure or range of pressures I needed. "I only have to adjust it so that your airway is open and it does all the rest" or some words like that. "IMO", he continued, after telling me the machine was unimpressive, "your BIPAP titration was a better result."

They finally mailed me my summaries from the PSG and the BIPAP titration. Below is a list of the results (the numbers in parentheses are from the PSG.)

SLEEP ANALYSIS
Total Sleep Time in Minutes 252 (172)
Sleep Efficiency Index in % 70 (42)
Sleep Latency in Minutes 13 (16)
REM Stage Percentage 17 (9)
REM Latency in Minutes ? (80)
Stage 3 & 4 Percentage ? (10)
Arousal Index 71 (32)

SLEEP DISTURBANCE PARAMETERS
Total Apneas 119 (20)
Total Hypopneas 44 (154)
Respiratory Effort Related Arousals 45 (49)
Respiratory Effort Related Arousal Index 11 (17)
Apnea Index 28 (7)
AHI 39 (60)
Lowest Oxygen Saturation 75 (74)
PLMs 23 (0) (Mattress was the pit, literally)
PLM Index 0 (0)

Cardiac Dysrhythmias None (None)

Additional info from PSG s summary.

RESPIRATORY PATTERN
Central Apneas 0
Mixed Apneas 0
OSAs 20 (average length 42 seconds, longest 69 seconds)
Hypopneas 154
AI 7
AHI (supine position) 61
AHI (REM Sleep) 66

Comments gratefully solicited.

Rogelah,

Sorry to hear it went so poorly

Based on the comment you have reported back, I am thinking the RT may not really understand the Vpap Adapt SV & what it was supposed to do allowing for your condition.

A worry not sure what else to say that is positive.
That original sleep data looks pretty poor. The desats are a big worry let alone the AHI. But the PSG numbers at the bottom do show a big improvement other than the hypopneas ?

DSM