Who needs auto machines?

Bill,

I guess I just can't see the lack of APAP mode as any limitation in the machine allowing for what it was designed to do.

It has AUTO capability (for both IPAP & EPAP), it has BiLevel capability, it has BiFlex as an added feature.

Lets look at the BiLevel aspect. I believe it is fair comment to say that BiLevel is regarded as the best form of relief to offer patients on xPAP. Relief in the sense of comfort. The problem in the past has always been the cost associated with adding the extra intelligence & plumbing to deliver BiLevel.

The early BiLevel machines were very big compared to the same generation of CPAP machines.

It is probably also fair to say that the biggest threat to CPAP therapy compliance by a patient is the discomfort associated with the therapy. There are several discomforts but some are worse than others. The hope of the therapy is that patients will clearly see that the problems of not sustaining the therapy are greater than the discomforts. It is a balancing act. As the machines improve & the cost comes down, the designers are tipping the balance in the favour of comfort for the user.

Looking at the obvious discomforts ...

- Having to don a mask to go to sleep
- Breathing out against a pressure
- The problems of fitting a mask such that it avoids pain/leaks/squeaks etc:
- The noise of the therapy (machine & mask air noise)
- The side effects we each experience such as
o Swallowing air
o Chest pains

I believe that if the list were prioritized the #1 issue would be the breathing out against pressure and its side effects which flow into most of the other points

Logically the more the designers can do to ease the breathing out pressure the more the balance of comfort shifts to the users.

Coming back to the BiLevel, it as best as I can tell is #1 in offering the chance to be compliant & remain so.

This leads me to say that an AUTO mode that keeps IPAP 3+ cms away from EPAP if that is what is needed to get an AUTO BiPap to function effectively then why add APAP mode as is already available in the AUTO machine.

I guess I am coming from the perspective that the designers of the Remstar BiPap have produced a remarkable machine and that a straight APAP mode as is in the AUTO machine serves no purpose.

Cheers

DSM

RG,

Agreed

DSM

rested gal wrote:An auto-titrating machine compensates some for leaks, but nothing takes the place of a good fitting mask for handling leaks.

That's a very important point but not completely true.

APAP can compensate for leaks because it has a pressure sensor which
is needed for event detection algorithms.

On the other hand CPAP can also have pressure sensor, although not as
necessary, and there are many CPAPs with leak compensation functonality.

Another advantage of having a pressure sensor is automatic altitude
compensation. You will observe that xPAPs with leak compensation can also
compensate for altitudes automatically.

Ergin wrote:

rested gal wrote:An auto-titrating machine compensates some for leaks, but nothing takes the place of a good fitting mask for handling leaks.

That's a very important point but not completely true.

Ergin, what part of that quote from rested gal isn't completely true?

Anonymous DSM wrote:I guess I just can't see the lack of APAP mode as any limitation in the machine allowing for what it was designed to do.

DSM, you're probably right, generally. However, based upon my own experience, after thinking about this a little while, I believe there are exceptions worth bringing up.

Bi-level breathing is quite different from the normal breathing experience in the same way that C-flex is different from the normal breathing experience. Now, many, perhaps most, folks take to C-flex immediately and describe it in glowing terms. But, just reading through the posts here, people choose varying degrees of C-flex. Many folks, either don't like, or don't derive optimum benefit from C-flex level 3 and choose one of the lower levels. My guess would be that some of these same people would also prefer CPAP to BiPAP for the same reason, and, similarly would prefer APAP to Auto-BiPAP for those very reasons (whatever they are). C-flex level 3, after all, provides the most exhalation relief on a straight CPAP, but not as much relief as BiPAP does. Some folks don't even like C-flex at all. (I suspect I'm in that category, but I am willing to come back and give it a try again after I've sorted out some other things going on with my therapy.)

Regards,
Bill (not being argumentative, just trying to reason things through)

Time, once again, to correct an earlier error I made.

The Auto-BiPAP has four modes, but I listed them incorrectly earlier. They are:
1) BiPAP
2) BiFlex
3) Auto-BiPAP
4) Auto-BiFlex

The nuances of operation determine how they can be used, so I'll just state a couple of things about that. In BiPAP mode, EPAP can be set equal to IPAP, hence CPAP operation can be achieved in the non-Auto modes. In Auto modes IPAP must be at least 3 cm higher than EPAP, hence operation identical to APAP cannot be achieved with the Auto-BiPAP.

Hopefully my earlier post didn't cause anyone too much confusion.

Regards,
Bill

From a previous thread on this topic:

Anonymous wrote:This autotitrating BiPAP will automatically adjust the EPAP/IPAP spread (on an as-needed basis). It will adjust that EPAP/IPAP spread between the boundaries of 0 and whatever PS Max happens to be set at.

These two objectives will balance how that EPAP/IPAP spread fluctuates on-demand:

1) comfort,

2) obstructions to address during expiration requiring a pressure that converges with the pressure required during inspiration

Addressing crucial obstructions will obviously take algorithmic priority over comfort. Think of the EPAP/IPAP spread as fluctuating or being a variable. that variable is simple PS resultant. That fluctuating "PS resultant" value will be limited by a hard-coded PS Min value of zero, and a user-set PS Max value between 3 and 8 cm.

Anonymous wrote:Setting EPAP=IPAP while this machine is in traditional BiLevel mode will allow this machine to run as a straight CPAP machine. PS Max is not a limiting parameter in traditional BiLevel mode. PS Max is available only in AutoBiLevel mode or AutoBiLevel mode with BiFlex.

Setting this machine up in AutoBIPAP mode, without BiFlex mode, and a PS Max of 3 cm is as close as this machine is going to get to a conventional AutoPAP. Setting this machine up in AutoBiPAP mode, with BiFlex mode, and a PS Max of 3 cm is as close as this machine is going to get to running like a REMstar Auto with C-Flex.

Rested Gal" wrote:An auto-titrating machine compensates some for leaks, but nothing takes the place of a good fitting mask for handling leaks.

Egrin wrote:APAP can compensate for leaks because it has a pressure sensor which is needed for event detection algorithms.

APAP can compensate for leaks up to a certain point as Rested Gal mentioned. However, when a leak's magnitude outstrips an APAP's ability to pressure-compensate, then all bets are off by the way of sleep event detection and a correct pressure response.

That is precisely why APAP data sets incorporate a way of reflecting when the leak is too large. The Respironics Encore Pro data set identifies excessive leaks as "large leaks". The Silver Lining 3 data set by PB reflects excessive leaks by graphically depicting a red "leaks" line juxtaposed agains a purple "leaks max" line. That purple "leaks max" line can be thought of as a "maximum allowable leaks" level.

I agree that a well-fitting, comfortable, unobstrusive mask is the most important aspect of compliance, but so is the prescribed pressure. If a newbie is slapped with anything above say 12 on a CPAP the noise of the machine will be louder, the initial sensation of not being able to breathe or exhale at that pressure for even a few minutes, less 7-8 hours, can be very daunting, and cause the user to rip off the mask in a fit of claustrophobia and never put it back on again.

And let us not all forget that every machine has a ramp feature which helps the user get to sleep at a lower, more comfortable pressure. Sometimes these are set so low, the user feels as if they can get no air at all, but have to wait until they return to their DME or Dr. to get the lower pressure adjusted. But how many even call the Dr or DME to mention this. They think this is what they get, can't be changed and they'll have to live with it. So, they quit.

It seems to me that many Dr.s who prescribe CPAP are 1. going the cheap way, if they provide the machines themselves or split the profit from the cost of the machine and what the insurance will pay with the DME or 2. don't care if they see the patient more than once a year.

The DME will push the CPAP with the excuse that that is all their insurance will pay for, when they know darn good and well that the insurance pays one fee for any kind of machine. They are in it for the profit, so the cheaper the machine's cost, which comes with the hose, etc. for which they charge separately, they will make more money on a CPAP rather than a BiLevel or VPAP. Same thing applies to the mask. Insurance pays one amount, no matter what is charged.

I don't know how many times I've asked people why they didn't get X mask or an APAP or BiPap when they had very high pressures, and they were told that was all their insurance would pay for.

Does anyone know of an insurance plan/provider whom they have personally contacted that said they would definitely not pay for anything but a CPAP?

Janelle wrote:If a newbie is slapped with anything above say 12 on a CPAP the noise of the machine will be louder, the initial sensation of not being able to breathe or exhale at that pressure for even a few minutes, less 7-8 hours, can be very daunting, and cause the user to rip off the mask in a fit of claustrophobia and never put it back on again.

However, there are Respironics straight CPAP machines that offer C-Flex so there is exhalation relief provided. I agree, exhalation relief can make a big difference, but you don't need an APAP to get it. In fact no other APAPs besides the Respironics have an exhalation relief feature when used in auto mode. The ResMed S8 Vantage Auto has the EPR feature, but it can't be used in auto mode. Then there's the Puritan Bennett 420e which doesn't have any type of exhalation relief feature in any mode--cpap or apap. So if a newbie is slapped with anything above 12, a Respironics straight CPAP machine with C-Flex would be just the ticket to combat that problem.

My point was that newbies are forced to get a CHEAP CPAP, not one with CFlex, which some DME and Drs deny even exists. The patient has to know to ask for it and then convince a Dr. he needs it, because they don't carry that brand or model.