Replies to This Discussion

Permalink Reply by Mike on April 20, 2009 at 1:52am

Those truckers are lucky to have you as a tech, and I think it's sensible and economic to skip the titration and put them on an auto-adjusting machine with advanced data capabilities so that you can adjust settings on the fly. i have a buddy with this machine. i'll ask him to post his thoughts.

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Permalink Reply by RockRpsgt on April 20, 2009 at 1:59am

Thanks Mike. This is my first experience with an "end user machine" so I want to make sure I get them all the info. They actually gave me a demo to try out. I belive we are going to start seeing alot of these types of studies for anyone with any type of commercial drivers/pilots licenses. From the rumors I have heard a sleep study is going to be a requirement to get one of these licenses in the very near future

Mike said:

Those truckers are lucky to have you as a tech, and I think it's sensible and economic to skip the titration and put them on an auto-adjusting machine with advanced data capabilities so that you can adjust settings on the fly. i have a buddy with this machine. i'll ask him to post his thoughts.

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Permalink Reply by Brad Beckwith on April 20, 2009 at 2:43am

That is such a broad question. Do you have some specifics you would like to know about? There are many pages of writing to simply describe all. Let us know what you want and we will try and help. I have sold many of these and have 26 demo machines in our pool. I also use one.

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Permalink Reply by RockRpsgt on April 20, 2009 at 2:48am

Nything that might not be in the manuals. Things they might want to watch for. Accessories that might be needed. Electrical issues. Keep in mind that most of these people will be using them in a truck cab. I believe that the average road time for these drivers is 2 weeks out 3 days home. They are required to use the machine on the road and at home.

Brad Beckwith said:

That is such a broad question. Do you have some specifics you would like to know about? There are many pages of writing to simply describe all. Let us know what you want and we will try and help. I have sold many of these and have 26 demo machines in our pool. I also use one.

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Permalink Reply by Daniel on April 20, 2009 at 12:56pm

When ResMed devices are in Auto mode, there is no concept of Ramp. It starts at the minimum pressure and can't go below that. It has a feature called Settling, that holds at the Min Pressure for a specified period of time before the algorithm kicks in. If you set the min to the 95th percentile, you'd be doing a disservice to your patients, especially those with a relatively high 95th %ile pressure.

Another thing to look out for is the DC connector in the back. For the S8 series, it is not an actual DC input. It is a connector for their own pure sine wave convertor. You must use ResMed's own convertor, or you risk damaging the device. The convertor takes 12V DC power and converts it to carefully specified AC power. Using that connector also disables the heating element for the humidifier, which would drain a battery very quickly.

Unlike Respironics, you can enable or disable the Smart Start Feature. If you set the Mask Choice to Full Face Mask, it automatically disables Smart Start, because the anti-rebreathing valves on FFMs would confuse the feature anyway. Activating Leak Alert also disables Smart Start. If you enabled Leak Alert, and then decide to turn it off, you must remember to reactivate Smart Start, because it won't do it automatically.

The device knows when there is a humidifier connected. When the device is turned off in the morning, it will continue to gently blow (< 1cmH2O) in order to cool the hot plate and dry out the tube for about an hour. Sometimes patients think there is something wrong because it seems like it doesn't shut down completely.

The H4i humidifier comes with a wonderful yellow plastic tool to cover the holes in the chamber when you want to clean it. One of its lesser known features is that it is also a measuring device used in combination with the Max FIll line on the chamber to help create a 1:10 vinegar and water mix. Very clever.

The Autoset II is a great device. It's way quieter than a REMstar Auto, and has many well thought out features that are subtly different from Respironics. Not better or worse, just different.

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Permalink Reply by RockRpsgt on April 20, 2009 at 1:21pm

Thanks Daniel Levy. That is all great info. I believe that the drivers can purchase the resmed inverter through their own hub after the appointment. I believe that is the only cost to them.

So are you saying that if I set the setting feature to 45 minutes that I will actually be inhibiting their treatment?

Daniel Levy said:

When ResMed devices are in Auto mode, there is no concept of Ramp. It starts at the minimum pressure and can't go below that. It has a feature called Settling, that holds at the Min Pressure for a specified period of time before the algorithm kicks in. If you set the min to the 95th percentile, you'd be doing a disservice to your patients, especially those with a relatively high 95th %ile pressure.

Another thing to look out for is the DC connector in the back. For the S8 series, it is not an actual DC input. It is a connector for their own pure sine wave convertor. You must use ResMed's own convertor, or you risk damaging the device. The convertor takes 12V DC power and converts it to carefully specified AC power. Using that connector also disables the heating element for the humidifier, which would drain a battery very quickly.

Unlike Respironics, you can enable or disable the Smart Start Feature. If you set the Mask Choice to Full Face Mask, it automatically disables Smart Start, because the anti-rebreathing valves on FFMs would confuse the feature anyway. Activating Leak Alert also disables Smart Start. If you enabled Leak Alert, and then decide to turn it off, you must remember to reactivate Smart Start, because it won't do it automatically.

The device knows when there is a humidifier connected. When the device is turned off in the morning, it will continue to gently blow (< 1cmH2O) in order to cool the hot plate and dry out the tube for about an hour. Sometimes patients think there is something wrong because it seems like it doesn't shut down completely.

The H4i humidifier comes with a wonderful yellow plastic tool to cover the holes in the chamber when you want to clean it. One of its lesser known features is that it is also a measuring device used in combination with the Max FIll line on the chamber to help create a 1:10 vinegar and water mix. Very clever.

The Autoset II is a great device. It's way quieter than a REMstar Auto, and has many well thought out features that are subtly different from Respironics. Not better or worse, just different.

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Permalink Reply by RockRpsgt on April 20, 2009 at 1:29pm

Not an option JNK. For this reason I am suggesting that each driver add his PCP to the release form and advising that he/she sit down and go over it with them. I tell them that a Doc is trained to see thing s that I am not. These things could be very important to their health. Not an ideal way to perform a study, but I have to make the best with what I am given. At the very least these are studies that probably would not have been performed had it been for this program.
j n k said:

I'm no pro, but I got opinions anyway . . .

I would suggest to your management that whatever company is paying should agree to a minimal criteria for diagnosis so that a modified split-night could be done for each driver to get at least some titrating in. PLMs and centrals could be unmasked that way, not to mention that drivers with high-pressure needs that would require autobilevel could be identified and titrated for it immediately. I consider titration to be a big part of diagnosis, regardless of the names given to the procedures.

I also hope that part of the deal is that the drivers get a follow up so that the minimum on the machine can be moved up to their reported 95% pressure after the first week or two, instead of their being expected to use the machines set wide-open forever. I would offer to allow them to make that one-time adjustment themselves, or with help over the phone, if needed.

Those are my opinions, though I realize it mixes all the roles and crosses some lines and so may be completely impractical, or impossible, the way things work in the real world.

jeff

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Permalink Reply by Judy on April 20, 2009 at 2:59pm

Tell them how to acccess their data via the advanced patient menu. They can NOT alter their therapy settings via this menu but it will keep them informed of their own progress - or lack of it - so they know sooner when to ask for help. When you set up the Vantage you have to turn access to the advanced/detailed menu ON from the Clinicians Menu for them to be able to access the advanced/detailed patient menu.

Access to the advanced patient menu once it is turned on:
Press the Left and Right buttons and hold for 4-5 seconds. Efficacy Data will appear in the LCD screen. From there on it is just a matter of Left button to Enter, Right button to Exit, Up button to return to the previous screen, Down button to proceed to the next screen.

STRESS THE IMPORTANCE of paying attention to their Leak rate and HOW to determine their true Leak rate as too high a Leak will result in unreliable data. The MASK is very important in this regard as you know - but make sure THEY know that. They may well end up changing masks so it is IMPORTANT that the Mask Selection is also set appropriately for each mask change.

If a non-Resmed mask the Mask Selection should be set to Standard and at the Standard setting the Resmeds automatically deduct 0.4 L/s or 24 L/M from the reported Leak rate. The mask literature then becomes very important for the allowed vent rate table. Use the reported 95th percentile of pressure to determine the proper allowed vent rate and then do the math. Remember 24 L/M has already been deducted.

If a Resmed mask is used, and the proper mask selection is set, the Resmeds will automatically deduct the proper allowed vent rate for the pressure and the reported Leak rate will be the true 95th percentile of Leak.

I've forgotten: either the Resmeds report the Leak rate at L/s on the LCD and/or you have the option when setting it up whether it is to report in L/M or L/s. If you can't change the L/s to L/M then you must also explain the conversion to them when evaluating their Leak rate. They should know or be told what an acceptable Leak rate appearing on the LCD screen is for them so they know when to ask for help in getting that Leak rate down if necessary.

Also explain not to be bothered because the Resmeds keep running on low pressure even when turned off for some 10-15 minutes or so to dry out any dampness from the humidifier. That used to drive me nuts! I'd go back in the bedroom, it would be running on low, I'd turn it off which then told it to run for another 10-15 minutes ... it was a vicious cycle until I read the manual and realized what was going on! Color me red-faced!

If using a non-Resmed mask is going to be the most confusing thing for them - at least going by my personal experience. The rest is really a piece of cake.

Oh - the usual: an AHI less than 5.0 is great. You wanna see the AI lower than the HI, don't worry about the HI as long as the AHI is below 5.0.

I think that is pretty much it as far as I remember my early days on a Resmed.

Daniel Levy mentioned the importance of the proper converter, whatever, for battery use. cpap.com explains the PROPER converter/whatever needed for running on battery power. All that is beyond me and my experience.

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Permalink Reply by Daniel on April 20, 2009 at 3:00pm

With an open Rx of 4 - 20cm, you would definitely be doing a patient a disservice by setting the Settling Time to 45 minutes, since it would virtually guarantee they are being undertreated during that time. The Settling feature is there because ResMed's Auto algorithm is different than Respironics - it responds on a breath-by-breath basis to "flattening" of the breath cycle. Since our breathing naturally flattens a bit while we are first falling asleep, the pressure would rise at a time when it might inhibit one's abiility to fall asleep. I usually ask the patient how long it typically takes them to fall asleep and set the Settling Time accordingly. Typically I set it for 15 minutes, and rarely go higher than 20 minutes.

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Permalink Reply by RockRpsgt on April 20, 2009 at 3:57pm

That is great info as we were told to set it at 45 minutes. I will relay this info to the staff. Thanks

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Permalink Reply by RockRpsgt on April 20, 2009 at 3:59pm

Thanks JUdy

Judy said:

Tell them how to acccess their data via the advanced patient menu. They can NOT alter their therapy settings via this menu but it will keep them informed of their own progress - or lack of it - so they know sooner when to ask for help. When you set up the Vantage you have to turn access to the advanced/detailed menu ON from the Clinicians Menu for them to be able to access the advanced/detailed patient menu.

Access to the advanced patient menu once it is turned on:
Press the Left and Right buttons and hold for 4-5 seconds. Efficacy Data will appear in the LCD screen. From there on it is just a matter of Left button to Enter, Right button to Exit, Up button to return to the previous screen, Down button to proceed to the next screen.

STRESS THE IMPORTANCE of paying attention to their Leak rate and HOW to determine their true Leak rate as too high a Leak will result in unreliable data. The MASK is very important in this regard as you know - but make sure THEY know that. They may well end up changing masks so it is IMPORTANT that the Mask Selection is also set appropriately for each mask change.

If a non-Resmed mask the Mask Selection should be set to Standard and at the Standard setting the Resmeds automatically deduct 0.4 L/s or 24 L/M from the reported Leak rate. The mask literature then becomes very important for the allowed vent rate table. Use the reported 95th percentile of pressure to determine the proper allowed vent rate and then do the math. Remember 24 L/M has already been deducted.

If a Resmed mask is used, and the proper mask selection is set, the Resmeds will automatically deduct the proper allowed vent rate for the pressure and the reported Leak rate will be the true 95th percentile of Leak.

I've forgotten: either the Resmeds report the Leak rate at L/s on the LCD and/or you have the option when setting it up whether it is to report in L/M or L/s. If you can't change the L/s to L/M then you must also explain the conversion to them when evaluating their Leak rate. They should know or be told what an acceptable Leak rate appearing on the LCD screen is for them so they know when to ask for help in getting that Leak rate down if necessary.

Also explain not to be bothered because the Resmeds keep running on low pressure even when turned off for some 10-15 minutes or so to dry out any dampness from the humidifier. That used to drive me nuts! I'd go back in the bedroom, it would be running on low, I'd turn it off which then told it to run for another 10-15 minutes ... it was a vicious cycle until I read the manual and realized what was going on! Color me red-faced!

If using a non-Resmed mask is going to be the most confusing thing for them - at least going by my personal experience. The rest is really a piece of cake.

Oh - the usual: an AHI less than 5.0 is great. You wanna see the AI lower than the HI, don't worry about the HI as long as the AHI is below 5.0.

I think that is pretty much it as far as I remember my early days on a Resmed.

Daniel Levy mentioned the importance of the proper converter, whatever, for battery use. cpap.com explains the PROPER converter/whatever needed for running on battery power. All that is beyond me and my experience.

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Permalink Reply by Judy on April 20, 2009 at 4:32pm

Rock Hinkle, I know not all, in fact probably most, "apneans" aren't "into" knowing much about their CPAP therapy except that the doctor told them they have OSA and they need to use the CPAP. But I would think since these truckers' jobs depend on adequate xPAP therapy to "keep on truckin'", I would guess that the extra encouragement of good data, or the feeling of having some control in seeing their results and getting help sooner when they need it, would be of great importance and encouragement to them. Sometimes keeping their job provides more incentive than "you'll die if you don't use your xPAP".

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