Changed me to the Resmed Vpap III

Today they took me off the Resmed s8 Elite and put me on the Vpap III. Remember I had mentioned all the problems with the sleep lab? Well my orginal pressure they had me on for the first time ever was 10 which I could hardly tell there was air blowing. The machine they had me on to test me again showed I needed to stay at an 18-20. Which I understand is quite a high number. They told me that it is possible I have "Central Apnea" which will require even a different machine they tell me.

Does anyone have an opinion on the Vpap III? I have until tomorrow to decide if I am going to give up my s8 or not. Unfortunately my s8 doesn't have the EPR which is the primary reason they put me on the Bipap. They have recomended a different sleep lab for me as well, I refused to return to the one that did pretty much nothing for me.

froger25 wrote:They have recomended a different sleep lab for me as well, I refused to return to the one that did pretty much nothing for me.

Good for you. There's a lot to be said for voting with your feet. Hope the next lab works out better for you.

Sorry, I can't provide any info on your other questions.

Regards,
Bill

Vpap III is the same shape as a S7 style xPAP.

There are 2 main models, the VPAP III S & VPAP III S/T. (I believe there is also a VPAP III S/T-A but I forget what the -A adds).

These are excellent BiLevel machines.

I believe I can predict that with the right settings, you will find this machine very easy to breathe with.

Ignoring all the complex medical reasons why some people are given BiLevels, there are just so many ordinary benefits for the non-complicated medical users, these include :-

- The reduction in extra exhalation effort which occurs with straight CPAP

- Better adherence to titration recommendations that with an AUTO & thus
better results

- Following the above point, this means *less* mask squeaks when we
breathe out as the pressure drops rather than compounds

- A BiLevel is like a big Cflex feature without the negative side effects

- By switching to a BiLevel, I personally got great reduction in the effects of
Aerophagia (burping & f*rting. The latter being more than just a PITB )

Good luck

DSM

_________________

CPAPopedia Keywords Contained In This Post (Click For Definition): cflex, aerophagia

froger25 wrote:Today they took me off the Resmed s8 Elite and put me on the Vpap III. Remember I had mentioned all the problems with the sleep lab? Well my orginal pressure they had me on for the first time ever was 10 which I could hardly tell there was air blowing. The machine they had me on to test me again showed I needed to stay at an 18-20. Which I understand is quite a high number. They told me that it is possible I have "Central Apnea" which will require even a different machine they tell me.

Does anyone have an opinion on the Vpap III? I have until tomorrow to decide if I am going to give up my s8 or not. Unfortunately my s8 doesn't have the EPR which is the primary reason they put me on the Bipap. They have recomended a different sleep lab for me as well, I refused to return to the one that did pretty much nothing for me.

froger, if I recall correctly, the autopap they used to "test" you again -- the machine that found you need "18-20" -- was an older model of autopap...the Virtuoso. If I'm not mistaken, the old Virtuoso is a snore-based auto, not a modern flow-based auto.

Before I would ever allow myself to be put on that kind of high pressure with any machine, even a bi-level, I would insist on another trial with autopap. But this time, using a flow-based auto...not an out-of-date snore-based machine.

If a trial with a modern autopap, like the Respironics REMstar Auto with C-Flex, or the ResMed S7 Spirit, or the ResMed S8 Vantage (works the same as the Spirit when both are in auto mode) shows that you do, indeed, need a high pressure most of the night, then the ResMed VPAP III bi-level machine would be a very good one. So is the Respironics BiPAP Pro 2. Either of those would be a good choice of bi-level machine and software is available for both those if you were interested in monitoring your own progress.

However, if a trial with a modern autopap showed that need a very high pressure only occasionally during the night, I'd want an autopap so that I could spend most of the night at lower pressures.

If it looked like high pressure was needed close to half the night, then I'd want one specific machine...the Respironics BiPAP Auto with Bi-Flex. That one is a combo machine that offers both specific setting relief for exhaling and the advantage of autopap's ability to vary the pressure as needed.

Bi-level machines are wonderful for exhalation relief if a person must use a pressure all the time or almost all the time that is higher than the person can be comfortable exhaling against. However, I would be seriously questioning whether I really needed the kind of high pressure they are about to saddle you with.

[quote"froger25"]Unfortunately my s8 doesn't have the EPR which is the primary reason they put me on the Bipap.[/quote]

I'm pretty sure that the S8 Elite, the machine you said they took from you, does have EPR. If the DME told you it doesn't, I'd be questioning that. If it was an S7 Elite, then it didn't have EPR; but the S8 Elite does, as far as I know.

dsm wrote:- Better adherence to titration recommendations that with an AUTO & thus better results

Not necessarily.
Different types of machines suit different people for different reasons, but to make a sweeping generalization that a bi-level machine, simply by virtue of being a bi-level machine, is going to give better results than an autopap is just not so, imho.

dsm wrote: Following the above point, this means *less* mask squeaks when we breathe out as the pressure drops rather than compounds

Not necessarily.
If a person is put on bi-level with an IPAP pressure of 19 or 20 as froger says they are planning to do, then the EPAP pressure, while lower, is STILL going to be quite high. I don't understand what you mean by "rather than compounds" - ?

rested gal wrote:

froger25 wrote: <snip>
froger, if I recall correctly, the autopap they used to "test" you again -- the machine that found you need "18-20" -- was an older model of autopap...the Virtuoso. If I'm not mistaken, the old Virtuoso is a snore-based auto, not a modern flow-based auto.

Before I would ever allow myself to be put on that kind of high pressure with any machine, even a bi-level, I would insist on another trial with autopap. But this time, using a flow-based auto...not an out-of-date snore-based machine.

Hi RG,

Just wanted to clarify your comment re 'snore based machine vs flow-based'

Actually both old and modern AUTOs are 'snore' based

To clarify, A snore sets up an oscillation in the airflow and the flow-sensors detect this.

What I believe you meant to say (as I know you know this topic inside out ) is 'snore sound' based AUTO vs 'airflow-sensor' based AUTO.

Cheers

DSM

rested gal wrote:
<snip>

I'm pretty sure that the S8 Elite, the machine you said they took from you, does have EPR. If the DME told you it doesn't, I'd be questioning that. If it was an S7 Elite, then it didn't have EPR; but the S8 Elite does, as far as I know.

dsm wrote:- Better adherence to titration recommendations that with an AUTO & thus better results

Not necessarily.
Different types of machines suit different people for different reasons, but to make a sweeping generalization that a bi-level machine, simply by virtue of being a bi-level machine, is going to give better results than an autopap is just not so, imho.

dsm wrote: Following the above point, this means *less* mask squeaks when we breathe out as the pressure drops rather than compounds

Not necessarily.
If a person is put on bi-level with an IPAP pressure of 19 or 20 as froger says they are planning to do, then the EPAP pressure, while lower, is STILL going to be quite high. I don't understand what you mean by "rather than compounds" - ?

RG,

I just realised that my list got out of seq (I added the 2nd point in after doing the list) so point 3 shd have applied to point 1.

Re point 2, what I was meaning to convey here was that a Bilevel allows the user to stick with their titration CMS on IPAP and to set a comfortably lower CMS for EPAP.

An AUTO set too low, is going to 'chase' apnea events and try to get on top of them and as we both really know, some AUTOs are slow at getting on top. Whereas a BiLevel that keeps IPAP at the titration level is largely already on top of the events before they occur rather than after.

I do agree with you that point 3 in the sequence I accidentally put them in, did seem contradictory.

Cheers & thanks for catching that

DSM

dsm wrote:An AUTO set too low, is going to 'chase' apnea events and try to get on top of them and as we both really know, some AUTOs are slow at getting on top.

Undeniably there's an art to setting a good range of pressure with an autopap. For some users, the minimum pressure setting in particular can be crucial to getting effective treatment. For others, an autopap could be left wide open and be able to prevent most or all events.

If a person's events are normally preceded by sufficient precursor characteristics that let the autopap "do its thing", the events will be warded off preventively just fine -- even with a autopap's minimum pressure set considerably lower than a PSG titration would recommend.

dsm wrote:Whereas a BiLevel that keeps IPAP at the titration level is largely already on top of the events before they occur rather than after.

True, but if the person's titrated pressure is a rather high pressure in the first place (which is often the case leading to a bi-level Rx) there can be problems in getting good treatment from a bi-level machine...even if it prevents all events.

Possible problems such as:

1. a pressure too high to be comfortable, even with a lower (but nonetheless high pressure) EPAP.

2. mask leak difficulties at the high pressures.

3. aerophagia at the higher pressures.

I still maintain that if a person is prescribed a high pressure, as froger65 has been, and was about to be slammed with a 19 or 20 IPAP pressure, I'd want a trial with a modern autopap first -- to get as much information as possible about what pressure I really needed.

I doubt what I'm going to suggest next would ever happen -- doctors and DMEs are too busy to devote this kind of time to individuals, plus all they're probably interested in looking at is the "90th" or "95th" percentile average pressure:

I think that the trial with a modern autopap ought to be done with downloads every 4 days and the DETAILED data for each night examined. The pressure range should be tweaked, if necessary, DURING the trial.

The very scenario you mentioned, dsm...that of an autopap not able to stay ahead of events (I'd add... "of SOME people's events" ) could lead to an inappropriately high titration outcome from the auto-titrating trial itself. Looking at the data every few days during the trial might reveal whether the range should be adjusted to make the trial truly useful.

Even if they were willing to look at the downloaded data that often and that closely, I'm making a BIG assumption that the doctor or DME would even know what they were looking at in the detailed data, aren't I? And would even know what settings changes to make.

rested gal wrote:
<snip>

dsm wrote:Whereas a BiLevel that keeps IPAP at the titration level is largely already on top of the events before they occur rather than after.

True, but if the person's titrated pressure is a rather high pressure in the first place (which is often the case leading to a bi-level Rx) there can be problems in getting good treatment from a bi-level machine...even if it prevents all events.

Possible problems such as:

1. a pressure too high to be comfortable, even with a lower (but nonetheless high pressure) EPAP.

2. mask leak difficulties at the high pressures.

3. aerophagia at the higher pressures.

<snip>

I think that the trial with a modern autopap ought to be done with downloads every 4 days and the DETAILED data for each night examined. The pressure range should be tweaked, if necessary, DURING the trial.

The very scenario you mentioned, dsm...that of an autopap not able to stay ahead of events (I'd add... "of SOME people's events" ) could lead to an inappropriately high titration outcome from the auto-titrating trial itself. Looking at the data every few days during the trial might reveal whether the range should be adjusted to make the trial truly useful.

Even if they were willing to look at the downloaded data that often and that closely, I'm making a BIG assumption that the doctor or DME would even know what they were looking at in the detailed data, aren't I? And would even know what settings changes to make.

RG,

Your point 1. I am puzzled by this comment. The only way I can possibly see an IPAP pressure being to high is if the BiLevel is pumping air into the user faster than the user can physically breathe thus creating discomfort - I just don't think that is a usual scenario in any way.

Your point 2. Again I am puzzled. When I am breathing in the IPAP pressure is being depleted into my lungs. As the flow reduceds to zero all good BiLevels switch to EPAP before I as the breather have increased the pressure by any noticable measure so the pressure that may have been in the mask if it was a straight CPAP just isn't there.

Tell me, how does the breathing out pressure (as in my bilevel case set to 8 CMS ) create any more problems with my mask than my AUTO which I usually set to a low of 12 CMS (say even lower, 10 CMS) ??? - your logic escapes me.

Your point 3: Even more mystifying. One of my great pleasures in switching to a BiLevel from my AUTOs was because the Aerophagia all but went. Please don't try to tell me that I must be different from all other xPAP users (you are inclined to push that line ) as I am quite satisfied that aerophagia is *mostly* created from users trying to breath out against high pressure such that a least path of resistance for some air, becomes the path to the stomach. It is somewhat illogical to me to argue that reducing the exhale pressure (as a BiLevel does) causes much air to try to divert into the stomach.

I did find that having cflex set to max on my AUTO, *seemed* to be a major contributor to serious aerophagia. I have seen other people report here that dropping cflex back made a difference re aerophagia for them too.

(I'd add... "of SOME people's events" Wink )

Is this you suggesting again that I must be 'different'

Re your other comments - no problem

Cheers

Doug

PS I really enjoy these discussions. It really forces us to think and for me, my head is spinning from all the conceptualizing & visualizing going on

D

PPS

RG,
It occurred to me today that there may be one other issue to do with recovering a users airway blockage that we may not have explored enough.

I was trying to visualize a person's airway collapsing due to an apnea (aided by some medical diagrams I have access to). What I saw in my minds eye was this person's chest muscles trying to suck air in down their windpipe but with the airway being sucked closed as it collapses (classic apnea blockage).

Now if any device tries to apply increased pressure from above (thru the mouth/nose) then part of my visualization is seeing that extra pressure adding to the force holding the airway closed. The added pressure from above & the lungs sucking from below.

It made me wonder if the only way to clear some blockages is for the person to go through an arousal, shift their position & thus change the pressure points which will then allow air to flow again.

Of course any good AUTO will then want to bump up the Positive Airway Pressure to keep the airway held open & prevent it being sucked closed again.

So my question is, "Could an AUTO be capable of increasing pressure such that it contributes to an obstructive blockage rather than helping remove it " ? - food for thought

Cheers

DSM

dsm, I'm sorry but I'll have to let this discussion fall by the wayside. Regardless of what kind of machine is delivering a high pressure, you and I apparently have such completely different concepts of so many aspects of continuous positive air pressure treatment and the machines that deliver the treatment .... and differences in our own experiences... I'm at a loss where to start.

I mean this in the kindest way -- I'm just not up to it.

I'm glad you have a machine that suits you well.

rested gal wrote:dsm, I'm sorry but I'll have to let this discussion fall by the wayside. Regardless of what kind of machine is delivering a high pressure, you and I apparently have such completely different concepts of so many aspects of continuous positive air pressure treatment and the machines that deliver the treatment .... and differences in our own experiences... I'm at a loss where to start.

I mean this in the kindest way -- I'm just not up to it.

I'm glad you have a machine that suits you well.

RG,

Are you not interested in at least discussing the mechanics of an apnea. I would have thought this was core to all you are interested in

Cheers

DSM

Older snore-based autopaps employed traditional acoustical sensors only and no flow sensors. The industry to this day refers to them as "snore based".

Modern autopaps use flow sensors rather than traditional acoustical sensors. They sense limited patient airflow by the way of apneas, hypopneas, and flow limitations. They also derive snore signals from this same patient airflow signal channel as mentioned. Because these modern autopaps use either pneumotach-based or even paddle-activated hall-effect flow sensors, the industry refers to these modern autopaps as "flow based".

Anonymous wrote:Older snore-based autopaps employed traditional acoustical sensors only and no flow sensors. The industry to this day refers to them as "snore based".

Modern autopaps use flow sensors rather than traditional acoustical sensors. They sense limited patient airflow by the way of apneas, hypopneas, and flow limitations. They also derive snore signals from this same patient airflow signal channel as mentioned. Because these modern autopaps use either pneumotach-based or even paddle-activated hall-effect flow sensors, the industry refers to these modern autopaps as "flow based".

Guest,

That makes sense but such references are difficult to find on the Internet.

However, this Government site discusses AUTO-titrating devices and makes some very interesting remarks, some relevant to points made by other posters in this thread.

FROM http://www.guideline.gov/summary/summar ... 1&nbr=2407


POTENTIAL BENEFITS

* In general, the guidelines offer an evaluation of auto-titrating continuous positive airway pressure that may assist clinicians in making a more informed decision on its use in the treatment of obstructive sleep apnea.

* One potential use of auto-titrating continuous positive airway pressure is to identify a single pressure for use with a standard continuous positive airway device for subsequent treatment of obstructive sleep apnea. Based on Level I and II and Grade A and B evidence, auto-titrating continuous positive airway pressure devices using methods that involve snoring, apnea or hypopnea monitoring by airflow, airflow against time, or impedance by the forced oscillation technique may effectively determine a pressure to reduce sleep-disordered breathing events to the same extent as standard continuous positive airway pressure titration. Current Level I and II and Grade A and B evidence is specific to each device, including current software and device version. Some devices have not been fully tested in Level I and Level II trials. Caution should be exercised in selecting a particular device for use. Titration is attended in these studies so that issues such as mask fit, pressure leak, and occurrences of transient hypoxemia can be identified and properly managed.

* Another potential use of auto-titrating continuous positive airway pressure is to treat patients with obstructive sleep apnea on a long-term basis. Based on Level I and II and Grade A and B evidence, auto-titrating continuous positive airway pressure devices using methods that involve snoring, apnea or hypopnea monitoring by airflow, airflow against time, or impedance by the forced oscillation technique may effectively adjust pressures to reduce sleep-disordered breathing events to the same extent as standard continuous positive airway pressure titration. Current Level I and II and Grade A and B evidence is specific to each device, including current software and device version. Caution should be exercised in selecting a particular device for use. Since the initial continuous positive airway pressure or auto-titrating continuous positive airway pressure titration is attended, other issues such as mask fit, mask leak, and transient hypoxemia can be identified and managed at the time of titration.

POTENTIAL HARMS

* Central apnea during auto-titrating positive airway pressure treatment or titration may occur in some patients.
* Pressure intolerance can occur with continuous positive airway pressure, along with nasal congestion and dryness.
* Many sleep physicians have encountered patients with intact airflow on continuous positive airway pressure who have persistent oxyhemoglobin desaturation during rapid eye movement sleep, presumably secondary to hypoventilation.
* Mask/mouth leaks may lead to problems using auto-titrating positive airway pressure devices.

Subgroups Most Likely to be Harmed:

Patients with lung disease and obstructive sleep apnea, or obesity hypoventilation syndrome might also potentially have problems during unattended auto-titrating positive airway pressure titrations. These patients can desaturate during sleep in the absence of apnea or hypopnea, especially during rapid eye movement sleep.

QUALIFYING STATEMENTS

* The intent here is to present the evidence for auto-titrating positive airway pressure's (APAPs) utility, not to make direct treatment recommendations. Nonetheless, the American Academy of Sleep Medicine recognizes this information may affect treatment decisions. The American Academy of Sleep Medicine has previously published practice parameters for the diagnosis of obstructive sleep apnea (OSA) and the recommendations here do not modify those guidelines. The American Academy of Sleep Medicine also has previously published practice parameters on the determination of continuous positive airway pressure (CPAP) for the treatment of obstructive sleep apnea. The recommendations here add to those previous guidelines when auto-titrating positive airway pressure is used to titrate continuous positive airway pressure or treat obstructive sleep apnea.

* There were several factors complicating the analysis. First, there are many different devices and findings from one device may not extrapolate to others. Second, many of the studies were clinical series in which use of the device was shown to be clinically feasible and effective but not compared to conventional continuous positive airway pressure treatment or placebo. The entry criteria were not always clearly stated so that in some studies there may have been a selection bias. Third, even when randomized controlled trials were performed, the designs varied significantly.

* These practice parameters define principles of practice that should meet the needs of most patients in most situations. These guidelines should not, however, be considered inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding propriety of any specific care must be made by the physician, in light of the individual circumstances presented by the patient, available diagnostic tools, accessible treatment options, and resources.

**This additional comment is interesting ...

# Patients with the following conditions are not currently candidates for auto-titrating positive airway pressure (APAP) titration or treatment. (Berry, et al., 2002; sections 5.5, 5.8, and Table 1) (Standard):

* congestive heart failure
* lung disease such as chronic obstructive pulmonary disease
* patients expected to have nocturnal arterial oxyhemoglobin desaturation due to conditions other than OSA (e.g., obesity hypoventilation syndrome)
* patients who do not snore (either due to palate surgery or naturally) should not be titrated with an APAP device that relies on vibration or sound in the device's algorithm.

rested gal wrote:dsm, you and I apparently have such completely different concepts of so many aspects of continuous positive air pressure treatment and the machines that deliver the treatment .... and differences in our own experiences... I'm at a loss where to start.

I mean this in the kindest way -- I'm just not up to it.

R.G.- In light of recently witnessed discussions, I think the rest of us find that perfectly understandable. Your frank and honest reply speaks volumes.

Anonymous wrote:

rested gal wrote:dsm, you and I apparently have such completely different concepts of so many aspects of continuous positive air pressure treatment and the machines that deliver the treatment .... and differences in our own experiences... I'm at a loss where to start.

I mean this in the kindest way -- I'm just not up to it.

R.G.- In light of recently witnessed discussions, I think the rest of us find that perfectly understandable. Your frank and honest reply speaks volumes.

An anon post ?

Hmmmmm.

I have been on CPAP for the past 4 months. My pressure is 15. I was using a ResMed CPAP machine an the Ultra Mirage Mask. I have been experiencing bloating (my face, my eyes, pouches under my eyes (BIG BAGGAGE), and a bloated stomach, not to mention much gas (very embarassing, to say the least). As of last Friday, they switched me to a VPAPIII machine which lowers my pressure on exhaling. I have seen a noticable difference in my face swelling. The baggage under my eyes is smaller. My stomach is still large (I guess this will take a while to go down). I do experience mask leaks during the night as the pressure goes up. And that drives me crazy, so I don't get a good night's sleep.

My question is, is the S8 Elite machine with EPR as good a machine (and quiet) as the VPAP III? I really want a smaller machine as I travel and the VPAP III is very bulky.

Thank you for your time and help.