ResMed iVAPS - how do you set it up?

This machine seems a bit complicated compared to a normal bi-level machine. There are settings for height, target patient respiratory rate, pressure support min and max, and EPAP. I have read the titration guide, but it also seems like the machine has an option to "learn" the optimal settings automatically? Wondering if there are any other users out there .

Hi, I might be able to help a bit and run you through the settings.
First off I'd put up your sleepyhead chart. we are going to use your average respiration, tidal volume and minute vent from that.
I would also get the resscan program from apneaboard in their software section. It will also show your Va (alveolar ventilation). The st-a has few glitches with sleepyhead, but sleepyhead is still worth using too.
It seems more complicated than it actually is.

Here are screen shots from last night in iVAPS mode:

Looks like SleepyHead may be having some partial issues with this fancy machine.
You might want to get ResScan up and running if you can.

Yes, you will need resscan as well. I said where to get it in my first post, let me know if you have trouble.
did you also get the s9 st-a clinical manual, also available for apneaboard

do you have a full face mask? it will take out any variables like mouth breathing and would be better to set up the machine, you can go back to nasal afterwards.

Okay, put in your height, and tell me and I will double check your settings on my machine.
target pt rate 19
adjust target Va till you see MV 6.2l/min ( tomorrow it will either be around 6.2 or what sleepyhead shows 'Med, minute vent, 6.5' now, or inbetween. we can adjust from there, what we don't want to do is over ventilate, so it's to double check your current settings)
what number does it give for Vt when you do the Va and MV adjustment? and what Vt/kg number?

leave it as epap min 10 for now.
what is you min PS? 3 or 4?
have max ps as high as the machine will go.

what is the Ti min/max, rise time, trigger and cycle?

I just got resscan. I am using the aircurve 10 st-a, but the manual is pretty much the same as the s9.

right now my settings are from previous:

target patient rate: 17
min ps: 6
max ps: 20
epap: 4 (I don't have osa, i am using this machine purely to ventilate - i have a severe restrictive lung disease)

target Va is 4.4
mv is 5.6
vt is 334 ml
vt/kg is 8.1 ml/kg ideal body weight

if i switch pt rate to 19 then the mv gets closer to what it shows as a result, at 6.1


ti min: 1.5s
ti max: 2.7s

trigger: very high
cycle: very low

the longer Ti helps the inhale not cut off for me.


my respiratory rate has been decreasing slowly as ive bumped up the target Va, probably because i'm getting more air/tidal volume so less hypoventilation is happening.

i'm not sure exactly how to set height...my spine is very curved so i dont stand exactly straight. my height gets measured at the doc around 58-59 inches. so that chart you showed me earlier my vt needs to be up to about 400 - 420?

do you have the current titration guide?
https://www.scribd.com/document/3676589 ... Amer-Eng-1

I still use the previous one, as I'm lazy.
https://www.scribd.com/document/3534028 ... -Titration

keep epap at 4 and min ps at 6
I'd still have the max ps to 25

What is the rise time? default is 300ms for restrictive

put your target patient rate on your actual respiration rate, so it would be 19 (in ST mode you have the backup rate a couple under your actual rate and 17 would be right)

You want the longer insp when you first lay down, till your breathing settles?
you max insp was 2.08, so more than 2.10 should ever be needed as your max and you won't need 2.5. I'd also be fine with 1.6, Default on RR 19 is 1.6 and your Med was 1.58
min insp 0.8 default. I think your min 1.5 might be a bit high, as it is just under your Med insp. unless this is what your doctor wants. I'd try 1.0-1.2 if you want to. 0.8 should also be fine.

give yourself a bit more Va to bring the MV to 6.2 or 6.3
The tidal volume and respiration rate work together, one goes down and the other goes up. As you are finding out, the RR is also settling as you tune the Va. For now I would stick with RR19, till you have the machine working okay and adjust the RR as to your results. and then if needed, have a look at decreasing rr and increasing Vt through more min PS with your doctors approval.

I think you may finish up with Va 4.8 with RR19, but we will go slowly. I put your stats in my machine
https://i.imgur.com/Un48Gpp.jpg

my rise time is set at 300ms. seems the most comfortable for me out of all of them.

i'll lower my ti min a bit. just wanted to make sure im not able to breathe shallow at night while asleep. the machine is smart and actually limits my ti max when i raise my target rate. at target rate 19 the ti max allowed is 2.1 sec. I'm going to lower the ti min to 1.2 sec tonight and see how that goes.

my rr is normally kind of high, it takes more work to breathe for me in general.

i'll post the charts tomorrow after the night. with the resscan as well. until then - thanks

Or, if you don't want to deal with the scribed nonsense:

https://www.resmed.com/us/dam/documents ... er_eng.pdf

Here is last night in both sleepy head and res scan. I screen shot the machine's actual settings and then the results from res scan. Since I bumped down my Ti min, looks like my respiratory rate got a bit faster. But that could also be because of the lower tidal volume.

In prefix, but I could be wrong.
Va 4.6
Ti min 0.8
rise time 200
pressure the same
try medium trigger, it shouldn't feel like you are sucking to get it to increase pressure, nor should it fell like it is ahead of you. I'd also try low cycle, you have a mechanical problem and not a neuromuscular. I would need to look into whether I would suggest medium cycle. I'm not sure, so try default low.
use your F20 mask and put your cms50 up
you don't use Ti for other than it is meant to be used for.


the rest...........
One thing I saw you write as I read an old thread is that you weren't under the care of a sleep doctor/pulmonologist? I don't know your insurance, but I can understand you not wanting the cost of further sleep studies. You really do need a good doctor though. Some of the stuff that I read you were told, is just scary wrong.

I'd try Va4.6 because you were titrated at 20/4 and that was MV6.8, we are splitting the difference between now and then. I saw on that thread that you have a cms50, It would give you good feedback while you set up your machine now.

still min ps still 6 for now, I think the auto Va will get what it wants. Your required PS will and does vary during the night, depending on sleep position and such.
minTi of 1.2 is better I:E ratio and has bought your MED down from 1.5 to 1.25, you do need time to exhale with RR19
I'd still go min Ti 0.8, which is a long min setting when 0.3 is default normal. Your insp time should stay above this. at RR19 your cycle is 3 seconds. I would read more about Ti and what it does. I'd move rise time to 150-200 and perhaps increase epap/peep and min PS, if you think you want quicker/deeper inflation from shallow breath. The way you had it was like a PAC mode that does a timed I:E. That isn't what you need. The Ti settings you had didn't have room for you to move. I've had issues with the person who told you to increase the Ti with other matters. Forums can be dangerous, including what I say. It should all be put past your doctor. If you haven't a good one, get one. Forums are to fill in the gaps between appointments and to suggest questions to ask.


stuff to think about.
Some nasal masks can leak with the high pressure pulse and I don't think the machine will show a pulse leak properly. It needs to be manually checked. I haven't used the mask fit function that blows higher pressure on the st-a. try it and see if it blows high enough. You could also put it in S mode at 30/25 to see if you are getting leaks.
You still have the F20 FFM available? That would be better while you are setting up the machine and removes variable factors, like the mouth breathing you were having. Disadvantage is if you have a beard. It will have to go to mutton chops/side burns for now.

I found an old chart where you were on S mode 20/4. You were titrated on that and MV was 6.8, TV/Vt was med 340, 95% 440, max 880 and still a RR 19
If an 20/4 gave those numbers, there is no sense trying use more PS for more Vt. 300-340 may just be a volume your chest is happy with for now.
http://i.imgur.com/vsDgLEo.jpg

do you have afternoon naps? If you do, it is a good time to try different settings to see if it's better or worse. Have you done the learn mode for a half hour and see what the machine suggests for RR and Va and that will give the rest. I would use the default Ti min 0.8 and min PS4 for this. It will give another data set. (I only used it once and the results weren't anywhere close to what cpap mode was showing in sleepyhead, so I used that)

I didn't see what the doctor wants as a target Va or MV posted by you. What was the original iVAPS script? Given it's a mechanical and not a nuromuscular problem, it also has other factors.
So far it looks like you may to follow the settings, reduce it to 4.4 you get 4.4, I don't know if that is too high or too low.
If MV 6.1 is the right one for you or closer to 6.4 or even the 6.8 from 20/4. It would depend on your size, health and general lung ability to exchange o2 and co2.
The cms50 can also help here, if your o2 is over 92% with minimal time under 92%. You have a decent machine that will finely adjust how much air you are getting. I would also get a blood gas to confirm it's all okay.

When I was titrated a few years ago it was indeed 20 ipap / 4 epap, and thankfully I was under direct care from the director of pulmonary care. he told the lab to go straight to bi-level if the CO2 rose to a certain level for a certain amount of time. And to only raise IPAP when CO2 rose, and to only touch EPAP if I had obstructive apneas (which I didn't). It was a split-night though, so I slept maybe 4-5 hours using the mask?

Unfortunately I live in NY now and so far I have seen several clueless sleep docs. They don't know what iVAPS is, have never heard of a trilogy ventilator (as an example), etc. I met a neurologist at a sleep clinic and I had to show her a picture lol. They also don't care to look into my issues - all they do is view the compliance data and see that my AHI is under control. I may be moving to my old city next year so I'd probably go back there when I get the chance if my new job insurance would cover.

I did have a problem last night while awake before falling asleep - the stupid machine kept forcing a breath ahead of me, so it did machine breaths at 19 bpm rr for almost an hour. I don't think I've ever seen that happen so long. My median inspiratory time last night was 1.48 - when ti min is 1.2 and ti max is 2.1, so i do think i will need to bump the ti min up some as i increase the target va / tidal volume, as its causing me to breathe slower. or maybe like you said, relax the trigger/cycle to high/low maybe, instead of very high/very low. My inspiratory time chart shows that I am often breathing near the Ti max of 2.1 seconds. i had the trigger on high because maybe a few months ago i found while awake i was trying hard to inhale and sometimes the machine wouldn't respond. i could probably loosen the cycle a bit though.

I can tell you that last night, since I bumped up the target Va to 4.7, I feel better overall (less headache, easier to breathe [that one is subjective, and could be a lot of variables of course]). I will post those screens sometime today when I get a chance. of course the mv and vt increased as they should.

i am not sure about adjusting the rise time at this time - i find the 300ms pretty comfortable and 3-6 is recommended for restrictive lung people. and it seems my rr is going down as we increase the target va, so the longer rise would make sense to me. i like reducing the rr, as that decreases the wasted air dead space in each breath. i would agree though if my rr remained 20+ that adjusting the rise time to match though (faster) makes sense.

i have a full face mask (F&P simplus) but i'm not really a big fan. I tend to breathe through my mouth at night when i use it and i wake up more often, and in the morning i have gross "gunk" built up into the corner of my mask, and dry skin around my mouth. i have played with humidity of course but doesn't help. i can also feel the pressures wings way more with the ffm. i seem to need higher pressures as well. i think my nasal mask has good leak numbers honestly...but i do get your point about removing variables.

i think i should probably be getting to around 350 - 420 tidal volume. last night was 340ml and i felt better than with 300ml. if i am 59 inches than Respironics recommends 420ml, but i may not need quite that much, my chest wall is very rigid so my lungs don't properly inflate, so it may be no use to move that much air in and out.

Here are last night's screens:

I'd trust resscan numbers and use sleepyhead chart, because the resscan charts are hard to set up
back off the RR to 18 and reduce it down as you go, you could even preempt it and try 17, I don't know where it will finish up. You can see in the sleepyhead respiration chart the straight line, where you were over cooked and needed a lower RR. You can also see it in the drop of spontaneous triggered breaths to 53%, the machine giving you a breath 47% of the time.

I'm happy with Va4.7 if you are. when I dialled you into my machine it came out at 4.8 in the picture link that I posted before. I had your MV 6.5 and height at 155 to allow for the curvature. It's just easier to build up to this and adjust on the way. I would also want the cms50 to confirm all's well. you may not need as much. The machine is guessing the dead air space in your wind pipe, it may be altered from the curvature.

your tidal volume will change with your RR, one will go down and the other up, the machine is going to give you Va 4.7 and will sit you on 30cm if it has to. there was a half hour at 4:00 when it needed a bit more pressure and got up to 24cm.

You are misunderstanding what Ti does, because I think of bad advice. It is also why I don't like advising over the PM, if someone thinks I'm wrong, they will challenge me to show why. It's a whole lot safer. Mistakes can be made by anyone. We are all just cpap users, none are med qualified.
Back it off to min 0.8 and see. Ti doesn't substitute for properly adjusted machine. If you told me you were going to try the default 0.3 for a normal for a night, I'd say I think it will be okay. It isn't a factor in your average inspiration time or respiration rate. They want the min a bit longer than for a normal min 0.3 to make sure you get better mixing of air. They don't want a short breath under 0.8 at RR19.. lets split the difference and you try 1.0 tonight, if you can get your RR down to 15 it will be right, going by the titration guide.

ajack wrote: ↑

Sun Apr 08, 2018 9:55 am

I'd trust resscan numbers and use sleepyhead chart, because the resscan charts are hard to set up
back off the RR to 18 and reduce it down as you go, you could even preempt it and try 17, I don't know where it will finish up. You can see in the sleepyhead respiration chart the straight line, where you were over cooked and needed a lower RR. You can also see it in the drop of spontaneous triggered breaths to 53%, the machine giving you a breath 47% of the time.

I'm happy with Va4.7 if you are. when I dialled you into my machine it came out at 4.8 in the picture link that I posted before. I had your MV 6.5 and height at 155 to allow for the curvature. It's just easier to build up to this and adjust on the way. I would also want the cms50 to confirm all's well. you may not need as much. The machine is guessing the dead air space in your wind pipe, it may be altered from the curvature.

your tidal volume will change with your RR, one will go down and the other up, the machine is going to give you Va 4.7 and will sit you on 30cm if it has to. there was a half hour at 4:00 when it needed a bit more pressure and got up to 24cm.

You are misunderstanding what Ti does, because I think of bad advice. It is also why I don't like advising over the PM, if someone thinks I'm wrong, they will challenge me to show why. It's a whole lot safer. Mistakes can be made by anyone. We are all just cpap users, none are med qualified.
Back it off to min 0.8 and see. Ti doesn't substitute for properly adjusted machine. If you told me you were going to try the default 0.3 for a normal for a night, I'd say I think it will be okay. It isn't a factor in your average inspiration time or respiration rate. They want the min a bit longer than for a normal min 0.3 to make sure you get better mixing of air. They don't want a short breath under 0.8 at RR19.. lets split the difference and you try 1.0 tonight, if you can get your RR down to 15 it will be right, going by the titration guide.

Ah okay i had my height set to 58 inches, which according to res scan is 145cm (google says 147cm to be exact, but the resmed machine only goes by 2 inches at a time of course). So that should explain why our values will vary a bit when dialed in.

According to ResMed, the ti min setting helps to insure adequate time for gas exchange. Since I have a chest wall disorder, the online research says someone like me often prematurely cycles from IPAP to EPAP.

That's why I raised the Ti min a bit, because sometimes the breathe cut off while awake, so I imagine it gets even worse while asleep. Like I can have a measured Ti on the screen of 1.8s live and awake, and then machine still cuts over to EPAP unless i raise the Ti min. The trigger maybe too sensitive - maybe I should try "high" instead of "very high."

Of course, I wouldn't want the machine to force a Ti (like in pressure control mode) necessarily. But I think the idea is to breathe more like a "normal person" at night, so I can counter act what I'm doing while awake (fast rr, shallow breaths to minimize work of breathing).

I read from a ResMed paper from one of their sponsored RT's about "complex ventilation strategies" or something like that, and it says to monitor the Ti while awake, and then make sure there isn't a large discrepancy when asleep (say i breathe Ti 1.6s while awake, then when asleep my body defaults to the Ti min of say .8 seconds - they would consider that a problem worth raising the Ti min a bit for - to prevent the shallow fast breathing). Of course, as I raise the tidal volume that may sort itself out anyway - could just not be getting the amount of volume I want.

I'm going to try 18 bpm target rate tonight, and adjust the dial so the target Va is around 8ml/kg. Hopefully way less forced breaths tonight.

I do need to bust the pulse oximeter out of the closet, I haven't used it in a while.