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Bipap AVAPS problems
#1
Hi, I am a new member (an expat Australian living in Thailand).   I have used a Resmed S9 auto CPAP since I was diagnosed with apnea after a colon cancer stage 3 operation the apnea was picked up during a colonoscopy, after which I  had a sleep test.  I also suffer from COPD (emphysema of the lower lung and bronchiectasis), but managed with the S9 auto until after I was diagnosed with lung cancer in later 2015. Sine 2014 I have also used an oxygen concentrator with the CPAP due to low nocturnal oxygen levels. 

The diagnosis was followed by a risky operation using a scope and intensive targeted radiation, leaving my ability to breath much worse, although I still go to the gym four times a week, but maybe not so energetic as i was (anyway I am 74).   However, I began to feel that the effects of the CPAP pressure, particularly when it was increased to 20. I was becoming extremely fatigued and tired due to waking from the high pressure on weakened lungs.   My pulmonary specialist advised and made an appointment with a sleep specialist who was previously a pulmonary specialist.   I had a sleep test on 5 Feb with inhale pressure of 23 and exhale of 14.  The specialist prescribed a bipap machine.   I find it confusing which one to buy and the models available in Thailand are limited and very expensive, but buying overseas would make servicing difficult.  

At first I thought about keeping with Resmed, but they did not  really seem interested in providing service. After carrying out research on the web I felt that when comparing Resmed with the Respironics Bipap AVAPS System One, the Resmed algorithm is much more aggressive and does not adjust pressure the same way.  The Respironic Bipap AVAPs is not so flashy and does not have a coloured screen or autostart and stop.  Anyway,  last night I used one for the first time (on trail for seven days) and found it very gentle and I slept much better. I also tried a Weinmann, but found it also very aggressive with a cumbersome humidifier that  does not hold enough water for a night's use.     I am still quite confused and would appreciate any advice as I need a  machine that I will be able to use as my COPD progresses.   Also I use a Mac normally and used Sleepyhead to get data from the S9.  This morning I thought  I would be able to see how my first night went, but found Sleepyhead does not read the Bipap AVAPS. I downloaded EncoreBasics from this website to my PC (not Mac) but received a  message that it requires an additional  Microsoft extension framework,  but this does not download onto my PC. Can anyone advise
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#2
Bump2
I'm bumping your thread so those that use bipaps can better advise.

Good luck and welcome to Apnea Board.
OpalRose
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#3
Your BiPAP AVAPS is probably model DS1060P or 1061P and I believe the newest version of SleepyHead will read that machine's data, as will the Philips EncoreBasic or EncorePro. This machine does not produce a detailed wave form, so there won't be the level of information you may have seen on other CPAPs or bilevels. Let me know if my model reference is correct and we can check on it. The AVAPS provides a specific purpose beyond simple BiPAP S or BiPAP auto so it would help to know the settings you're using, in terms of mode, EPAP, IPAP BPM, target volume etc. With a PS of 9.0 cm the machine is practically doing all the work of inhalation for you. The machine will also give you the 1-day, 7-day and 30 day efficacy information on-screen.

90% of what is important is how you feel using the device. If you are better rested, and the machine is syncing well with your breathing needs, then chances are the AHI and other information is going to fall into place. As Rose suggested, not a lot of us use the AVAPS machines, so there is a limited knowledge base from users, but we will do our best to answer questions or encourage you to succeed.
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#4
Thanks  Hi Sleeprider, thanks very much for your advice.  The device is presently on trial from a Philips Respironics dealer who attends the hospital where I had the sleep test.  I cannot find any reference to the model numbers you suggest, but on the bottom of the machine it states Bipap Avaps C series INTL30  Ref 1161T.  

Sorry I am a bit dumb regarding BiIPAP as I have only been using for a few days on trial.   The EPAP and IPAP that was recommended after the sleep test is 14/23 .  I had to call the technician who installed it back to set the ramp as he said he only set it to the Doctor's recommendation's - the EPAP and IPAP recommendation. 

Thanks for the updated SleepyHead. I just printed the results after 4 days of use and it indicates that the AHI is 18.93 which SleepyHead suggests is "Horrible , please consult your doctor."   The obstructive index is 2.87, Hypopnea Index 5.05 Clear Airways Index 11.02 Average Leak Rate 13.44.  It shows average EPAP 13.65, Min 11.90, Max EPAP 13.80 Average IPAP 18.32.  It is set in AVAPS mode.  I felt pretty awful this morning, waking up fatigued and with a headache and feel that I am not getting much benefit from the BIPAP AVAPS machine.   I am thinking of going back to my old S9 CAPAP for tonight at least.  The Resmed people will come tomorrow afternoon to show me the S9 VPAP ST-A with IVAPS.  

I am quite confused now and do not know what to do.  It is difficult to contact the Doctor and I do not seem to be getting much benefit from the BIPAP/AVAPS.  As I said, I am pretty dumb when it comes to BIPAP (or even CPAP) machines and I cannot find any reference to BPM, PS or target volume.  As my wife and I have to buy the machine we are still in the trail period so I would appreciate any advice on what I should do and what type or brand of machine would be the best.  Resmed were going to bring along a Stella 100, but we told them we do not  have the resources to purchase such a machine and feel it is not necessary,  so they are bringing the ST-A and another model to try.  I am disappointed with Phillips here in Bangkok and also my attending sleep doctor. I thank you very much for your expert advice and look forward to your comments on my post. Again, thank you so much, Sam 
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#5
I don't know what your diagnosis is, but the AVAPS machines are intended for people with respiratory insufficiency arising from severe COPD, obesity hypoventlation and other restrictive diseases that need a machine that will provide an assured volume of air through high pressure support and a respiratory backup rate. If your problem was central or complex apnea, the machine you wanted is an adaptive servo ventilator, which allows for spontaneous breathing, but can provide pressure support to support breathing during central apnea and hypopnea, while providing positive air pressure to deal with obstructive apnea. That is a lot of technical stuff. The S9 VPAP ST IVAPS is an improvement on the Philips ST AVAPS, because it has a variable EPAP and intellegent pressure support algorithm.

I'm not such an expert with this level of equipment and have only a basic understanding of its function and applications. If you can fill in the blanks on what condition(s) are being treated, I might have a better understanding of why you are getting this kind of equipment.
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#6
HI again, Sleeprider and thanks again.

I have COPD emphysema in both lower lobes and bronchiectasis in middle lobe as well as OSA, but not central apnea.  I am not obese but well built and 74 years of age..    It sounds as if the Bipap AVAPS is ok but the Resmed S9 VPAP ST - A with IVAPS sounds more interesting and I am more familiar with Resmed. The Resmed reps will come tomorrow with a couple of machines including the ST - A with IVAPS.  So I thank you very much and will update on the results and our decision on an appropriate machine. 

Thanks again and best regards, Sam
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#7
That explains the AVAPS just fine. I think you should have much better results with the Resmed ST AVAPS IVAP since it is a much more intelligent machine that should automatically vary to meet your needs. Good luck.
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#8
Hi Sleeprider, it has been some time since I posted and I said I would update you on some of the issues that I am having or had.   First, I tried the Bipap Avaps and also the Resmed VPAP ST with AVAPS.  I have found a number of issues, but these may only be particular to Thailand.  First, I find difficult to find a sleep doctor with the technical knowledge of bipap or VPAP machines.  Second both Respironics and Resmed here supply directly through authorised dealers, but there are other non-registered suppliers around that cannot provide after-sales service, so it is important use an authorised dealer.   Indeed, most authorised dealers appear not to be knowledgable about bipap machines or therapy.  Thirdly, it is even more difficult to find a sleep doctor that has the technical knowledge to prescribe bipap settings.  A few weeks ago, while I was trying the bipap AVAPS, Resmed contacted me to suggested I try their VPAP ST with AVAPS.  However, I found the Resmed agent to be rude and did not understand the medical problems related to COPD. Indeed, at first both companies only wanted to set the machine to the level prescribed in the sleep test report (14 Epap and 23 Ipap).   Resmed set the machine to ST and refused to turn on and set AVAPS. From discussions with them I do not think they were able to set the AVAPs and insisted that they could only set the machine to the pressures recommended by the doctor.  They became very rude and I had to remind them that I was the patient not the doctor.  They would not compromise (or maybe did not know how to set) so I sent the machine back. Sad as I used the S9 Auto Set since early 2013.   The authorised Respironics company did try to help, inviting me to visit their office and talk to the technician. He lowered the pressure to 20, but this did not solve the problem of headaches, bloated stomach and extreme fatigue.  My emphysemic lungs can only operate at 33 per cent (I had a spirometry and other lung tests last week. ) so could not really take the pressure.  Moreover, my original sleep doctor was only available for appointment in late April and is always late and busy when I do see him.  Therefore, my wife made an appointment for me to see a doctor at Bangkok Hospital. He was very good, but admitted that he was a sleep neurologist and could only deal with OSA and not COPD; however, he gave me the names of three pulmonary sleep specialists.  An appointment  was arranged for last Thursday and I found the doctor to be knowledgable about OSA and COPD problems, but not with bipap technical issues.  By this time, I was becoming pretty desperate and researched the web, particularly the Apnea Board postings.   Eventually my wife phoned the supplier and explained the problem to the technician; he admitted he knew very little about Bipap AVAPS, but  gave her the name of a technician who did.  At first the guy was cautious as he did not want to upset the doctors and the sleep report only stated 14 EPAP and 23 IPAP pressures and recommended a bipap machine; it  did not address other settings.  The technician asked me to download Encore Basic.  I tried but could not open it properly on my spare PC (I do have the Sleepy Head on my Mac).  So he suggested that I zip the data file from the SD card and email it to him.  This I did and he quickly sent me the report and pointed out that my mask leaks were very high and I needed to solve this issue first. He also suggested that part of the problem may be due to a low lung capacity and poor pressure tolerance, as each day I awake with a headache and bloated stomach.  Last night I lowered the IPAP to 18 resulting in AHI of 3.73 and with minimum air leaks.   This is a step forward for me.  During the process I have learned something of the problems including that people with COPD must adjust the tidal volume differently from the normal height and weight measurement to accommodate a different "dead spot," which I have done by trail and error.   I have tried various masks and find that FF masks tend to leak more, so tried the True Blue nasal mask with a chin strap, but somedays my blocked sinuses prevent me from using it or when I use I  awake with a bloated stomach (maybe my mouth opens). Last night I reverted to an Airfit F10  (I also have an Airfit F20 and FX) with some success.  I can empathise with people trying to deal with these issues,  particularly  those with COPD.  Moreover, since a lung cancer operation in 2015 my lungs have deteriorated making it essential  I find help with bipap issues;  it is difficult here in Thailand but am slowly getting there. I would like to thank you and other Apnea Board members for your inputs and encouragement.
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#9
Thanks for the update. If you would like to post the settings you are using we can talk through any issues and we can try to support you with some ideas. There is no reason you should not experiment with lower pressures, as it is the pressure support and target ventilation rates that should be key in your therapy effectiveness and tolerance.

As difficult as your therapy is in Thailand, I think good knowledge of AVAPS is not common anywhere, and ultimately, a trial and error approach, with the objective of achieving both comfort and adequate minute vent rates is probably as good as anything. This should be something a good clinic can achieve more quickly than the end user, and the lack of a good research clinic that can titrate more complex patients is probably the biggest obstacle you face.
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#10
Hi again Sleeprider and again thank you for your encouragement and support.   I visited the pulmonary sleep doctor yesterday, but as I indicated previously she does not really understand Biapap AVAPS.  However, advised to use a nasal mask if possible and gave me antihistamine and Singular to dry out my sinuses.  She also advised me to use 2ML of oxygen(I also have an oxygen concentrator) as my nocturnal oxygen goes down. I am surprised the original sleep doctor did not suggest this after the titration sleep test.   She also said that the recommended IPAP of 23 is too  high for my lung  condition and said that comfort and good sleep is more important. I am still feeling very fatigued from using the Bipap AVAPS  I realize that  a Bipap ST would have been more relevant than AVAPS, although as my condition worsens I guess I may need AVAPS in the future.  The present settings now are: 

Mode: ST 
AVAPS: off   
IPAP    18
EPAP    12
BPM     12
TI        1.0
Rise time on
Rise time: 3
Ramp 45
Ramp start 8.0
heated tube on
humidity and temp 3
System one on
System one X1
Patient alarm 15 but other alarms off. 

The boss at the Respironics agency suggested that I get a blood oxygen level test so will get one tomorrow (Saturday).

MY aHI for two days since I reduced IPAP to 18 and been good. On 21st it was 3.73 and on 22nd 2.90 but SleephHead indicated too much mask leaks.  But last night it was 6.46 with bad mask leaks.   I had to use my Resmed Airfit F10 as my sinuses were blocked but hopefully tonight will use the True Blue. 

I woud really appreciate your advice on this.  Best regards Thanks
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