ResMed AirCurve 10 VAuto or ST

[biyahero]

The Airmini is not going to resemble a bilevel machine, however you can use EPR on that machine.  The Airmini clinical manual is available from Apnea board by request. Follow directions here.  https://www.apneaboard.com/adjust-cpap-p...tup-manual
 
It should be easy to set the Airmini to 16-20 with EPR 3, but of course this is nothing like what you will get from the Vauto.

Thanks Sleeprider.  

I understand that the AirMini won't be anything like the AirCurve VAuto, but I hope that it will be good enough for my frequent (every other month) 10 - 14 day travels so I don't have to drag the AirCurve around the world and deal with the increasingly obnoxious and intrusive airport security.  

Do you think I would suffer any deleterious effects from using the AirMini maybe two weeks every other month and the AirCurve VAuto the rest of the time?  

The only problem I seem to have with the AirMini now is since I use an F20 Full Face Mask there is no humidity available on the AirMini and my mouth gets dryer than with the AirSence 10 AutoSet.. aside from the Ramp Up appears to start at 5 cwp which makes me feel like I am not getting enough air until it increases ... which I hope I can fix by changing the settings.

[jaswilliams]

I would personally would not use a travel machine for 30% of my sleep if it does not provide effective treatment (10 days out of 30) I would carry my full-size machine when I travel. In fact I do I work abroad 4 days a fortnight and carry my full-size cpap device with me

[Sleeprider]

I'm certain you can change the pressure and time settings for ramp. I'm sure you are aware of the Resmed HumidX and HumidX Plus that can be added to increase humidity (heat-moisture-exchanger HME). These only work with the nasal and pillow masks. I can think of a way that your F20 could be retrofitted to use it by using materials like are described in the EERS wiki. Unless you pack a free-standing humidifier, I don't see a current solution for that problem, and that would take away any size advantage to the Airmini.

As far as negative effect, I think you may not sleep as well, but it shouldn't affect your health. I don't find the Aircurve too large to pack, even on the motorcycle, so while I understand you are traveling the world on business, I still don't see the Aircurve 10 as a show-stopper.

[biyahero]

I'm certain you can change the pressure and time settings for ramp. I'm sure you are aware of the Resmed HumidX and HumidX Plus that can be added to increase humidity (heat-moisture-exchanger HME). These only work with the nasal and pillow masks. I can think of a way that your F20 could be retrofitted to use it by using materials like are described in the EERS wiki.  Unless you pack a free-standing humidifier, I don't see a current solution for that problem, and that would take away any size advantage to the Airmini.

As far as negative effect, I think you may not sleep as well, but it shouldn't affect your health.  I don't find the Aircurve too large to pack, even on the motorcycle, so while I understand you are traveling the world on business, I still don't see the Aircurve 10 as a show-stopper. 

That might be something I could do to get a free standing humidifier and leave it at the place I stay for up to two weeks or so and use it when I am there.  That way I would only be using the AirMini without the humidifier for a day or two while actually traveling.  I could conceivable drag the AirCurve 10 around if I find a suitable backpack again.  I had one before that would accommodate my computer and the AirSense 10 but the burglars got it last year and I haven't been able to find a replacement that allows the zipper to open all the way to the bottom which is what I need to be able to get the AirSense to fit in it.

A more pressing issue now is that I forced the VA to take back the unused ST machine they issued me by tricking me and claiming initially before I went there to pick it up that it WAS a VAuto, and then later when I went there and said look it says ST not VAuto the vendor lied again and claimed it was better and had all the same capabilities as the VAuto and more.

When I researched that and found it not to be true, I complained and now returned it.  

However the complication is that the way my Sleep Doctor wrote the initial consult indicates that she wanted a fixed pressure unit, which is what the ST machine was set to in "S" Therapy Mode. Now the VA is saying what is the reason I want the VAuto because the fixed pressure therapy mode on the ST machine complied with the "consult" which did, because it was poorly written, indicate she wanted a fixed pressure mode, when in fact she wanted all along the VAuto.

So now the VA refuses to order the VAuto  until or unless I convince them why the ST it unsuitable.  They said:

I had an extensive discussion with [...], for your machine. Given the prior machine that was ordered is very similar to the new one that was placed, that it's best to get input from pulmonary regarding why this specific machine is now being requesting. We have had difficulty getting records from Dr. XXX let alone contacting her and thus are requesting a consult from our Pulmonologist to help guide the proper selection for machine before a new one is ordered. I'm apologize for the inconvenience. It is not clear in the notes from XXXX as to what the exact settings are. 

So is there a concise (so that maybe they can understand it) way to explain the difference between the ST AND VAuto machines.  Otherwise their plan is I have to fly back around the world for the "earliest appointment" with some new bozo in Pulmonary to argue about settings on July 26 before the will maybe order the correct machine.

[biyahero]

Well I sent this information to the VA PCP describing the differences in the various modes:

VAuto
    Automatically Adjusts Pressure in response to flow limitation, snore and obstructive apneas. 
    Pressure Support (PS) is fixed throughout the night and can be set by the clinician.
    
    S (Spontaneous)
    Senses when the patient is inhaling and exhaling, and supplies appropriate pressures accordingly.
    Both treatment pressures are preset: Inspiration (IPAP) and Expiration (EPAP)
    
    ST (Spontaneous Timed)
    Augments any breaths initiated by the patient, but also supplies additional breaths if the breath rate falls below
    the clinician set "backup" respiratory rate. For patients with COPD, NMD, OHS and other respiratory conditions.
    
    T (Timed)
    Supplies a clinician-set respiratory rate and inspiratory/expiratory time regardless of patient effort.
    For patients with COPD, NMD, OHS and other respiratory conditions.
    
and how I don't have any conditions that would make ST or T modes useful at all, that the ST machine only has the last three modes and what I need and what my Sleep Doctor wanted me to use was the VAuto mode which is not present on the ST Machine.

I also supplied the VA Doctor with the "complete list of settings" for the VAuto machine she has been harping about for months, and an explanation (thanks to the information I learned here in this forum) that if the machine were set that way in VAuto mode the my therapy would start at IPAP 16 (Min EPAP + PS) EPAP 12 and the VAuto Therapy would sense the pressure I need and respond accordingly ... if I needed more pressure it would increase up to Max IPAP 25 and EPAP 21 if needed, but it would not unnecessarily start out and stay at the Max IPAP 25 and Min EPAP 21 the whole sleep period as would be the case if the machine were operated in S (Fixed) Therapy Mode. 

My Sleep Doctor also sent the VA Doctor an email supporting the VAuto Choice.

The VA Doctor doesn't care to understand that, as her assistant replied:

Dr. XXX (the VA Doctor) did get the email from Dr. XXX (my Sleep Doctor)i. Due to the complexity of your case Dr. XXXX (my Sleep Doctor) agrees that you should see the Pulmonologist. You will need to see them in order to get the new machine. 

Yeah right, the complexity of my case.

They just want me to accept the ST Machine that their vendor had on hand, which I am not doing.

So now it is just waiting to see the "earliest appointment" for this Pulmonologist Clown on July 26 and hope he is not just a puppet of the VA Doctor and will cause them to order the VAuto machine.

[biyahero]

[...]
I can think of a way that your F20 could be retrofitted to use it by using materials like are described in the EERS wiki.  Unless you pack a free-standing humidifier, I don't see a current solution for that problem, and that would take away any size advantage to the Airmini.

As far as negative effect, I think you may not sleep as well, but it shouldn't affect your health.  I don't find the Aircurve too large to pack, even on the motorcycle, so while I understand you are traveling the world on business, I still don't see the Aircurve 10 as a show-stopper.

Sleeprider could you please advise me on where I could find thei EERS Wiki? I wouldn't pack a free-standing humidifier but I might get one and leave it where I spend a week or ten days on my trips and that way I would only have no humidification during maybe 24 to 30 hours during the actual traveling and sleeping in airport transit areas.

I used to carry my AirCurve 10 AutoSet around with me, so if ever I actually get my AirCurve 10 VAuto I could do it if I find the correct backpack replacement that will accommodate it and my computer, but that is why I purchased the AirMini to avoid the airport hassles where lately they want you to take everything electronic larger than a cellphone out of your bag and inspect it.

[Sleeprider]

Here you go for EERS http://www.apneaboard.com/wiki/index.php...ace_(EERS)
All the parts are readily available, and I think the article also links to the thread where other users of EERS discuss their experience. In your case, we are talking about blocking the vent on your mask, adding a single 6-inch or less piece of Corr-A-Flex, and attaching the safety valve and Whisper vent between your CPAP hose and the mask. An HME would be fitted between the safety valve and the mask.

It looks like you have made all the right arguments for the Vauto. One feature the ST lacks that is in most other VPAP models is the "Easybreathe ™" algorithm. This is the flow shaping that makes the VPAP S, Vauto and ASV have the wave-shaped pressure transitions between EPAP and IPAP. The ST on the other hand has a square wave without pressure transitions, so basically provides EPAP pressure and switches IPAP on and off abruptly. The comfort difference is very notable. An additional argument would be to read the intended uses of the ST machine from the Resmed Titration Guide. I believe the information is on pages 28 and 34. https://www.resmed.com/us/dam/documents/...er_eng.pdf

In addition the ST is a different higher class of machine than the Vauto and VPAP S, both of which provide bilevel therapy consistent with HCPCS Code E0470, and are the same Medicare insurance billing code. The ST on the other hand is a bilevel with backup rate and is normally not provided without appropriate complications such as COPD, Neuromuscular disorders or obesity hypoventilation. It is HCPCS billing code E0471. It makes no sense to provide you with this more expensive therapy targeted at pulmonary disease. No doctor or pulmonologist would agree with your sleep doctor who clearly has no clue about the use of these machines.

[biyahero]

It looks like you have made all the right arguments for the Vauto.  One feature the ST lacks that is in most other VPAP models is the "Easybreathe ™" algorithm. This is the flow shaping that makes the VPAP S, Vauto and ASV have the wave-shaped pressure transitions between EPAP and IPAP.  The ST on the other hand has a square wave without pressure transitions, so basically provides EPAP pressure and switches IPAP on and off abruptly.  The comfort difference is very notable.  An additional argument would be to read the intended uses of the ST machine from the Resmed Titration Guide.  I believe the information is on pages 28 and 34.  https://www.resmed.com/us/dam/documents/...er_eng.pdf  

In addition the ST is a different higher class of machine than the Vauto and VPAP S, both of which provide bilevel therapy consistent with HCPCS Code E0470, and are the same Medicare insurance billing code.  The ST on the other hand is a bilevel with backup rate and is normally not provided without appropriate complications such as COPD, Neuromuscular disorders or obesity hypoventilation.  It is HCPCS billing code E0471.  It makes no sense to provide you with this more expensive therapy targeted at pulmonary disease.  No doctor or pulmonologist would agree with your  sleep doctor who clearly has no clue about the use of these machines.

Thanks for the info about EERS SleepRider!

As for the Vauto, the information in your last post is the best yet in explaining why the ST machine is unsuitable, and much better that the charts and other information in the Resmed Titration Guide, especially the information about wave shaped vs square shaped pressure transitions, as well as the intended use for the ST ... that part about the intended use for the various models I have already told the VA Doctor and the Prosthetics, who has to actually order the machine, about a gazillion times already and sent them the charts from the ResMed Manual showing the therapy modes available on each model.

So I will use your wonderful explanation above as ammunition to get them to admit the difference in the machines.

Just to clarify, my Sleep Doctor is not the one at fault here ... she is wonderful and really has gone out of her way to try to get me the VAuto machine.  It is true the her consult that was sent to the VA Doctor was poorly written ... perhaps by her assistant ... and that consult did indicate that she wanted a fixed pressure machine, as it said "CPAP max pressure is only 20cwp and suspect he needs more pressure. Will change to Bilevel 25/21cwp which the VA will provide.".  

So that is part of the root of the problem.  However that very night I asked her which BiLevel she wanted me to use and she said the VAuto, and in uncountable phone calls and email messages since then she made it clear to the VA Doctor that she wanted the VA Doctor to order the VAuto. She also consulted with her ResMed Rep and he agreed the VAuto was what I should have.

The way it works at the VA is my Sleep Doctor has to sent her "consult" record or prescription for what machine she wants the VA to order for me, the the VA Doctor sends an order for that machine to Prosthetics who actually order the machine (if they feel like it). So in spite of the fact that my Sleep Doctor has done everything possible to make it abundantly clear that she wants the VAuto to everyone, my VA Doctor chooses to not understand.  

Now I did eventually ask the VA Doctor's assistant how that ST machine got chosen and ordered and his response was:

I pulled up the consult placed on Jan 25 for your BiPap machine. 

It was ordered as: "Positive Airway Pressure (PAP) Therapy (Choose ONE) 

Fixed Bilevel (BiPAP) Therapy 

Machine: Resmed Aircurve 10 Bilevel S/T with HumidAir and ClimateLine Air # 37307 

Pressure: bilevel 25/21 cwp" 



I then pulled up the notes from Dr. XXX (my sleep doctor) and it does say "Will change to Bilevel 25/21cwp which the VA will provide." 
But I do not see the actual name of the machine in her notes. 

So I responded that it looked like to me that the (Choose ONE) meant they were using a computer program that offered multiple choices of machine and they happened to choose "Resmed Aircurve 10 Bilevel S/T with HumidAir and ClimateLine Air # 37307" at random, when IF IF my Sleep Doctor really wanted a fixed bilevel machine as the poorly written consult indicated she did, then there should have been other menu choices such as "Resmed AirCurve 10 BiLevel VAuto with HumidAir and ClimateLine Air SKU 37212 ". I am sure there also would be a menu choice for "Resmed AirCurve 10 BiLevel S" machine as well since the S, VAuto, and ST machines can all be set to operate in S fixed mode.

It turns out that I was correct and the VA Doctor did put in a new order using that menu for the "Resmed AirCurve 10 VAuto with HumidAir and ClimateLine Air SKU 37212". 

However Prosthetics in the meantime had found out that a local supplier had a ST machine and wanted to get me off their back when I appeared there to complain about why I had not gotten any supplies in six months, and they lied to me when I asked if they were sure it was a VAuto Machine, as did the vendor when I called before going there.

Now the VA Doctor and Prosthetics both claim to not understand the problem since the ST machine can operate in S Therapy Mode, which is what technically the original consult did say, although my Sleep Doctor has gone to extraordinary lengths to make it clear to them that the VAuto machine is what she want operating in VAuto Mode.  They pretend to not understand because they want to pawn off this ST machine on me.

So our latest plan now is that my Sleep Medicine Doctor is going to fit me in her schedule in June for yet another consult and in the report for this consult she will make extremely clear that she wants the VAuto machine AND specify the "exact settings" which my VA Doctor has been harping on for months, so they can't pretend that she wanted a Fixed Level BiPap operating in S Therapy Mode, even though they should understand that after she has sent them about a gazillion messages and phone calls specifying the VAuto.

So we'll see what happens next. 

Thanks so much for your great explanation of the differences in the machines, especially this part, which I can use in arguments about why EVEN IF we wanted a fixed level machine, the ST is not suitable!

"Easybreathe ™" algorithm. This is the flow shaping that makes the VPAP S, Vauto and ASV have the wave-shaped pressure transitions between EPAP and IPAP.  The ST on the other hand has a square wave without pressure transitions, so basically provides EPAP pressure and switches IPAP on and off abruptly.  The comfort difference is very notable.

[Sleeprider]

Hopefully you can get it straightened out. The easiest solution would have been if your doctor had specified the Aircurve 10 Vauto from the beginning, and prescribed or suggested a range of bilevel pressure. I'm sure you will find the Vauto is much more comfortable thanks to Easybreathe™. In addition to that feature, the Vauto allows the sensitivity for IPAP trigger and EPAP cycle to be fine-tuned, as well as minimum and maximum inspiratory time (TiMin, TiMax) to be set. The settings can be used to further enhance efficacy. I believe the use of the settings was discussed in the titration guide. The ST lacks these features.

[biyahero]

Hopefully you can get it straightened out.  The easiest solution would have been if your doctor had specified the Aircurve 10 Vauto from the beginning, and prescribed or suggested a range of bilevel pressure.  I'm sure you will find the Vauto is much more comfortable thanks to Easybreathe™.  In addition to that feature, the Vauto allows the sensitivity for IPAP trigger and EPAP cycle to be fine-tuned, as well as minimum and maximum inspiratory time (TiMin, TiMax) to be set. The settings can be used to further enhance efficacy.  I believe the use of the settings was discussed in the titration guide.  The ST lacks these features.

Thank you Sleeprider.  That is more good information that I didn't know about the ability for sensitivity for the IPAP trigger and EPAP cycle to be fine tuned, as well as minimum and maximum inspiratory time (TiMin, TiMax) to be set. 

I looked at the titration guide and he chart with the checkmarks of the features for the different machines, but for example the EasyBreath Feature I really didn't know what it did until you explained it!

So hopefully I will get it straightened out one way or another.... right now I'm working on being fit in my Sleep Medicine Doctor's schedule at the end of June when we will both be there.  

It would have been easiest if she had specified the AirCurve 10 VAuto specifically in the beginning as you say, but she didn't, and none of us including me are perfect, so we'll just have to work with this.  She always has really gone out her way to give me the best care possible ... even beyond the scope of Sleep Medicine ... more so than any of my other Doctors, so I will never be critical of any mistakes she may have made.

In the meantime, should I be transitioning to OSCAR?  I still have the original SleepyHead Version v1.0.0-beta-2 for Mac, and am still very much a novice with it.  It has a bewildering array of information, which apparently I did something wrong the first time I tried to post a chart here since it didn't come out.  Would I be better off upgrading to OSCAR now and if I do that should I first uninstall SleepyHead?

I did learn some surprising things from SleepyHead, one of which one which was that the pressure goes up and down throughout the night and doesn't just go up to 19.8 and stay there as I would have expected from the sleep report shown on the AirSense 10 Machine. I did notice that every three or four months there were be a super brief "Clear" event (which would show on the machine as 0.1) and of these 3 events over the past year, all of them occurred at pressures of ~ 14 cwp, so I changed the settings on my AirSense 10 from 12-20 cwp to 16-20 cwp and there have been no more of these events since.

Thanks for your continued invaluable help!