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[Equipment] Help With S9 VPAP Auto Settings
#11
RE: Help With S9 VPAP Auto Settings
I'm going with maxIPAP=13, minEPAP=4, and PS=6. As far as I can tell that's as close as I can get to the PRS1 settings I described in the first post.

Tonight will be my first night ...

Sleepster

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#12
RE: Help With S9 VPAP Auto Settings
(06-29-2014, 06:21 PM)Sleepster Wrote: I'm going with maxIPAP=13, minEPAP=4, and PS=6. As far as I can tell that's as close as I can get to the PRS1 settings I described in the first post.

Tonight will be my first night ...

we're all eagerly awaiting your results!
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#13
RE: Help With S9 VPAP Auto Settings
(06-28-2014, 04:12 PM)Sleepster Wrote: I had finally settled on the following settings for my fixed-pressure PRS1 BiPAP 650P and they've been there for about a year or so:

IPAP = 12,
EPAP = 9,
Bi-Flex = 3.

At these settings I still swallow air on some nights, but not on most nights. My 7-day and 30-day AHI averages stay between 1.5 and 2.5, with a single night's AHI never (or maybe rarely) rising above 3.

So I'm thinking of the following settings for the VPAP Auto:

min EPAP = 4
max IPAP = 13
PS = 6

This will allow me to maintain the difference in pressure of 6 that I currently have with the PRS1 (IPAP - EPAP + BiFlex = 12 - 9 + 3 = 6) and allow the IPAP to float between 10 and 13. Hopefully it won't go above 12 too often, and may stay down closer to 11.

The goal of course is to prevent aerophagia as much as possible and lower my AHI.

Hi Sleepster,

Regarding http://bipapautomseries.respironics.eu which is the picture of BiFlex which diamaunt posted showing the effect of various BiFlex settings, it shows that BiFlex always returns to the set EPAP pressure (a also known as the Ending EPAP pressure or EEPAP) before the next inhalation begins. (Not shown is that the next inhalation may start well after the BiFlex pressure relief has completely ended.)

With BiFlex, beginning EPAP and ending EPAP are different. In your case, for EPAP setting of 9 and BiFlex setting of 3:

Ending EPAP = the EPAP setting

Beginning EPAP = (EPAP setting) - BiFlex = 9 - (approximately 3) = approximately 6

With BiFlex of 3, although your beginning EPAP may have been perhaps as low as 6 soon after the start of exhalation (while you were exhaling most strongly) the BiFlex pressure reduction is based on how fast (the rate of exhalation, as plotted on the Flow plot) you are exhaling, and in normal sleep we stop exhaling (and BiFlex ends) well before the beginning of the next inhalation.

It is the Ending EPAP pressure which often is most critical in preventing obstructive apneas from starting. If the EEPAP is too low, an obstructive apnea may begin, either before we start to inhale, or immediately after we begin to inhale when the suction of starting to inhale manages to completely close off the relaxed and nearly-collapsed airway.

The problem with setting Pressure Support to 6 is this may worsen aerophagia, as this is twice as much PS as you have been using. With the PRS1 BiPAP Pro, the PS was IPAP - EEPAP = 3. A larger PS than 3 may worsen aerophagia.

Instead, I suggest that the closest settings on the S9 VPAP Auto (closest to your previous settings on the PRS1 BiPAP Pro) would be:
PS = 3 or 4
Min EPAP = 8 or 9
Max IPAP = 12 or 13

By changing to the ResMed S9 VPAP Auto you lose the very nice extra pressure relief afforded by BiFlex (which does not lower your End EPAP and therefore does not increase the likelihood of obstructive apneas, unlike simply lowering the EPAP setting would do).

Take care,
--- Vaughn

ADDED: Also, another difference between the S9 VPAP Auto versus the PRS1 BiPAP is that the S9 VPAP Auto is always seeking to return to the Min EPAP setting. After the EPAP is raised in response to obstructive events (including Apnea, hypopnea, Flow Limitation and Snore), the lower the MIN EPAP setting is, the faster the EPAP pressure will be lowered again (perhaps allowing obstructive events again), so it is not good to have the Min EPAP set much lower than what you actually need. Since you may need EPAP to be around 9 to prevent most apneas the Min EPAP setting on the S9 VPAP Auto should not be too much lower than this. For example, somewhere between 7 and 9 would probably be optimal.

ALSO: Decreasing the Trigger Sensitivity will delay the beginning of IPAP and may lessen aerophagia (but would likely be less comfortable). Increasing the Cycle Sensitivity would advance the end of IPAP and may lessen aerophagia (but would likely be less comfortable). I think a higher Trigger sensitivity and a lower Cycle sensitivity (these settings would advance and lengthen the IPAP period) is more comfortable and satisfies my desire to breath deeply with minimal effort, but the earlier and longer IPAP period obviously would tend to increase the tendency to swallow air.
.
The Advisory Member group provides advice and suggestions to Apnea Board administrators and staff on matters concerning Apnea Board operation and administrative policies.  Membership in the Advisory Member group should not be understood as in any way implying medical expertise or qualification for advising Sleep Apnea patients concerning their treatment.
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#14
RE: Help With S9 VPAP Auto Settings
(06-29-2014, 08:13 PM)vsheline Wrote: Regarding http://bipapautomseries.respironics.eu which is the picture of BiFlex which diamaunt posted showing the effect of various BiFlex settings, it shows that BiFlex always returns to the set EPAP pressure (a also known as the Ending EPAP pressure or EEPAP) before the next inhalation begins. (Not shown is that the next inhalation may start well after the BiFlex pressure relief has completely ended.)

That is the same graph that I see in the clinician's manual for the BiPAP I have. Isn't it a graph of pressure versus time? And as I read it, it shows the beginning EPAP equal to the ending EPAP. In other words the EPAP pressure shown at the left edge of the graph equals the EPAP pressure shown at the right edge of the graph.

Quote:In your case, for EPAP setting of 9 and BiFlex setting of 3:

Ending EPAP = the EPAP setting

Ok, I follow you. That's 9.

Quote:Beginning EPAP = (EPAP setting) - BiFlex = 9 - (approximately 3) = approximately 6

Well, I would call this the bottomed-out EPAP pressure. It's the lowest pressure shown on that graph and it occurs during the exhalation, very shortly after the beginning of the exhalation. At this point the exhalation pressure starts to rise and will continue to do so until it reaches the EPAP pressure of 9. What happens after that is not shown on that graph, as you say, but the pressure stays there at 9 until the patient starts to inhale, at which point it rises to the IPAP pressure of 12. If you imagine the cycle shown on that graph repeating itself, you see the section labeled "A" where the pressure is rising from 9 to 12.

Quote:With BiFlex of 3, although your beginning EPAP may have been perhaps as low as 6 soon after the start of exhalation (while you were exhaling most strongly) the BiFlex pressure reduction is based on how fast (the rate of exhalation, as plotted on the Flow plot) you are exhaling, and in normal sleep we stop exhaling (and BiFlex ends) well before the beginning of the next inhalation.

Ok. I follow you here. But when you say the "beginning EPAP may have been perhaps as low as 6 soon after the start of exhalation" what you're referring to is what I've called the bottomed-out EPAP, which occurs not at the beginning of the exhalation, but as you say, soon after.

I think we're on the same page here. Smile

Quote:It is the Ending EPAP pressure which often is most critical in preventing obstructive apneas from starting. If the EEPAP is too low, an obstructive apnea may begin, either before we start to inhale, or immediately after we begin to inhale when the suction of starting to inhale manages to completely close off the relaxed and nearly-collapsed airway.

Yes, I agree completely.

Quote:The problem with setting Pressure Support to 6 is this may worsen aerophagia, as this is twice as much PS as you have been using. With the PRS1 BiPAP Pro, the PS was IPAP - EEPAP = 3. A larger PS than 3 may worsen aerophagia.

Well, we do agree though that with my BiPAP the PS was 6 if you look at the IPAP of 12 minus the bottomed-out EPAP of approximately 6. The way I see it the EPAP will rise back up to 9 before the exhalation ends.

Ah Ha Big Grin Now I think I'm getting what you're saying. Let's say I put the VPAP in fixed pressures mode with a IPAP of 12 and EPAP of 6. The PS will be 6 and at the end of an exhalation the pressure will be only 6. That's not gonna be the same as the BiPAP settings!

Quote:By changing to the ResMed S9 VPAP Auto you lose the very nice extra pressure relief afforded by BiFlex (which does not lower your End EPAP and therefore does not increase the likelihood of obstructive apneas, unlike simply lowering the EPAP setting would do).

Yes, you're correct. Now I see it. The Bi-Flex feature really is substantial and not just a bell or whistle. I think I never really understood this until now.

Quote:Instead, I suggest that the closest settings on the S9 VPAP Auto (closest to your previous settings on the PRS1 BiPAP Pro) would be:
PS = 3 or 4
Min EPAP = 8 or 9
Max IPAP = 12 or 13

Well, if I set the max IPAP at 12 I'm not going to get the possibility of treating those few OA's and H's that I'm currently experiencing at a fixed IPAP of 12.

I think I'll try

PS = 3
Min EPAP = 8
Max IPAP = 13

Thanks, Vaughn.

Sleepster

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#15
RE: Help With S9 VPAP Auto Settings
Got 8 hours of use.
AHI 1.2.
95th percentile IPAP pressure 12.2.

Swallowed a bit of air, which as I noted in the first post happens from time to time. I'll have to wait and see what happens in the next few days or more before I make any adjustments.

A thought occurred to me. If I have PS = 3 I'm essentially where I'd be with a EPR of 3 on an Autoset machine with a pressure range of 11-13.
Sleepster

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#16
RE: Help With S9 VPAP Auto Settings
One more thing, Vaughn ...

(06-29-2014, 08:13 PM)vsheline Wrote: The problem with setting Pressure Support to 6 is this may worsen aerophagia, as this is twice as much PS as you have been using. With the PRS1 BiPAP Pro, the PS was IPAP - EEPAP = 3. A larger PS than 3 may worsen aerophagia.

I don't understand how this would make aerophagia worse. I can see how it would make the OA and H indices go up. But it seems to me it would help with the aerophagia.

I'm seeing this whole thing as a trade-off between treating OSA (which requires higher pressures) and treating aerophagia (which requires lower pressures). We want the pressure high enough to treat the apneas and hypopneas, but low enough to prevent aerophagia. This is the essence of why bilevel therapy is used to treat OSA patients with CPAP-induced aerophagia.
Sleepster

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#17
RE: Help With S9 VPAP Auto Settings
(06-30-2014, 09:55 AM)Sleepster Wrote: A thought occurred to me. If I have PS = 3 I'm essentially where I'd be with a EPR of 3 on an Autoset machine with a pressure range of 11-13.

that's correct, though you can futz with ti, trigger and cycle and change how it feels if you wish.
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#18
RE: Help With S9 VPAP Auto Settings
(06-30-2014, 11:25 AM)Sleepster Wrote: One more thing, Vaughn ...

(06-29-2014, 08:13 PM)vsheline Wrote: The problem with setting Pressure Support to 6 is this may worsen aerophagia, as this is twice as much PS as you have been using. With the PRS1 BiPAP Pro, the PS was IPAP - EEPAP = 3. A larger PS than 3 may worsen aerophagia.

I don't understand how this would make aerophagia worse. I can see how it would make the OA and H indices go up. But it seems to me it would help with the aerophagia.

Hi Sleepster,

You and I are not discussing what I think would be the more common case when using bi-level treatment, where EPAP is kept the same, and as PS is increased there is a corresponding increase in IPAP (because EPAP + PS = IPAP). Of course, in that case we would both agree that increasing PS and IPAP would tend to increase aerophagia.

Instead, we are discussing what I think would be the less common case, where IPAP is kept the same, and as PS is increased there is a corresponding decrease in EPAP because in this case IPAP - PS = EPAP. (This would be like increasing EPR, because IPAP - EPR = EPAP). If I follow you, your thinking is that in this case the lower EPAP would tend to lessen aerophagia, although the lower EPAP would also tend to increase the likelihood of obstructive apneas.

My thinking was:
(A) that the air swallowing would occur almost totally at the higher IPAP pressure (for example, 11), so, for example, lowering EPAP from 8 (with PS = 3) to 7 (with PS = 4) would not significantly decrease aerophagia during EPAP (because already little or no air swallowing is occurring during EPAP, so there is little or no further improvement possible during EPAP), and
(B) that the bigger jump when changing from EPAP to IPAP would likely increase the tendency to swallow air.

Not sure about this. It is just a hunch on my part that the larger jump to IPAP (especially if occurring sharply) would likely increase aerophagia more than the lower EPAP would reduce aerophagia.

A longer and slower transition to IPAP (risetime) would be helpful in reducing aerophagia, but on the S9 VPAP Auto the risetime is adjustable only in S mode (not when in Auto mode).
.
The Advisory Member group provides advice and suggestions to Apnea Board administrators and staff on matters concerning Apnea Board operation and administrative policies.  Membership in the Advisory Member group should not be understood as in any way implying medical expertise or qualification for advising Sleep Apnea patients concerning their treatment.
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#19
RE: Help With S9 VPAP Auto Settings
That makes sense, Vaughn. I wonder, then, what is the basic clinical theory is behind switching the patient from CPAP to BiPAP to treat aerophagia? I thought it was common practice.
Sleepster

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#20
RE: Help With S9 VPAP Auto Settings
(06-30-2014, 11:29 PM)Sleepster Wrote: That makes sense, Vaughn. I wonder, then, what is the basic clinical theory is behind switching the patient from CPAP to BiPAP to treat aerophagia? I thought it was common practice.

The closer EPAP is to IPAP, obviously the more it will reduce aerophagia to reduce EPAP. But when the difference is already 3 or more, I am not sure how much aerophagia can be reduced by further reduction of EPAP. Probably depends on the person.

One of the main reasons to switch to bi-level treatment is that many patients have some amount of Upper Airway Resistance Syndrome (UARS) during inhalation, which means additional pressure is needed during inhalation, or else sleep is more difficult and less restful.

Also, in general, a benefit of raising PS is that it makes it easier to breathe. To take an extreme example, when I am in the middle of a central event, if my ASV machine does nothing more than raise PS to around 10 or 11, it will be doing ALL the work of breathing for me.

A downside of raising PS is that it may worsen aerophagia and (even if it does not cause an increase in Centrals, which too much Pressure Support can trigger in some patients) it may cause hyperventilation and too much oxygen in the blood. If for long periods the SpO2 (saturation percentage of O2) is much higher than 96% it can cause health problems. If the O2 content is too high for too long, this will increase oxidation (creation of free radicals), which is a cause of cardiovascular disease (like atherosclerosis), accelerates the normal process of aging, and can render some prescription medications ineffective.

On the other hand, some patients have unusual lung conditions which may benefit from higher PS, like 6 or 7 or 8, just to keep their SpO2 above 90%.

However, if someone is using more PS than about 4 or 5, I think they should be periodically checking (weekly or monthly) their SpO2 using a recording pulse oximeter.



The Advisory Member group provides advice and suggestions to Apnea Board administrators and staff on matters concerning Apnea Board operation and administrative policies.  Membership in the Advisory Member group should not be understood as in any way implying medical expertise or qualification for advising Sleep Apnea patients concerning their treatment.
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