Revision as of 02:25, 6 April 2024

This article is part of the official OSCAR software project. (OSCAR Help)

Oscar Optimisation for Lowenstein

Prisma Smart & Prisma 20A Devices

Lowenstein PrismaLine machines produce a lot of overlays and event flags. If left in default view, this excessive data will overwhelm your OSCAR display. It will make it impossible for forum members and medical professionals, to quickly understand how you are responding to your machine and its settings. Here are a few tips to help clean up that display and make the detailed data your machine is producing, a lot more meaningful.

If you are starting with a fresh Oscar install make sure to optimize first according to apneaboard recommendations here:

https://www.apneaboard.com/wiki/index.php?title=OSCAR_Chart_Organization

	Event Types Let's start by cleaning up the excessive event types. Goto the indicated drop-down at the bottom of the page and select only those event types circled near the top in red. The remaining events are the main ones we are interested in.
	Flow Limitation Flag Color Flow limitation flags can be very visually distracting when there are a lot of them and they are colored black. Change from black to something much milder, like orange or dark yellow. Goto file > preferences > events tab. Double click on the color swatch for flow limitations. The color scheme seen in these examples was used to tone out some of the psychedelia. Any simplification of appearance can be an advantage when going over data with scowling industry professionals. Major event flags are colored mid to dark blue, RERA orange and flow limitations dark yellow.Under the waveforms tab, most waveforms have been set to grey and dark grey.
	Adjust y-axis scaling For a clean and consistent view of your breathing flow rates, right click the Y-Axis (left side) of the flow rate chart and set the Y-Axis to override. Set the axis to -120 min and 120 max. This will give a good all round view of nice regular breathing, along with clear indication of any 'arousal spikes'. While you are in the Flow Rate chart menu, remove all overlays. Finally, click & drag the bottom border of the Flow Rate graph and resize to your preference.

Advanced users may set Y-Axis over-ride on many of the other charts as well. This increases user friendliness and read-ability. Otherwise, outlier data can re-scale the chart, causing irregular display of the main data and confusing day to day comparisons. The increments of Y-Axis may also end up in strange divisions. On the included examples, most of the Y-Axis have been overidden to give a repeatable and consistant view of each metric. A couple that increase usefulness are, leak rate 0-50 with dotted line at leak threshhold and tidal volume 0-1000. Mask Pressure & Pressure can benefit from overide by setting to a tighter range around your own specific pressures. Try make all Y-Axis increments equal whole numbers. A dotted line at max mask pressure can be handy if using APAP.

Prisma Bi-Level Devices

Apart from the above display settings, Lowenstein Bi-level devices can need some extra tweaking.

	Display Deep-Sleep In Bi-level modes deep-sleep is no longer displayed. This data is based off of the rRMVFluctuation signal. When this waveform drops to less than 1.50 it indicates a period of deep-sleep. So if you would still like to easily view your estimated deep-sleep, which is very useful for assessing therapy changes, then you can do this by overriding the autofit y-axis scaling to only show a max of 1.50 Any visible waveform sections will then denote deep sleep periods. Besure to uncheck DS(deepsleep) event type in the dropdown of your main display, if it is not displaying anymore.
	User Defined Flow Limitations Many Prisma therapy modes don't show flow limitations in Oscar. When this is the case (Resmed users included) you can utilize the custom event flagging in Oscar preferences. Setting the second user definable event to a percentage of 70% and length 7sec gives quite an accurate representation of these events.
	User Defined Flow Limitations 2 Rename the event to something like User Defined Flow Limitation and the flag to UDFL. Select its overview option if you would like to see flow limitation over time in the statistics overview screen. Finally, in your event types drop down, deselect the non working FL and select your new UDFL event. NOTE If the custom flags are not showing after restarting Oscar, you will have to use the 'rebuild cpap data' menu option.

PrismaLine CPAP & APAP modes

SoftPAP Compared to EPR

There is quite a difference in the so called "comfort" settings of the various CPAP & APAP machines. These comfort settings are in fact, limited versions of Bi-level or Tri-Level modes of therapy. These modes in a lot of instances, form the basis of the multi-Level therapy found on higher level machines which are normally used for more complicated ventilation needs.

Lowenstein SoftPap is here compared in application to the EPR of Resmed.

Algorithm differences

Below is Oscar's representation of the changing pressure whilst using Softpap2 at a CPAP pressure of 12cmH2o. This offers a pressure support of 3cmH2o. This is the maximum PS achievable with the Prisma Smart and delivers the same support as Resmeds EPR 3, although as you will see, the differing air delivery of the two devices affects how this pressure support affects breathing.

We can see clearly, the bi-level algorithm in use by Lowenstein. Notice that following the drop from IPAP to EPAP, the machine immediately begins to ramp back up to IPAP pressure. It meets closely with the beginning of inspiration. This is how Lowenstein achieves Apnea control at lower pressures. By returning to max pressure near the end of exhalation (when Apneas develop), the airway is fully supported.

In contrast, the Resmed example below shows the very different implementation of its Bi-Level mode. The lower EPAP pressure is maintained, it does not provide a movement toward IPAP pressure until the beginning of inspiration. Full IPAP is not reached until mid to late inspiration.

Often when pressure is insufficient, you can see in a Resmed trace, the second hump in the flow rate and/or the fuller second half of inspiration. The example above has pressure set to 6cmH2o and with EPR of 2 (a common minimum pressure new users are sent home with). You can see the obvious instability. This is why with a Resmed machine, the moment you switch on EPR, you must increase minimum pressure.

This same principle is not generally needed with Lowenstein. This is because of how each Bi-Level mode is implemented. You must use each tool by simply understanding how each works.

Response to Events

Another consideration when setting either SoftPap or EPR, is how each responds during an event. Resmed machines maintain EPAP pressure during events, whereas Lowenstein maintains IPAP or EEPAP pressure. EEPAP is your main set pressure without the 1cnH2o applied ontop during Tri-Level mode.

Resmed EPR3

Lowenstein SoftPap2

Flow Limitations

Lowenstein softPAP 1 & 2 algorithm favors Apnea control at lower pressures, but does come at a cost in some individuals. If you look closely at previous example, you can see the holding of steady pressure right through inspiration, can allow inspiratory instability in susceptible persons. UARS sufferers may experience persistent narrowing of the airway when this mode of therapy is applied.

This is where Softpap3 or Tri-level support comes in. This mode is introduced in the Prisma20a models and beyond. In this mode the machine addresses the problem of flow limitations by adding an extra level of inspiratory support. This mode applies an extra 1cmH2o to your set machine max pressure. This raises your IPAP by 1cmH2o and leverages the increasing pressure and flow to stabilize the airway. This mode has different trigger points for following your breathing pattern.

Normally, in regular Softpap and EPR, the ramp rate is constant. Here, you can see in the example below, that the ramp rate of Softpap3 or Tri-level mode, increases and decreases to stay in time with shorter and longer breaths. The maximum pressure support offered by Tri-Level mode is 4, but only @ 12cm H2o and beyond. Below is a period of flow limitation that softpap 3 is managing.

Unfortunately for Prisma Smart users, this mode of support is not available.

As you can see, each of these machines must be approached very differently in use. They are tools with various modes of operation, different strengths and weaknesses. Lower level machines are factory limited to reduce the amount of useful pressure support. These entry level machines are often only useful for rudimentary control of OSA. Many people who turn up seeking help actually just need these Bi-level or Tri-level modes properly applied. In quite a few instances, more levels of pressure support and trigger adjustments etc will be needed and so a step up in machine required. You would be advised to quickly figure out if your machine will do what it needs to. Stop torturing yourself if you need to move to a better machine.

SoftPap Application in Detail

SoftPap pressure support is variable as pressure goes up. This is best explained visually with another chart. Gotta love charts. Remember that PrismaSmart only has access to the first 2 levels of softpap. Prisma20a and above to level 3 softpap, which is really Lowenstein's Tri-level mode.

You can see that as cpap pressure is increased, the size of pressure support increases at set intervals. 8cmH2o and 12cmH2o are key pressures when this happens. You can have a situation where your IPAP is increased by double that of your EPAP. You can also maintain constant EPAP, whilst auto apap increases your IPAP pressure like this below. Where this could come into play is if you are sitting just beneath one of these pressures with your Apnea well controlled but can benefit from a bump in upper pressure limits during REM. If a user is shy of high pressure, or suffers aerophasia around one of these pressures, this smaller step in EPAP can help. You could, as above image shows, set APAP with a range of 11.5cm to 12cm & softPap 3. During REM or a positional change etc, the extra support kicks in on any flow limitations that develop with virtually no detectable EPAP increase. The Prisma20a can hold this extra pressure for just the right length of time during a rough patch, before letting you back down. This may only put you into aerophasia territory for a very limited time the whole night and minimizes disturbances from moving pressures. Also of note, is what happens at low pressures using SoftPap. On SoftPap 3 the first few pressures are identical. I wonder how many beginners and doctors think they are gradually increasing their pressure over a period, when they are actually not changing anything but a number on the LCD display.

PrismaLine Bi-Level Modes

Bi-Level Lowenstein models like the Prisma25ST and Prisma30ST offer an array of features for bi-level therapy. All of the modes described sofar and those immediately following form the main body of machines offering what is known as pressure targeted ventilation (PTV). This is in contrast to volume targeted ventilation(VTV). PTV aims to hit settable pressure targets like IPAP and EPAP, leaving volumes variable, whereas VTV aims to hit a settable Volume target where pressure remains variable. PTV is used in a majority of non invasive ventilation machines.

Due to the increasing complexity of Bi-level support, and the miriad of adjustments offered by Lowenstein, a number of predetermined settings called "scopes" are provided in each mode. These presets are designed and tested to be a starting point for differing pulmonary conditions and co-comorbidities. These are:

• OVERLAP which is designed for users with obstructive sleep apnea and mild to medium COPD.
• HYPOV which is designed for users with nocturnal hypoventilation.
• OSAS which is designed for users with severe obstructive sleep apnea and a high pressure requirement.

We are going to try explore the various settings available to not only adjust a "scope", but also for creation of your own "scopes". Custom scopes can be manually entered directly into the machine or saved and recalled from within the PrismaTS software and uploaded to a device via LAN or SD card.

With pressure targeted ventilation, volume is variable. This is determined by the interaction of machine settings, user physiology and pulmonary condition. The variability of this system necessitates careful assessment of each of these three areas, to allow making informed choices when trying to achieve ventilation synchrony, a concept whereby machine and user are in time and satisfying the respiratory need without fighting each other, which can cause arousal and poor sleep quality, despite possible OSA control.

A major setting to grasp on Lowenstein Bi-/Tri level machines, is BisoftPAP. This alters pressure settings and shapes the delivery algorithm dramatically. It is settable in every mode except T mode. The four settings are BiSoft0 (Off), BiSoft1, BiSoft2 and TRILevel
	These BiSoft modes incrementally apply a gradual ramp upto a pressure called EEPAP (end expiratory positive airway pressure). This end of expiration pressure is a critical time for airway collapse and pre-stenting in preparation for inspiration. Lowenstein recommends that a user be setup in one of the Bi-Level stages first, then apply Tri-Level setting to apply their predetermined reduction of pressures for comfort. It is also recommended to return to Bi-level for further adjustment. I believe this is because the machine adds and subtracts pressure from IPAP and EPAP in unpredictable ways due to unseen algorithms as you reach certain pressures.

Further adjustments to the flow shape can be made.

Trigger An inspiratory trigger sensitivity is settable in 3 stages or can be left in Auto for the machine to determine.		Ramp Pressure rise time can be set to three levels and affects the duration of the inspiration ramp.
Ti/Tset The relative inspiration duration can be set between 25% - 67%. This controls the threshold of peak flow for cycling to expiration.

S

T

S/T

Auto S

Auto S/T

Anticyclic Servoventilation

The PrismaCR models of Lowensteins PrismaLine range offer an ASV mode for treatment of central and mixed apnea.

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