Abstract:
The method describes a means of automatic determination of required pressure levels of a breathable gas for treating sleep apnea or other respiratory disorder such as sleep hypoventilation or chronic obstructive pulmonary disease. The method makes use of a face mask nasal prongs or similar means with venting system for elimination of expired gas to atmosphere, gas delivery tubing, and a computer controlled fan or blower or other similar source of pressurised breathable gas.

Description:
CROSS REFERENCE TO RELATED APPLICATIONS 
       [0001]    This patent is a full specification based on Australian provisional patent application number 2006904770 
       STATEMENT REGARDING FEBERALLY SPONSORED RESEARCH OR DEVELOPMENT 
       [0002]    Not Applicable 
       REFERENCE TO SEQUENCE LISTING, A TABLE, OR A COMPUTER PROGRAM LISITNG COMPACT DISK APPENDIX 
       [0003]    Not Applicable 
       BACKGROUND TO THE INVENTION 
       [0004]    Positive pressure therapies include nasal continuous positive airway pressure (CPAP) as used in the treatment of obstructive sleep apnea (OSA) and nasal intermittent positive pressure ventilation for breathing support in chronic restrictive and obstructive lung diseases and associated acute exacerbations. A user will wear a nasal or nose mouth mask connected by a tube or flexible conduit connected to a positive pressure air flow generator. The mask system consists of a flexible mask cushion, which also acts as a gasket to prevent loss of gas pressure inside the mask, attached to a mask frame or manifold and attached to the user&#39;s head via a head strap or head gear. The mask assembly usually covers the nose but can also cover both the nose and mouth to circumvent mouth leaks and breathing. Alternatively, the mask device may be designed to sit superficially on or be partially inserted into the user&#39;s nares. 
         [0005]    The general purpose of the apparatus consisting tubing, mask and pressure generator or source is to maintain a positive gas pressure, typically between 0 and 40 centimetres of water (cm H2O), but most practically between 4 and 20 cm H2O, within the user&#39;s airway to improve or facilitate gas exchange within the gas exchanging areas of the lung and/or prevent collapse of the upper or non exchanging parts of the upper airway. Most commonly a single pressure (CPAP) will be used to treat sleep apnea, while 2 pressures can be used to expand and deflate the lungs where ventilatory support is required in cases of respiratory insufficiency. This technique may also have a role to improve comfort in treatment of sleep apnea. 
         [0006]    Treatment of OSA, using positive pressure techniques, is often prescribed using fixed CPAP, with the pressure preset in a sleep laboratory. Alternatively, an automatic machine may be used with an ability to provide CPAP where pressure is continuously, gradually and automatically adjusted during a treatment session in response to upper respiratory air flow characteristics, such as the shape of the inspiratory flow time curve, presence of snore or associated pressure and flow changes or overt apnea. Once established, treatment is routinely used in the home. 
         [0007]    Alternatively a separate pressure may be applied during inspiration and a lower pressure used for expiration such as described in U.S. Pat. No. 5,148,802. In this case the pressures will be preset and the transition from one pressure to another will be initiated by the patient as they move through inspiration to expiration and vice versa. The rational for this modality is that the patient will find the exhalation pressure lower and hence more comfortable to breathe against, particularly in sleep apnea. In addition the device augments ventilation in addition to providing positive pressure by assisting with movement of air into and out of the lungs by successive pressure inflation and deflation. This will be useful where the patient has some lung insufficiency or muscular deficiency either in combination with or absence of upper airway instability. 
         [0008]    Currently automatic selection of pressures for this bilevel modality is limited or difficult particularly during sleep where ventilatory support for hypoventilation syndromes (or hyperventilation/hypoventilation syndromes such as Cheyne Stokes Respiration) and sleep apnea must be managed simultaneously (complex sleep apnea); in sleep apnea the expiratory pressure needed to negate airway closure at the immediate transition from the expiratory pause to inspiration must be set in conjunction with ventilatory support parameters. In automatically controlled CPAP, that is having expiratory and inspiratory pressures set equally, it is possible to set this pressure by simply monitoring inspiratory flow behaviour as discussed above. Typically the 2 pressures will be established manually in a controlled study wherein the user is monitored and the pressures adjusted to a chienve the desired treatment outcomes which can include control of sleep apnea as well maintaining ventilatory requirements 
         [0009]    A further method of support for providing respiratory assistance in respiratory impairment is described in U.S. Pat. No. 4,773,411. In this technique, termed airway pressure release ventilation (APRV), support is provided substantially by CPAP to enhance residual functional capacity with periodic release of pressure to provide passive reduction of lung volume. This periodic release is not breath to breath and the user will typically breath spontaneously at the preset CPAP pressure. Settings are manually selected by attendants, that is the CPAP level, the release level and release duration as well the number of breaths depending on the patient&#39;s respiratory state and hence is suited to attended or in hospital situations and is not designed for treating simple or complex sleep apnea. 
         [0010]    During quiet breathing without pressure assistance, such as during sleep or awake involuntary, or spontaneous, breathing, there is a pronounced period of respiratory quiescence whereby the elastic recoil of the lungs and chest wall returns the lungs to their functional residual capacity (FRC). In response to chemoreceptor activity the diaphragmatic muscles, principally, will be innervated to increase negative intrapleural pressure thereby expanding the lung volume. Normally this activity is under autonomic control but during the awake state it may be overridden and air may be moved consciously into and out of the lungs by diaphragmatic and intercostal muscles. In this sense respiration is distinguished from other life sustaining functions, such as heart rate, cardiac contractility and pressure which are entirely within the control of the autonomic system and the individual only has indirect control over these parameters. 
         [0011]    Respiratory rate and duration is under control of the respiratory centre located in the reticular substance of the medulla oblongata and pons. These centres respond to changes in blood gas levels and acidity either directly or indirectly through peripheral chemoreceptors. Functionally it may be divided into three neuronal groups comprising the dorsally located inspiratory area, ventrally located expiratory area and the pneumotaxic area of the pons. Normally the rhythmic nature of breathing is controlled principally by the inspiratory area. Neurones in this area are able to oscillate spontaneously in a crescendo like manner gradually increasing intensity causing the diaphragm to contract and causing an inspiratory movement. This gradual increase lasts about 2 seconds in quiet breathing. Conversely during expiration, the inspiratory area becomes dormant for about 3 seconds and the cycle repeats. During normal quiet breathing the expiratory area remains substantially dormant as exhalation is possible through elastic recoil of the lung and chest wall, although some muscular innervation may be present to control smoothness of expiration to prevent expiratory heave, such as seen during sighs and other involuntary movements to for example rebalance atelectic regions in the lungs. 
         [0012]    During nasal CPAP therapy, for treatment of sleep apnea for example, we have 2 important observations. First the lungs are expanded by an amount proportional to the compliance of the lungs and chest wall and the applied air pressure. Hence, the FRC is increased over that observed when the user is breathing at atmospheric pressure. This can be described by the following 
         [0000]      FRC (CPAP)=FRC atm+Δ  V   CPAP   (1) 
         [0013]    Where FRC (CPAP)=functional residual capacity on CPAP 
         [0014]    FRC atm=functional residual capacity at atmospheric pressure 
         [0015]    Δ V CPAP =change in lung volume after CPAP is applied 
         [0016]    Normal compliance for lungs and chest wall is about 0.13 litres/cm H2O. Hence at 10 cm H2O this delta volume is in the vicinity of 1.3 litres. This figure may be reduced for restrictive diseases, however most sleep apnea patients and those with obstructive pulmonary diseases will have normal or near normal lung and thoracic compliance. To place this in perspective, tidal volume during quiet breathing is about 500 ml. Hence we can see that CPAP at therapeutic levels distends the lungs by more the twice the tidal volume, and will reduce the inspiratory reserve volume. 
         [0017]    Second, CPAP for many users, as seen for example in those receiving treatment for sleep apnea, feels unnatural and in some uncomfortable. This is often described as discomfort of having to breathe out against the CPAP pressure. For this reason, an alternative to CPAP is to provide a lower pressure during expiration, so called bi-level treatment as discussed. The problem with this modality is that it is not simple to automatically determine the optimal minimum or expiratory pressure level needed to prevent airway closure at the transition from expiration to inspiration if user initiated. 
         [0018]    Based on these observations it is possible to postulate that during quiet breathing on CPAP, the breathing cycle is reversed or partly reversed. That is inspiratory cycle occurs to a varying degree by positive pressure inflation/recoil and expiration by innervation of expiratory muscles as opposed to elastic recoil. 
         [0019]    In this case equation 1 may be more appropriately written as equation 2 
         [0000]      IRV (CPAP)=TLC−(FRC atm+Δ  V   CPAP )  (2) 
         [0020]    Where 
         [0021]    TLC=total lung capacity 
         [0022]    IRV=inspiratory reserve volume 
         [0023]    CPAP=applied pressure which limits inspiratory drive for quiet breathing 
         [0024]    Since expiration, in the absence of CPAP, is by passive recoil in quiet breathing, this may explain some of the discomfort during routine CPAP, for example, that is expiration now requires active muscular effort. Another factor may be the continuous expansion of the lungs and chest wall by CPAP. This observation, however, is complicated by virtue of the fact that respiration can be overridden by voluntary effort. The unnatural sensation of CPAP during consciousness may lead to an “abnormal” voluntary or cortical response. However, if we assume that involuntary exhalation during CPAP use occurs against pressure recoil, this would then suggest that the medullary inspiratory area can be down regulated to interplay with the expiratory centre to maintain background respiratory rate (however respiratory control is further complicated by the pneumotaxic centre located in the pons which acts to either inhibit or uninhibit the inspiratory centre). A further explanation is related to stretch receptors within the walls of the bronchi and bronchioles which if over stretched, as may be seen during CPAP therapy, further limit inspiratory effort particularly during involuntary quiet breathing and sleep. This is known as the Hering-Breuer reflex and is known to become important once the lung volume is increased by about 1.5 litres above FRC; this would appear to be consistent with therapeutic CPAP levels. 
         [0025]    However, CPAP treatment remains broadly crude and variably tolerated. While acceptable for most severely affected patients, more comfortable and physiologic solutions are seen as essential to ensure an otherwise effective therapy does not itself become self limiting for a very debilitating and widespread condition. Furthermore, complex sleep apnea requires more complex solutions to provide background ventilatory support as well as sleep apnea treatment. Finally automatic selection of pressures simplifies prescription and remain adapative to a specific user&#39;s needs. 
       BRIEF SUMMARY OF THE INVENTION 
       [0026]    A device comprising an automatically adjusting pressure source of breathable gas, a delivery tube and a face mask in communication with a user&#39;s airway through nose or mouth is described and shown in  FIG. 1 . The user  1  wears a nose or nose mouth mask  2  connected to air delivery tube  3  in turn connected to pressure source  4 . The pressure source would normally be an electronically or electrically operated computer controlled fan or blower supplying a range of delivered pressures from atmospheric pressure up to 40 cm water pressures. Typical pressures would range between 0 and 20 cm H2O with the lowest employable pressure being dependent on carbon dioxide removal characteristics of the mask used. Pressures may be varied by either controlling the fan speed or by employing a spill valve to dump air to atmosphere either in isolation or in conjunction with varying the fan speed. These pressures would be ideally set and administered automatically by the algorithm contained within the computer program of the device. The device is designed to simultaneously treat sleep apnea, periodic breathing or hypoventilation in any combination of severity in spontaneously breathing patients either awake or asleep. 
     
    
     
       BRIEF DESCRIPTION OF THE SEVERAL VIEWS OF THE DRAWINGS 
         [0027]      FIG. 1 : Typical apparatus employing the method described by the invention 
           [0028]      FIG. 2 : Possible lung volume and applied pressure versus time profile based on volume change for delivered pressures between Plower (PL) and Pupper (PU) cm H2O. FRC  0  is residual reserve capacity at atmospheric (0 pressure) during quiet breathing. Transition to higher pressure after lung deflation is performed by the device and based on expired volume and/or flow time profile. Expiratory volume versus time profile is dependent on the elastic recoil properties of the lungs and chest wall, the delivered pressure time profile, the level of obstruction or flow restriction within the lungs (and upper airway if flow limited) and expiratory/inspiratory muscle activity if present. In uncomplicated sleep apnea it may assumed that lungs will be unobstructed and exhibit normal out flow at low pressures although upper airway flow may be obstructed. In practice it is expected the pressure time profile will be provided to provide optimal expiratory emptying prior to reinflation, having regard for patient synchronisation, comfort and ventilatory adequacy. Diagram shows volume versus time for quiet servo controlled breathing and profile may vary. Heavy line represents administered pressure, lighter line represents lung volume. Times are illustrative only and may be shorter or longer than shown. 
           [0029]      FIG. 3 : Pressure and lung volume profile with time where pressure is increased below total ventilatory requirements and user provides additional effort to augment total ventilations in line with requirements. Heavy line represents administered pressure, lighter line represents lung volume. Times are illustrative only and may be shorter or longer than shown. 
           [0030]      FIG. 4 : Pressure and lung volume profile with time where pressure is increased such that the rate of increase in pressure is matched to coincide with commencement of a user&#39;s inherent effort. Heavy line represents administered pressure, lighter line represents lung volume. Times are illustrative only and may be shorter or longer than shown. 
       
    
    
     DETAILED DESCRIPTION OF THE INVENTION  
       [0031]    While the invention described herein makes use of a vented face mask, tubing, and a blower unit, in common with other related nasal positive pressure therapies, the blower unit of the invention is designed to provide a more comfortable means for treating sleep apnea or other respiratory disorder such as sleep hypoventilation or COPD, by means of automatic respiratory support. The device is intended primarily, but not limited to use in the anaesthetised patient in quiet breathing in either wakefulness or sleep. The invention may be effectively used with a CPAP mask, full face mask, mouth mask, or nasal prongs or any combination thereof or any known mask systems for CPAP or nasal ventilation. 
         [0032]    The invention in part takes advantage of the expiratory pause of the respiratory cycle and provides a means of reversing the normal expiratory/inspiratory cycle such that expiratory pause is transferred to the end of the inspiratory cycle. In this way the patient is not required to “trigger” the inspiratory phase. A typical breathing pattern is shown in  FIG. 2  where at  5  pressure release occurs on each patient triggered (cycled) or initiated expiration. At  6  the device automatically reinflates the lung after a desired expired volume has been achieved (calculated to prevent lung hyperinflation). This has a further advantage of eliminating need for user triggering to an upper pressure which is inherently insensitive due to hysteresis and need to avoid false triggering. At  7  inspiratory efforts at an upper pressure level are minimised by providing sufficient background minute ventilation through pressure release and activating stretch receptors at an appropriate level of lung inflation above normal FRC to down regulate inspiratory effort. In absence of monitoring airway instability as a means to provide closed loop feedback control of an administered pressure, minimisation of inspiratory effort is important in sleep apnea to provide airway stability. In the context of the invention minimisation of inherent effort is also important during hyperventilation in periodic breathing. At  8  the machine is able to pre-empt an expiratory impulse by timed backup. 
         [0033]    The observations discussed in the previous section lead to the possibility of controlling inherent respiration indirectly by activating and deactivating, for example the stretch receptors to control or down regulate inspiratory effort or by provision of machine ventilation. The invention then consists of a servo controlled flow generator attached to a mask attached to the users nose and or mouth. The device will be able to monitor respiratory in and out flow, as well as mask pressure, and vent and mask leak. The device would be able to provide a level of inspiratory support sufficient for normal quiet breathing but could be designed to operate under a broad range of operational conditions depending on the motor and power supply of the blower unit. Typically 12 breaths per minute with tidal volume for each breath of 500 millilitres would be provided. The minimum default release pressure level would be set in the range 0 and 4 cm H2O, but its operational range would be settable automatically by the device depending on air out flow characteristics or air trapping within the patient&#39;s airway and ventilatory requirements and need to eliminate carbon dioxide. This is could be achieved for example by monitoring volume or outflow and when reaching a suitable minimum, close to zero in the case of outflow, the pressure minium would be set at this level. This would principally be undertaken to reduce unnecessary work of the pressure source and provide a close match with a user&#39;s airway requirements. This may also be important in ensuring smooth flow transitions when the upper airway becomes spontaneously closed. However, determining this pressure, while potentially desirable is not considered essential for the satisfactory operation of the device. 
         [0034]    Pressure swing, that is the difference between the upper pressure and the lower pressure will govern the degree of provided ventilation or pressure support. It is clear that this swing must be superimposed on the minimum pressure. Hence the maximum and minimum pressures are further defined by the required swing or ventilatory support. Ventilation would be governed by the rate, tidal volume and average minute ventilation and based on average quiet, stable breathing levels, say over the past 2 to 10 minutes. This eliminates the influence of temporary increases in users effort due to sighs and yawns for example and provide more stable ventilatory control. The device is designed to pace or work at a user&#39;s own respiratory rate based on expiratory effort or impetus. Once cycled by expiratory effort the pressure will fall at a predetermined profile possibly under servo control, and once a given volume or flow target has been exhaled and/or pressure reached the unit will automatically cycle back to the preexpiratory pressure level. 
         [0035]    The preexpiratory level (the upper pressure level) will be set based on information about the required minute ventilation, and presence of residual inspiratory effort, which may include, for example, presence of snoring or presence of repeated residual inflows in absence of machine support (constant pressure). The presence of single sighs and yawns would be excluded from setting the upper pressure as these are necessarily aimed at improved gas exchange with the lungs e.g atelectasis. As discussed previously during CPAP treatment the Hering-Breuer effect will help to limit further patient inspiratory effort and lung inflation, however further inspiratory effort may indicate need for more ventilatory support or increased rate. This will partially be indicated by expiratory rate set by the user&#39;s own respiratory system within the medulla oblongata. In this way information from the user&#39;s respiratory centre is indirectly derived from the user&#39;s intrinsic rate and need for residual inspiratory effort. 
         [0036]    The device aims to find the optimal pressure swings and rate for ventilation to support flow of air into and out of the lungs based on full ventilatory support (no or limited inspiratory effort on part of the user). In other words air in flow to a user&#39;s respiratory system is achieved by positive pressure “push” at all points in the machine mediated inspiratory respiratory cycle. Recall that conventional CPAP, although using positive pressure may require alveolar pressure below the prescribed mask pressure during positive pressure recoil during inspiration. Practically, this may provide a prescribed pressure advantage of the current design over standard CPAP or bi-level pressure therapy. This apart the device is aimed to deliver physiologic sensible breathing and hence a more natural user experience concomitant with therapeutic pressure delivery. 
         [0037]    It can be appreciated that the minium pressure will be governed also, in addition to expiratory air flow characteristics as mentioned previously, by the required upper pressure and the difference between this value and the optimum swing or pressure difference to provide total ventilatory support. Hence the lower value may need to be increased to avoid over ventilation 
         [0038]    In summary the invention aims to:
       a) minimise patient respiratory effort so the invention provides most or all motive power for air movement into and out of the lungs by adapting operation to limit movement into the lungs by either pressure recoil or inspiratory effort. While the shape of part or all of any inspiratory effort flow time curve may be included it is envisaged this would in fact be a redundant feature as the device aims to provide optimal ventilation by providing positive pressure from the pressure source. However this may be provided as a further embodiment as discussed later   b) ideally determine a minimum pressure which is just sufficient to maintain airway patency during expiratory outflow and hence for allowing elastic recoil movement of air from the lungs. In this way continuous communication throughout the airway system is achieved. This may be maintained by continuous measurement and assessment of the shape of airflow versus time curve exiting the user&#39;s airway after compensating for vent and mask leak. This lower pressure will then represent the pressure below which no further elastic air flow from the user&#39;s respiratory system can occur. In an open airway at atmospheric pressure this pressure will be equal to zero. It should be noted however that this is not an essential feature of the device but rather a potentially desirable one.   c) determine pressure limits in addition to those as defined in a) and b) above which provides adequate minute ventilation based on quiet awake or somnolent breathing and other anatomical features, such as height, weight, tidal volume as required.   d) finding pressure limits and or rate which servo controls respiration, by being just above, below or at the patients own respiratory rate or inherit ventilatory needs.   e) provide pressure time profile which is optimally servo controlled by flow to provide a normal pattern of lung filling and emptying. This may range from a half square wave to a ramp or some other profile.   f) automatically restore administered pressure to an upper pressure from a lower pressure after lung emptying has been achieved       
 
         [0045]      FIG. 1  shows possible lung volume and device pressure profile during normal operation when pressures are applied over a range of lower and upper pressures. 
         [0046]    An important feature of the device is that inspiratory drive by the patient is rendered substantially redundant and there is no inspiratory triggered event as this is effectively muted by lung inflation and ventilatory support. This is undertaken entirely by the device. Furthermore, since the device aims to pace or pre-empt the user&#39;s respiratory centre the need to monitor the user&#39;s upper airway directly or in isolation becomes redundant as the device uses as much pressure as required to move the required volumes into and out of the lungs. 
         [0047]    In use a period of habituation and respiratory training on this therapy may be required. It also possible that typical settings, such as usual minute ventilation values, once derived may be initiated immediately on donning the mask or may be increased progressively to enable the user time to become accustomed to the pressure profile. The user is able at any time to breath at their own rate or depth during wakefulness so synchronisation is always maintained with the device. During sleep, background respiratory support will be entirely or substantially managed by the device. 
         [0048]    During typical use in treatment of sleep apnea, a possible means to commence a treatment session may include an initial period where upper pressure will be slowly increased from a base pressure, between 0 and 4 cm H2O (selectable). On a user initiated exhalation impulse the pressure will be allowed to proceed, as discussed, to the initial base level and then returned back to the upper pressure after a desired exhaled volume has been achieved. The upper pressure will continue to be increased, possibly over a period of several minutes or longer until inspiratory airflow due to effort at the upper level is inhibited or can be comfortably eliminated during wakefulness; there is no preset upper limit, although this may be set optionally. It is expected to be typically around 10 cm H2O and will vary between users. This level of support will also be in keeping with the moving average minute ventilation measured during a period of previous period of quiet breathing. The pressure profile will then look as in  FIG. 1 . 
         [0049]    When used for treatment of chronic obstructive pulmonary disease (COPD) including acute exacerbations, the device would likely be initiated in a different way depending on patient symptoms and degree of breathlessness and if the device is designed to eliminate sleep hypoventilation. The device would however commonly operate in obstructive diseases to automatically set the lower pressure above iPEEP and maintain an upper pressure level sufficient to eliminate inspiratory effort and provide maximal respiratory muscle unloading as well as provide respiratory support based on target ventilatory parameters. Starting regimes could be selected by the caregiver or user to provide rapid adoption of target values as required by the user. It should be noted however that establishing a target lower pressure to overcome iPEEP is not an essential feature of the invention. 
         [0050]    Clinically, sleep apnea in conjunction with sleep hypoventilation is commonly seen in obesity, lung disease or heart failure. Sleep apnea and hyperventilation may also be seen in heart failure. In these cases, prior to sleep, some background support can provided initially where the amount of initial support will be user dependent and provided according to individual comfort. A moving average of ventilation may be obtained during this period. On falling asleep if ventilation is subsequently calculated to be too high compared to a past moving average of ventilation, the difference between an upper and lower level must be decreased. Remembering also that it is desirable to maintain the airway open, while the upper pressure is designed to inhibit inspiratory effort and if that level, the lower pressure will then need to be increased if it is already at a minimum level. Increasing the lower pressure, although in excess of that required to maintain the airway open, will reduce the amount of ventilatory support while the upper pressure is maintained to limit spontaneous effort. Similarly, if the minute ventilation is found to be too low, then the upper pressure will needed to be increased or the lower pressure reduced subject to its minimum as discussed. 
         [0051]    In yet a further embodiment of the method, a pressure profile is applied to user&#39;s airway shown in  FIG. 3 . Rather than aiming to totally inhibit inspiratory effort and provide all support it is the aim of the device to provide a substantial or targeted level of support based on quiet breathing (a moving average estimate). In this way additional inspiratory effort may be under the control of the user as shown at  9 . The device then provides a minimum background level of support and additional efforts at an upper pressure level are monitored to ensure absence of snore and other indicators of inspiratory flow resistance such as flow limitation. To ensure adequate ventilation and airway patency, the upper pressure and lower pressure may be adjusted. For example if airway stability is achieved through an appropriate upper pressure but ventilation is excessive then the lower pressure may be increased, either independently or in conjunction with an upper pressure, which may act to dampen user initiated hyperventilatory efforts through lung expansion and reduced machine support. If ventilation is inadequate then the lower pressure may be reduced, and if this lower pressure is at a minimum level the upper pressure may be increased. 
         [0052]    In yet a further embodiment of the method, a pressure profile is applied to user&#39;s airway shown in  FIG. 4 . A partial level of support is provided wherein a target upper pressure is reached at a time point coincident with commencement of a user&#39;s inspiratory effort, that is when a user will take over the device&#39;s inspiratory support. This will be based on adjusting the rate of pressure increase based on past cycling rates, the level of a lower and upper pressure as well as the smoothness of the delivered volume time curve at  10  (this may also be achieved by monitoring flow). In the absence of user effort, rate of volume increase will be proportional to the rate of pressure increase provided by the device (Ps) with time (t) that is dPs/dt, where proportionality is dependent upon the mechanical properties of a user&#39;s respiratory system, hysteresis and surface tension effects. Of interest are only incremental user sponsored breathing efforts that will increase flow above that provided by the device while dPs/dt is greater than or equal to zero. Gas volume entering into a user&#39;s respiratory system V(t), volume as a function of time (t) or flow is then monitored to ensure that the rate of increase in pressure provides a rate of change of volume with time or flow versus time that is as smooth and seamless as possible for all periods while dV/dt&gt;0, that is while lung volume is increasing. It is evident that it may not always be possible to match exactly the rate of volume change provided by the device and a user&#39;s effort when dPs/dt is equal to a constant for Ps&gt;0, rather the aim is to ensure that the transition between completion of machine supported volume change coincides as closely as possible with commencement of user inspiratory effort. Notwithstanding that algorithms may be incorporated to provide non linear rates of pressure change to match the rate of volume change from machine pressure support to user initiated effort. Furthermore, snore and other indicators of inspiratory flow resistance such as flow limitation are monitored as before as well as ventilatory considerations as described above to ensure a targeted level of an upper and lower pressure. 
         [0053]    It is evident that the computerised blower apparatus to be operated according to the conditions of the methods as described will consist of pressure and flow sensors as well as analogue and digital signal conditioning hardware and software and may be constructed by techniques typically described in, but not limited to, the prior art. 
         [0054]    While the invention has been described with reference to a range of embodiments as described above, it will occur to those skilled in the art that various modifications and additions further to the disclosed methods discussed herein may be made without departing from the spirit and scope of the invention.