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Beyond Traditional PAP therapy Brian Gaden BSRT, RRT, RPSGT Sleep Consultant Philips Home Healthcare Solutions.

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Presentation on theme: "Beyond Traditional PAP therapy Brian Gaden BSRT, RRT, RPSGT Sleep Consultant Philips Home Healthcare Solutions."— Presentation transcript:

1 Beyond Traditional PAP therapy Brian Gaden BSRT, RRT, RPSGT Sleep Consultant Philips Home Healthcare Solutions

2 Objectives Review of pathology behind the need for ventilation Review of pathology behind the need for ventilation Central Sleep Apnea Central Sleep Apnea Overlap Disease Overlap Disease Obesity Hypoventilation Obesity Hypoventilation Neuromuscular Disorder Neuromuscular Disorder Describe the use of Servo ventilation for patients with Complex and Central Apnea Describe the use of Servo ventilation for patients with Complex and Central Apnea Describe the use of BiPAP S/T with AVAPS for patients with pulmonary disorders Describe the use of BiPAP S/T with AVAPS for patients with pulmonary disorders Describe the titration methods for patients requiring NIV Describe the titration methods for patients requiring NIV

3 Sleep Impact on the Respiratory System Cerebrum Brain Stem Spinal Cord Controller Mechanicoreceptors Chemorecptors Sensors/Feedback Effector Respiratory Muscles Airway Vessels and Function Gas Exchange Result

4 Sleep Disordered Breathing- Physiology review

5 Factors that may impact the function of the brain during sleep Change in blood flow Drug administration Change in cortical inputs Disease of the Cerebrum/Brain Stem/Spinal cord Loss of motor neurons due to disease Severing of the motor neurons Cerebrum Brain Stem Spinal Cord Controller

6 Impact of the respiratory muscles and airway vessels during sleep Any change can directly impact the respiratory system –Positional changes –Damage or loss of the respiratory muscles will –Damage to the airway support system –Damage to the airway vessels –Damage or loss of blood supply Effector Respiratory Muscles Airway Vessels Function

7 Problems with Gas Exchange during sleep Gas Exchange Result There can be several reasons for gas exchange to not occur: –Poor perfusion of the pulmonary system –Positional changes in perfusion –Destruction of the alveolar sacs due to underlying disease –Lack of ability to move gas into the alveolar sacs Muscle loss Conduction problem with nervous system impulse

8 Systemic monitoring systems that influence ventilation and oxygenation Central Chemoreceptors –Found inside of the brain to regulate and stimulate the respiratory system in the brain stem –Feedback system is thru acid/ carbon dioxide levels in the brain and body Peripheral Chemorecptors –Chemical Receptors found on the aortic arch and carotid artery –Send impulses to the brain stem to change the respiratory rate and pattern –Respond to both oxygen and carbon dioxide levels Mechanicoreceptors Chemorecptors Sensors/ Feedback

9 What happens in the lungs?

10 One thing to remember The primary drive to breathe is based upon the CO2 level in the blood. The primary drive to breathe is based upon the CO2 level in the blood. The secondary drive to breathe is based upon the O2 level in the blood. The secondary drive to breathe is based upon the O2 level in the blood. If CO2 levels are too high, the body responds by increasing ventilation to get rid of excess CO2 If CO2 levels are too high, the body responds by increasing ventilation to get rid of excess CO2 If CO2 levels are too low, the body responds by decreasing ( or stopping ) ventilation to allow CO2 to build back to normal levels If CO2 levels are too low, the body responds by decreasing ( or stopping ) ventilation to allow CO2 to build back to normal levels

11 Effect of Sleep on Normal Respiration McNicholas, Chest 2000; 117: – 50% ABG changes due to Decrease in Min. V 0.5 – 1.5 LPM

12 Normal Changes During Sleep Decrease in chemoreceptor sensitivity Decrease in chemoreceptor sensitivity Both oxygen and CO2 by 20 – 50% Both oxygen and CO2 by 20 – 50% Reduction in Alveolar Ventilation due to decrease in Reticular Activation Center activity Reduction in Alveolar Ventilation due to decrease in Reticular Activation Center activity Body position & increased airway resistance Body position & increased airway resistance Decrease in tidal and minute volume Decrease in tidal and minute volume Sum total of physical change causes the following for a normal patient : Sum total of physical change causes the following for a normal patient : Increase PaCO – 8 mmHg Increase PaCO – 8 mmHg Decrease PaO – 10 mmHg Decrease PaO – 10 mmHg Decrease SaO 2 - by 2% Decrease SaO 2 - by 2% McNicholas, Chest 2000; 117:

13 The complicated world of sleep disordered breathing Vast majority of SDB patients typical OSA profile Vast majority of SDB patients typical OSA profile 80 – 90% OSA 80 – 90% OSA AHI controlled by CPAP therapy AHI controlled by CPAP therapy Central Sleep Apnea Central Sleep Apnea Idiopathic Central Sleep Apnea Idiopathic Central Sleep Apnea Complex Sleep Apnea Complex Sleep Apnea CPAP Emergent events CPAP Emergent events Periodic Breathing (such as CSR) Periodic Breathing (such as CSR) CO2 and Chemoreceptor issue CO2 and Chemoreceptor issue Usually secondary to CHF Usually secondary to CHF Pulmonary Disorders: CO2 retention Pulmonary Disorders: CO2 retention Overlap Syndrome (OSA and COPD) Overlap Syndrome (OSA and COPD) Restrictive Disorders Restrictive Disorders Neuromuscular Disorders Neuromuscular Disorders Obesity Hypoventilation Syndrome Obesity Hypoventilation Syndrome OSA Idiopathic/PB Complex

14 Idiopathic Central Sleep Apnea Problem is with the controller mechanism (the brain) Problem is with the controller mechanism (the brain) Can be secondary to stroke, brain injury Can be secondary to stroke, brain injury Cause not always known Cause not always known Treatment is the same Treatment is the same

15 Idiopathic central sleep apnea – PSG view No output from respiratory center of the brain causing lack of movement of the thorax. No movement of thorax & abdomen causes apnea

16 Idiopathic central sleep apnea Cause of Idiopathic Central Apnea: Cause of Idiopathic Central Apnea: The respiratory center of the brain does not fire during sleep causing periodic apnea (see below) The respiratory center of the brain does not fire during sleep causing periodic apnea (see below) Seen during the diagnostic night and titration night Seen during the diagnostic night and titration night Generally seen in non REM sleep clears during REM sleep Generally seen in non REM sleep clears during REM sleep Generally seen in younger populations Generally seen in younger populations May appear as part of a neurological disease process or injury May appear as part of a neurological disease process or injury Relationship between chronic opioid therapy and central sleep apnea 1 Relationship between chronic opioid therapy and central sleep apnea 1 Impacts very small population of people Impacts very small population of people Apnea 1 Webster,et al. American Academy of Pain Medicine 2007

17 Treatment recommendations for idiopathic central sleep apnea Oxygen therapy Oxygen therapy Respiratory Stimulant medications Respiratory Stimulant medications NIV NIV BiPAP S/T BiPAP S/T Must be able to differentiate between Idiopathic CSA and Complex Apnea Must be able to differentiate between Idiopathic CSA and Complex Apnea Remember: <2% of SDB

18 What is complex apnea? Complex apnea occurs with the application of PAP therapy Complex apnea occurs with the application of PAP therapy Central apneas occur Central apneas occur Relative CO2 drop from application of PAP therapy Relative CO2 drop from application of PAP therapy REMEMBER: PAP does NOT fix central events! REMEMBER: PAP does NOT fix central events!

19 Complex Apneas on CPAP 7 cm H2O Cycle time for events is ~30 seconds Pittman Slides

20 Complex Sleep Apnea - Characteristics Characteristics of Complex Sleep Apnea Characteristics of Complex Sleep Apnea Typically emerges during titration not during diagnostic PSG Typically emerges during titration not during diagnostic PSG Emerges with the implementation of CPAP to alleviate OSA events 1 Emerges with the implementation of CPAP to alleviate OSA events 1 Occur at ~ 30 second intervals vs second interval with CSR Occur at ~ 30 second intervals vs second interval with CSR Complex Sleep Apnea is a mixture of OSA which converts over to central apnea upon CPAP application and opening of the airway 1 Complex Sleep Apnea is a mixture of OSA which converts over to central apnea upon CPAP application and opening of the airway 1 Minimal data available Minimal data available Estimated prevalence 1/7 or ~15% of the SDB population Estimated prevalence 1/7 or ~15% of the SDB population 1 Morganthaler, et. al. Sleep 2006; 29 (9):

21 Possible Cause of Complex Sleep Apnea ? Theory of Complex Apnea is due to a combination of airway resistance and respiratory drive 12 Theory of Complex Apnea is due to a combination of airway resistance and respiratory drive 12 Theory: once airway open with low levels of CPAP, OSA is eliminated with CPAP. The airway now allows for normal RR causing instability of CO2 receptors. Theory: once airway open with low levels of CPAP, OSA is eliminated with CPAP. The airway now allows for normal RR causing instability of CO2 receptors. With a normal breathing pattern, the patients brain function reads the change in CO2 and causes hypoventilation to occur. (slight change of 2 can cause instability) With a normal breathing pattern, the patients brain function reads the change in CO2 and causes hypoventilation to occur. (slight change of 2 can cause instability) Hyperventilation then leads to development of central apneas causing complex breathing events Hyperventilation then leads to development of central apneas causing complex breathing events Chemoreceptor issues unmasked when OSA is eliminated Chemoreceptor issues unmasked when OSA is eliminated 1 Interview with Dr. Younes & Dr. Sanders 2 Moganthaler, et.al. Sleep 2006 Complex ~35 sec

22 Treatment Strategies for Complex Sleep Apnea CPAP + Time on Therapy to reset chemoreceptors for patient CPAP + Time on Therapy to reset chemoreceptors for patient Must qualify with AHI > 5 with EDS OR AHI >15 Must qualify with AHI > 5 with EDS OR AHI >15 To move to AutoServo Ventilation must meet RAD criteria To move to AutoServo Ventilation must meet RAD criteria No improvement, try alternatives below No improvement, try alternatives below Medications + CPAP Medications + CPAP Auto Servo Ventilation Auto Servo Ventilation RAD policy for Complex Sleep Apnea RAD policy for Complex Sleep Apnea

23 Key Strategy When performing a titration where complex apnea presents, patience is the key When performing a titration where complex apnea presents, patience is the key Usually a difficult and tedious titration Usually a difficult and tedious titration In most cases, the CPAP emergent apnea will resolve with time to adjust to PAP pressure. In most cases, the CPAP emergent apnea will resolve with time to adjust to PAP pressure. Servo may be required if CSA persists Servo may be required if CSA persists

24 Periodic Breathing (such as CSR) What is the population mix? What do they look like on PSG? What is the treatment strategy for PB?

25

26 Periodic Breathing (such as Cheyne Stokes) Prevalence normally about 5% of patients Prevalence normally about 5% of patients Increase in prevalence with special populations Increase in prevalence with special populations Heart Failure (~40%-50%) Heart Failure (~40%-50%) Neurologic disorders (stroke) Neurologic disorders (stroke) Altitude Altitude Renal Failure, Dialysis patients Renal Failure, Dialysis patients Characteristics Characteristics Emerges in non REM sleep Emerges in non REM sleep May resolve in REM sleep May resolve in REM sleep May be seen prior to study and during diagnostic study May be seen prior to study and during diagnostic study

27 Periodic Breathing Characteristics: waxing and waning breathing pattern Characteristics: waxing and waning breathing pattern Length is based on disease process causing the breathing pattern Length is based on disease process causing the breathing pattern Longer events for patients in heart failure 1 (picture A) Longer events for patients in heart failure 1 (picture A) second events of CSR then followed by normal respiration (waxing and waning of Respiration) in patients with Heart failure second events of CSR then followed by normal respiration (waxing and waning of Respiration) in patients with Heart failure 1 Shorter events in those with preserved heart function 1 (picture B) Shorter events in those with preserved heart function 1 (picture B) 20 – 40 seconds on length with those with preserved heart function 1 20 – 40 seconds on length with those with preserved heart function 1 ~60 sec 1 Thomas, et. al. Curr. Opin Pulm Med A B

28 Treatment Recommendations for PB If patient has PB due to disease process, medical management of disease will help with management of PB If patient has PB due to disease process, medical management of disease will help with management of PB Medical Management of Heart Failure is KEY in treatment of CSR 1 Medical Management of Heart Failure is KEY in treatment of CSR 1 If the patient has predominately CSR, (CSR >50%), CSA > 5, AHI If the patient has predominately CSR, (CSR >50%), CSA > 5, AHI CPAP Therapy 1 CPAP Therapy 1 Auto Servo Ventilation 3 Auto Servo Ventilation 3 Bi-Level Therapy with back up rate 2 Bi-Level Therapy with back up rate 2 If the patient has predominately OSA (<50% CSR), CPAP should be prescribed If the patient has predominately OSA (<50% CSR), CPAP should be prescribed 1 Javaheri, et. al. Curr Treatment Option in CV Med: 2005:7: Kasi, et. al. Circ. J.; : Teschler et al, AJRCCM, 164: , 2001

29 Complicated Patients Patients have complicated and variable breathing Patients have complicated and variable breathing Auto PAP treats OSA Auto PAP treats OSA Auto Backup rate treats CSA Auto Backup rate treats CSA Variable IPAP (PS) treats periodic breathing Variable IPAP (PS) treats periodic breathing

30 ASV Initial Settings EPAP min - ?? EPAP min - ?? EPAP max -20cwp EPAP max -20cwp PS min – 0 PS min – 0 PS max- 10 PS max- 10 Backup rate- Auto Backup rate- Auto Max pressure - 25 Max pressure - 25 Be patient Document Must control leak How much leak is too much?

31 Central Sleep Apnea Summary Idiopathic CSA: BiLevel PAP with Backup rate Idiopathic CSA: BiLevel PAP with Backup rate Complex Apnea: PAP with patience. Servo if needed Complex Apnea: PAP with patience. Servo if needed Periodic Breathing: Servo Ventilation. BiPAP Auto SV Advanced Periodic Breathing: Servo Ventilation. BiPAP Auto SV Advanced

32 Absolute Hypoventilation Overlap disease Overlap disease Obesity Hypoventilation Syndrome Obesity Hypoventilation Syndrome Neuromuscular Disease Neuromuscular Disease CO2 retention CO2 retention

33 Strategy: Improve ventilation Provide consistent Tidal Volume (Vt) Provide consistent Tidal Volume (Vt) Volume targeted pressure ventilation (AVAPS) Volume targeted pressure ventilation (AVAPS) Consistent CO2 elimination Consistent CO2 elimination

34 Improving Quality of Life

35 COPD Overlap Syndrome A combination of OSAHS and COPD A combination of OSAHS and COPD Patients with overlap disease usually have a more significant oxygen desaturation Patients with overlap disease usually have a more significant oxygen desaturation More likely to develop pulmonary hypertension More likely to develop pulmonary hypertension CO2 retention due to hypoventilation CO2 retention due to hypoventilation Decrease in O2 levels are very evident on PSG Decrease in O2 levels are very evident on PSG

36 The COPD patient

37 Obesity Hypoventilation Syndrome Also known as Pickwickian Syndrome Also known as Pickwickian Syndrome Increase in CO2 during sleep (>10mmHg) Increase in CO2 during sleep (>10mmHg) BMI usually greater than 30kg/m2. BMI usually greater than 30kg/m2. No other reason for hypoventilation such as neuromuscluar disease, restrictive thoracic disease, obstructive lung disease or interstitial lung disease No other reason for hypoventilation such as neuromuscluar disease, restrictive thoracic disease, obstructive lung disease or interstitial lung disease Retains CO2 Retains CO2

38 Obesity Hypoventilation Patient

39 Neuromuscular disease Progressive muscle weakness that increases over time Progressive muscle weakness that increases over time Patient cannot ventilate adequately Patient cannot ventilate adequately Example: ALS Example: ALS NIV required to help patient ventilate NIV required to help patient ventilate Retains CO2 Retains CO2

40 Neuromuscular Disease

41 Pathology Overlaps coming from the Sleep Lab OSA Central/ Periodic SDB Neuro-MuscularDisorders COPD – Overlap Obesity Hypo- Ventilation Restrictive Thoracic Disorder Complex SDB

42 How do we help patients to breathe when they cannot?

43 Average Volume Assured Pressure Support (AVAPS) Acts primarily as a bilevel pressure support ventilator that is able to provide a constant tidal volume Acts primarily as a bilevel pressure support ventilator that is able to provide a constant tidal volume Automatically adjusts the pressure support level to maintain a consistent tidal volume Automatically adjusts the pressure support level to maintain a consistent tidal volume IPAP will automatically increase or decrease to maintain set tidal volume IPAP will automatically increase or decrease to maintain set tidal volume Volume targeted Pressure Ventilation Volume targeted Pressure Ventilation Progressive Ventilatory Insufficiency Progressive Ventilatory Insufficiency Neuromuscular Disease Neuromuscular Disease Amyotrophic Lateral Sclerosis Amyotrophic Lateral Sclerosis COPD COPD Positional Compromised Ventilation Positional Compromised Ventilation Obesity Hypoventilation Syndrome Obesity Hypoventilation Syndrome

44 How AVAPS works

45 The AVAPS Initial Settings ParametersRange EPAP Start low. Adjust for Apnea IPAP min 4 above EPAP IPAP max10 above IPAP min Tidal Volume8ml/kg IBW. Use chart

46 Titration Method for Patient on BiPAP AVAPS Continually assess ventilation through the following areas: Continually assess ventilation through the following areas: Respiratory Rate Respiratory Rate Tidal volume (ratio between EPAP and IPAPmax but must have a large enough delta between IPAPmin and IPAPmax to maintain) Tidal volume (ratio between EPAP and IPAPmax but must have a large enough delta between IPAPmin and IPAPmax to maintain) CO 2 levels* CO 2 levels* Continually assess oxygenation through Continually assess oxygenation through SaO 2 SaO 2 EPAP settings EPAP settings Try to maintain baseline CO 2 levels throughout the night if possible Try to maintain baseline CO 2 levels throughout the night if possible * If applicable

47 Be Patient! Break old habits!

48 AVAPS Strategy Be patient! Be patient! Titrate EPAP to overcome obstructive apnea Titrate EPAP to overcome obstructive apnea Set Tidal Volume properly Set Tidal Volume properly Monitor patient and document Monitor patient and document Control leak Control leak

49 Two Different patient groups Absolute Hypoventilation patients Absolute Hypoventilation patients AVAPS AVAPS Overlap disease Overlap disease Neuromuscular disease Neuromuscular disease OHS OHS Central Sleep Apnea Periodic Breathing Idiopathic CSA Complex CSA Servo

50 Take Away Points AVAPS- you must titrate EPAP AVAPS- you must titrate EPAP Monitor ventilation Monitor ventilation IPAP min 4 above EPAP IPAP min 4 above EPAP Must control leak! Must control leak! Servo- EPAP is auto titration Be patient! PS min is 0 Must control leak!

51 You might be feeling like this..

52 Resources Brian, Jerry, Tom, Jeff Andrew and Ben Brian, Jerry, Tom, Jeff Andrew and Ben Matt, Brian, Dax Matt, Brian, Dax Mark, Tom, Darryl Mark, Tom, Darryl The TEXAS team! The TEXAS team!

53 Thank you


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