ASV Help understanding the meaning of RAMP

Had my first night on ASV last night in in general it was awful, but that is another story. My main question after talking to my DME is whether I truly understand what RAMP really is. I noticed that all the menus on my machine did not list RAMP and the clinical menus (tricky little devils aren't we?) did not list it as well. That confused me. My DME told me that is because my min EPAP is already set as low as the machine can go i.e. 4cm H20 therefore it cannot go below this for a RAMP.

So - does that mean that Ramp only affects the min EPAP and none of the other pressures? The user manual for the machine just says that the "pressure" is reduced for a period of time but does not designate what type of pressure they are taking about.

My question then is, what pressure does the RAMP feature effect on my Res ASV machine and is she right that it only effects the min EPAP.

Learning in leaps and bounds, but tired as hell....

It is a comfort feature, and will start you at a lower EPAP and IPAP pressure, then slowly bring you up to the minimum EPAP and IPAP. There is a minimum pressure support, which is the minimum difference between the EPAP and the IPAP. So, for example, if your minimum EPAP is 7 and your minimum pressure support is 4, your starting IPAP would be 11. If you used ramp and you started out at 4 EPAP, then your IPAP would start at 8 (4 + 4).

But since you are already starting at a minimum EPAP of 4, you are correct in that the ramp does nothing for you.

And yes, ASV's are a real PIA at first. It DOES get better, but may take some adjustments as well as adjusting to it. By the way, if you scream into a full face mask, the ASV goes nuts!

Thanks for that explanation. Hmmmmmm what do you mean by "go nuts"?!?!?!!?

It is already ruining my life; how on earth could it get worse? (wink).

photonic wrote:Had my first night on ASV last night in in general it was awful, but that is another story. My main question after talking to my DME is whether I truly understand what RAMP really is. I noticed that all the menus on my machine did not list RAMP and the clinical menus (tricky little devils aren't we?) did not list it as well. That confused me. My DME told me that is because my min EPAP is already set as low as the machine can go i.e. 4cm H20 therefore it cannot go below this for a RAMP.

If the min EPAP = 4.0, then the RAMP is disabled on the PR machines because the EPAP cannot be lowered below 4cm.

So - does that mean that Ramp only affects the min EPAP and none of the other pressures? The user manual for the machine just says that the "pressure" is reduced for a period of time but does not designate what type of pressure they are taking about.

If your minimum EPAP is greater than 4cm, then the RAMP is enabled. The starting ramp EPAP is set in the clinical menu. The starting ramp IPAP = starting ramp EPAP + min PS. To make this clearer, let's suppose your settings were:

• min EPAP = 7
  max IPAP = 20
  min PS = 3
  max PS = 8
  ramp start EPAP = 4 (I'm not sure what the exact name of the starting ramp EPAP setting is, but it's close to this.)

In this case, any time the Ramp button is hit, the EPAP will be lowered to 4cm and the IPAP will be lowered to 7cm since ramp EPAP + min PS = 4 + 3 = 7. Once the ramp period is over, the minimum EPAP pressure the machine will use is 7cm, the minimum IPAP pressure the machine will use is 10 cm since min EPAP + min PS = 7 + 3 = 10. The maximum IPAP the machine can use is 20cm and the max EPAP the machine can use is 17 since 17 = max IPAP - min PS.

My question then is, what pressure does the RAMP feature effect on my Res ASV machine and is she right that it only effects the min EPAP.

If your min EPAP > 4, then RAMP would affect both the starting EPAP and starting IPAP pressure. But because min EPAP = 4, there's no way of using a RAMP.

Curiosity:

You've said your min EPAP = 4cm.

What are your min PS, max PS, and max IPAP settings?

Robysue,

Min EPAP 4
Max EPAP 15

Max Pressure 25

Min PS 0
Max PS 20

Any education on understanding these values would be much appreciated. Thanks for taking an interest!

photonic wrote:Robysue,

Min EPAP 4
Max EPAP 15

Max Pressure 25

Min PS 0
Max PS 20

Any education on understanding these values would be much appreciated. Thanks for taking an interest!

so they gave you a default out of the box setup, one would have thought you'd get something more tailored to you after all the doctors and techs and sleep studies and all that... as opposed to the 'bought it on craigslist and set it to default' option that I had

photonic wrote:Robysue,

Min EPAP 4
Max EPAP 15

Max Pressure 25

Min PS 0
Max PS 20

Any education on understanding these values would be much appreciated. Thanks for taking an interest!

You start the night off with:

• EPAP = Min EPAP = 4cm
• IPAP = Min EPAP + Min PS = 4 + 0 = 4cm

As events happen and as the ASV algorithm kicks in to trigger inhalations if necessary, your pressures can range as follows:

• Min EPAP <= Current EPAP <= Max EPAP all night, so 4 <= Current EPAP <= 15 all night long.

And for each breath you take:

• Current EPAP + min PS <= Current IPAP <= smaller of (Current EPAP + Max PS OR 25)

so for each breath you take:

• Current EPAP + 0 <= Current IPAP <= smaller of (Current EPAP + 20, 25)

which effectively means that for each breath you take:

• Current EPAP <= IPAP <= 25

And the up shot of this is that:

• 4 <= EPAP <= 15 all night long
• 4 <= IPAP <= 25 all night long
• 0 <= IPAP - EPAP <= 20 all night long.

In other words, it looks as though your PR System One ASV is set with the settings about as wide open as possible. The net result is that at any point during the night, your pressures could look like any of the following combinations:

• EPAP = 4 = Min EPAP, IPAP = 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 = Current EPAP + Max PS
• EPAP = 5, IPAP = 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 = max Pressure
• EPAP = 6, IPAP = 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 = max Pressure
• EPAP = 7, IPAP = 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 = max Pressure
• EPAP = 8, IPAP = 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 = max Pressure
• EPAP = 9, IPAP = 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 = max Pressure
• EPAP = 10, IPAP = 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 = max Pressure
• EPAP = 11, IPAP = 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 = max Pressure
• EPAP = 12, IPAP = 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 = max Pressure
• EPAP = 13, IPAP = 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 = max Pressure
• EPAP = 14, IPAP = 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 = max Pressure
• EPAP = 15 = Max EPAP, IPAP = 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 = max Pressure

When the ASV algorithm is kicking in and the machine is triggering breaths, the Current PS = Current IPAP - Current EPAP will typically be (much) larger than when the machine is "happy" with your respiratory effort. In other words, when you're running at a pressure combination of EPAP = 7, IPAP = 9, the machine is probably responding to obstructive events since Current PS = 9 - 7 = 2. But when you see a pressure combination of something like EPAP = 7, IPAP = 17, then Current PS = 17 - 7 = 10, there's a high probability that the ASV algorithm has kicked in and the machine is cycling between a high IPAP and a much lower EPAP in an effort to "trigger" inhalations and keep your tidal volume and/or minute ventilation within the parameters set by the ASV algorithm.

Just a gentle reminder to get and keep a copy of your sleep studies.
In there are the min EPAP and IPAP values, etc. that you need to compare with the actual machine settings.
Hang in there. It will all be good.

It's good to see that I am not the only one to dumb to understand the details of ASV.
Please keep asking dumb questions, so I can keep learning.

I have learned more about ASV in the past week from relevant posts then in the 9 months I have had the machine.

My min EPAP starts only at 6 so I don't use the ramp to fall asleep but sometimes snoring will trigger the machine to blast off like a rocket to 25/15 and the higher pressures often wake me up. When I do, the quickest way to reset is hit the ramp button, change positions, and get back to blissful dreamland.

I used to have claustrophobia, fight the rhythm of the machine, and be lucky to make the 4-hour compliance. It just takes time and persistence. Stick with it and you'll get there.

- Flappy