ResMed VPAP Machine Family Tree

jnk · Post by **jnk** » Tue Jun 30, 2009 6:24 pm

-SWS wrote:Haven't seen Muffy a.k.a. StillAnotherGuest

I've been missing the SAG-a-Muffin myself. Is there any way to bribe/lure him/her here?

I'm confused. Is it that the docs/RTs don't want to try the AVAPS thing, or is it that insurance dictates what is tried in which order, or is that part of the great unknown, or did I just miss that part of the discussion and need to reread more carefully?

Sorry to ask a silly question, but I got lost, somehow. (It happens.)

-SWS · Post by **-SWS** » Tue Jun 30, 2009 6:40 pm

jnk wrote:
-SWS wrote:Haven't seen Muffy a.k.a. StillAnotherGuest
I've been missing the SAG-a-Muffin myself. Is there any way to bribe/lure him/her here?

I'm confused. Is it that the docs/RTs don't want to try the AVAPS thing, or is it that insurance dictates what is tried in which order, or is that part of the great unknown, or did I just miss that part of the discussion and need to reread more carefully?

Sorry to ask a silly question, but I got lost, somehow. (It happens.)

If this thread continues on it's particularly intriguing path, I think Muffy's going to show.

As to why the doctor doesn't want to try AVAPS just yet. Ozij dropped an excellent off-the-cuff comment in an email. And I'm sure she won't mind my mentioning it, since it really is an excellent point. Her comment was that the doctor has all the current information at his disposal. This is one of those areas in medicine where the "art of medicine" becomes increasingly important since the "science of medicine" seems to be empirically lacking. So the doctor essentially needs to be the one practicing the art of medicine here IMHO. For all we know he may be spot-on, given all the medical facts at his disposal.

So it will be very interesting to see how this whole thing shapes up. In the mean time, we get to collectively learn, discuss, and offer rogelah our support.

jnk · Post by **jnk** » Tue Jun 30, 2009 7:33 pm

Artistic science, or scientific art--as long as it all lands in the right spot.

Thanks, that helps, -SWS!

rogelah · Post by **rogelah** » Wed Jul 01, 2009 12:46 am

Once more into the breach...

I went to a pulmonologist complaining of difficulty breathing when lying in bed and awake. I'm either in bed or in a wheelchair and sometimes when I am in bed I am asleep. I had been told in my 40s that there were 3 things I should be aware of that might occur to me with FSHD. One was calcification of the blood vessels at the back of the eyes for which I have regular examination by an ophthalmologist. Two was trouble swallowing; my regular doctor takes care of that with a tongue depressor. Three was trouble breathing.

The trouble breathing was something I noticed along with instances of what I have come to recognize as muscle weakening (dystrophy) in my upper body with instances involving my intercostals, a new site.

X-rays were done and nothing noted that would account for breathing problems and the pulmonologist exclaimed it was probably sleep apnea, something, I confess, I had never heard or read about. At no time did the lung guy suggest a consult with my neurologist who is on the staff of the same institution.

He wanted to do a PSG at which I balked. My degree is in Cellular Physiology (called Cell Biology today) and I insisted on an overnight oximetry test and spirometry. The oximetry showed definite desaturation below 88% for extended periods of time and the spirometry showed less than 50% of FVC. Couple this with shallow and short breathing, even when awake, and it should indicate muscle weakness as a high probability for an FSHD patient.

So, now I thought, I had his attention and scheduled the split night PSG CPAP titration. When I went for followup a week later, he pointed excitedly at a piece of long and narrow graph paper with squiggly lines resembling proof of an earthquake and exclaimed, "See, you stopped breathing fo 60 seconds not once but twice in a row!" Now he had my attention.

Of course the CPAP titration had failed because of a lack of my mask size. He wanted to schedule another CPAP titration. I was not enthusiastic about being manhandled by RTs who have no training in moving patients from wheelchair to bed and back to wheelchair and was still sore from the PSG with contusions to my skin wherever their fingers happened to grab.

He ordered a ResMed Autoset II because it could figure out right pressure. Three weeks later using it every night, I still had morning headaches, was not feeling rested and just wanted to sleep allday. I called; he ordered a BIPAP study; I went; RT ran a CPAP and was surprised when I told him I was there for a BIPAP. He blamed it on the lung guy saying he was not a sleep specialist.

So, he changed io a BIPAP titration and I went home excited. No headache. No feeling sleepy. I felt rested. We had found the Holy Grail! It was BIPAP! Imagine my surprise when they called to schedule a VPAP titration instead of telling me I was getting a BIPAP.

The VPAP quieted the OSAs evident on the BIPAP titration as markedly increased. Hypopeas are still up. RERAs were essentially the same. Oxygen desats were still low. Now he wanted to continue at home with a ResMed Adapt SV. I had had enough.

You know the rest. I think the lung guy is out of the picture because the orders he wrote confused the RTs and the sleep specialist is trying to figure out from the results they got how to get to the right place without starting over.

Thte reason I got out of cellular physiology years ago is because I was working with a group of MDs who were trying to discover some miracle in DNA. They were jealous of each other and secretive in their work to the point I couldn't function. Thank God I had taken a course in computers...it proved a lifesaver.

ozij · Post by **ozij** » Wed Jul 01, 2009 3:09 am

ozij wrote: If it were me I would want to understand:
What the doctor finds so confusing about my data?
How my diminished breathing capacity could effect the scoring of central vs. obstructive hypopneas (were both PSG and BIPAP titraton scored by the same persons?

Guess my thinking capacity is OK, since:

-SWS wrote: http://www.mda.org/publications/Quest/q152sleep.html

Sleep studies valuable? ...

When respiratory muscle weakness causes nighttime breathing problems, it doesn’t take a polysomnogram to diagnose it, says John Bach, a physical medicine and rehabilitation specialist at University Hospital in Newark, N.J.

In patients with neuromuscular disease, Bach determines the need for ventilatory therapy by assessing symptoms and measuring exhaled carbon dioxide and vital capacity while the person is sitting and lying down. If those measurements don’t yield useful information in the clinic, he has patients do them at home overnight.

Patients showing signs of hypoventilation should be offered a trial of nocturnal ventilation, Bach advises, “and if they feel better using it, let them do so.”

Bach questions the usefulness of polysomnograms for people with muscle diseases because the test “interprets all abnormalities as central or obstructive apneas rather than muscle weakness,” he says — especially when read by physicians unfamiliar with neuromuscular disease.

This misdiagnosis then leads to improper treatment, he says.

rogelah wrote:So, he changed io a BIPAP titration and I went home excited. No headache. No feeling sleepy. I felt rested. We had found the Holy Grail! It was BIPAP! Imagine my surprise when they called to schedule a VPAP titration instead of telling me I was getting a BIPAP.

I'm relieved the sleep doctor no longer thinks of an ASV.

jnk wrote:I'm confused. Is it that the docs/RTs don't want to try the AVAPS thing, or is it that insurance dictates what is tried in which order, or is that part of the great unknown, or did I just miss that part of the discussion and need to reread more carefully

?

I think the reply to this confusion is here:

rogelah wrote:I am also suspicious of a possible linkage in the Lab to DME to ResMed triangle.

Thas is my suspicion too.

Now:
You've got an Rx for a timed bi-level machine - make sure you have it your hands. You felt great after the BIPAP titration.
Maybe a bi-level S/T will do the job for you, and by the time you need something else, you will have more choice in volume controlling machines.

Alternatively:
I would find out if the Respironics BIPAP AVAPS has a different insurance code from the any other BIPAP /ST.
I would ask my insurance about direct reimbursment on of what I buy.
I would ask cpap.com if a the presnet Rx is good enough for me buy an AVAPS with.
And depending on the reply -- and my means -- I would buy an AVAPS.

Even if I did not need a new Rx, I would try to get the lung doctor and neurologists support for an AVAPS, since that one can handle both your suspected sleep apnea, and hypoventilation. Unlike the sleep doctors, these two are your long term doctors -- I think they will be happy to help you get the more sophisticated machine once they understand how it can bridge both their specialty and sleep apnea.

Here's to hoping you'll have a bi-level machine soon, giving you the treatment you need.

O.

ozij · Post by **ozij** » Wed Jul 01, 2009 3:39 am

SAG-a-Muffin
Left his shaddow waitnin' down the road for us a while....

jnk · Post by **jnk** » Wed Jul 01, 2009 9:00 am

I wonder how often it occurs that the RT reads the info about the home "sleep" machines, sees one that may be best for a particular patient for reasons not directly related to sleep, but then isn't in a position to have much influence on the thinking of the sleep doc because of professional-courtesy lines? I also wonder if inexperience in a particular area sometimes makes it a matter of which company-man, ResMed or Respironics, happens to be most accessible to a team?

Hopefully the doc heading the team is a humble man who is willing to think outside the boxes (or blowers, in this case) and try a few things. I think it would be cool if a few different rental machines from each company could be tried for a few weeks as part of the diagnostic/treatment routine, if there is no direct protocol but the titration translates well.

But I've always been a dreamer.

Anyway, it is nice that so many good links about so many different machines have been posted.

-SWS · Post by **-SWS** » Wed Jul 01, 2009 12:37 pm

ozij wrote: Guess my thinking capacity is OK, since:

Your predicted caveat was spot-on IMHO.

I discovered that Quest article only a few minutes before I posted it in this thread (please see edit below). When I saw the article mention PSG scoring and diagnosis can be easily misinterpreted in muscular dystrophy cases, I thought that may very well be what happened here: rogelah's doctor may have scored the PSG and diagnosed with an upper-airway apnea mindset, rather than a neuromuscular weakness paradigm. And as the Quest article alluded, that upper-airway apnea-minded diagnosis yielded a CPAP that would not work well with muscular dystrophy.

ozij wrote: And depending on the reply -- and my means -- I would buy an AVAPS.

I would definitely try to have that extra "volume assurance" feature in my bag of possible tools or options to rely on----since this is largely a volume problem IMO. Normalize volumes to address any erratic or sustained hypoventilation (due to muscular weakness typical of MD), and then provide a nice back-up rate to take care of any secondary central apneas as well.

Some or most of those secondary central apneas may clear by reducing the Work Of Breathing (WOB) and getting flow volumes consistently under control (both objectives accomplished via an optimal combination of low EPAP/high-PS/shorter-rise-times). That, in turn, may obviate heavy reliance on the backup rate. If (and only if) there really are upper-airway obstructions to stent, then that EPAP value will have to be very carefully increased.

__________________________________________________________________________________________________________________________________

on edit: Oops.. I see rogelah first published the above Quest article only a couple weeks ago in this post.

DesertRat · Post by **DesertRat** » Wed Jul 01, 2009 6:12 pm

dsm wrote:Rogelah

I am a NEW user to ResMed ASV but a 5-yr user of C/VPAPs. I am unable to deal with the 'dragon' - huffing & puffing
for 60-90 minutes (NOT 3 minutes as the Reps fantasize) until it finally 'learns' MY breathing pattern. I feel that Ii am participating in a 'beta-test' for the machine while paying huge fees for the priviledge. Where is the Ramp feature, where are some of the other settings that have been available in simple CPAP machines for years, and how about the filling instructions for the humidifier water tank - prehistoric! I am tired from inability to sleep because of this HUGE machine. Has anyone experienced similar problems - or - does anyone have solutions for the issues I am experiencing? I really do need a success here.

In support of the added posts, the ability of the Bipap AutoSV to adjust risetime, seems to me to be a great tuning tool for working out what is best in your case.

The Vpap AdaptSV is very good at what it specifically targets, but has no (none) adjustment for risetime & I believe the designers did this because it simplified the whole SV mechanism, but I sure wish I could vary the rise time in my one. My complaint is that it is always very fast & creates mask leaks that can be hard to manage. The Vpap AdaptSV is known to be leak intolerant.

Because the Bipap AutoSV can be set up as a Bipap S/T it has all the adjustments needed to run it just like one. Such a choice gives your doctor a wider range of options.

Good luck.

DSM

-SWS · Post by **-SWS** » Wed Jul 01, 2009 6:32 pm

DesertRat wrote: I am unable to deal with the 'dragon' - huffing & puffing for 60-90 minutes (NOT 3 minutes as the Reps fantasize) until it finally 'learns' MY breathing pattern.

I can't be certain what the reps described when they mentioned 3 minutes. But the 3 minutes we have been discussing in this thread specifically describes a moving time-window for patient flow averaging and targeting.

When you talk about your ASV initially "huffing & puffing" for 60-90 minutes to learn your breathing pattern, you are referring to something altogether different: the ASV's "adaptation phase". However, that adaptation phase supposedly takes the Resmed ASV 40 minutes, but usually far less. So if the ASV adaptation phase takes a good 60-90 minutes in your case, then perhaps you're having recurring problems with mask leaks. That ASV model is extremely sensitive to mask leaks. Also remember to run the ASV's Learn Circuit routine whenever you change masks, humidifiers, or anything else that affects the flow resistance of your pressure delivery circuit.

I would also point out that the Respironics brand AutoSV is supposed to be much more tolerant to mask leaks. Also that model does not have a machine "adaptation phase" either. If you're having trouble with the Resmed ASV features or algorithm, then perhaps you can talk your doctor into trying the Respironics near-equivalent. For some people who need servo ventilation, brand A seems to work better and for others brand B is the better choice:

kebsa wrote:the first machine i trialled actually made things worse not better despite it being a machine aimed at centrals- ir was a respironics, when i swapped to the resmed VPAP that i am still using i got great results instantly and the machine actually felt different to- obviously they algorithms in the 2 machines are very different and i wish i understood all this stuff well enough to work out why the difference- the DME techs i was sealing with said that some people with centrals did better with the respironics while others like me did bettter with the resmed

Good luck, DesertRat!

rogelah · Post by **rogelah** » Thu Jul 02, 2009 11:19 am

Replacement machine delivered. It is a ResMed VPAP III ST. Settings are:

Mode: ST
IPAP: 19.0
EPAP: 14.0
Resp Rate: 10
Rise Time: 300ms
IPAPmax: 2.00s
MAX I:E: 1:2
IPAPmin: 0.10s
Trigger: MED
Cycle: MED

And a cryptic PCB: none

Besides the IPAP and EPAP any thoughts on the others?

Called the DME.She said prescription was 14 EPAP, 19 IPAP and backup rate 15. I asked her who sets the machine up. She said the technician who delivered it. Well, he flunked. He brought a VPAP III ST (used for 416 hours) and manuals for an Adapt SV. I know he didn't set anything except IPAP and EPAP because I watched as he made the settings.

Now, anybody got any suggestions for the other settings so I don't blow m head off?

dsm · Post by **dsm** » Thu Jul 02, 2009 3:27 pm

rogelah wrote:Replacement machine delivered. It is a ResMed VPAP III ST. Settings are:

Mode: ST ### Yes
IPAP: 19.0 Seems highish but allowing for neuro-muscular disorder this may be typical ?
EPAP: 14.0 Once again, to me seems highish unless you have a significant OSA component
Resp Rate: 10 Shouldn't it be 15 ?
Rise Time: 300ms This is a normal for starting off. Fast Risetime=150 & Slow Risetime=900
IPAPmax: 2.00s A normal setting. (This setting relates to proportion of time spent inhaling).
MAX I:E: 1:2 The max inhale/exhale ratio
IPAPmin: 0.10s
Trigger: MED This is the sensitivity of the epap to ipap triggering. An adjustment feature added to the latest Vpap III models.
Cycle: MED This is the sensitivity of cycling (ipap to epap). Also an adjustment feature added to the latest Vpap III models.

And a cryptic PCB: none (added :3) I believe this refers to the printed circuit board = PCB and I think indicates its level).

Besides the IPAP and EPAP any thoughts on the others?

Called the DME.She said prescription was 14 EPAP, 19 IPAP and backup rate 15. I asked her who sets the machine up. She said the technician who delivered it. Well, he flunked. He brought a VPAP III ST (used for 416 hours) and manuals for an Adapt SV. I know he didn't set anything except IPAP and EPAP because I watched as he made the settings.

Now, anybody got any suggestions for the other settings so I don't blow m head off?

PS Here are links to the clin manuals
http://www.internetage.ws/cpapdata/manu ... %20usa.pdf
http://www.internetage.ws/cpapdata/manu ... 20(cd).pdf

DSM

2: PS - weren't you doing ok with an epap of 9 in earlier sleep studies ???

rogelah · Post by **rogelah** » Fri Jul 03, 2009 10:55 am

Changed RR to 15 (prescription value).
On machine 5 hours.
Leak rate 68 L/hr.
VT: 0-800.
Resp Rate: 0-29.
MV: 0.0-19.8.
AHI: 19.8.
AI: 1.0.

Notes:
Super dry mouth even with humidity control on 7. A semi-dried coating of phlegm in upper airway. Excessively dry tissues between cheeks and gums. Mild soreness at back of throat.
Trouble keeping bottom of mask sealed. Tightened lower straps but mask digs into face,
Lay awake for another hour. Fell asleep, without mask, and slept almost another 6 hours.

rogelah · Post by **rogelah** » Fri Jul 03, 2009 12:42 pm

There is only a 9 pin connector on the rear. How does one obtain detailed data?

dsm · Post by **dsm** » Fri Jul 03, 2009 8:19 pm

rogelah wrote:There is only a 9 pin connector on the rear. How does one obtain detailed data?

Rogelah

There are two sockets at the back of the Vpap III

1 = the Reslink module connector & is similar to a VGA computer screen socket.
2 = a serial port. Obtain a null modem cable (9-pin female to 9-pin female)

PM me re how to read the data from the serial port.

Cheers DSM
(this is pretty straight forward but you do need a PC or laptop that has a 9-pin serial port & that runs Windows 2000 or Windows XP (avoid Vista like the plague - MS are about to release Windows 7.0 which is their attempt to clean up their disastrous Vista).

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