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Who, What, Why, and When Gary Hamilton, BS, RRT Clinical Specialist ResMed.

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Presentation on theme: "Who, What, Why, and When Gary Hamilton, BS, RRT Clinical Specialist ResMed."— Presentation transcript:

1 Who, What, Why, and When Gary Hamilton, BS, RRT Clinical Specialist ResMed

2  Employed by ResMed  Own stock options of ResMed

3 By the end of this session, you should be able to:  Identify when a CPAP may not be the device of choice  Recognize different uses of bilevel and the different disease states it is applicable to  Describe what tools are available to: ◦ Increase tolerance and compliance ◦ Treat the disease and/or disorder  Understand how to impact patient outcomes by proper utilization of bilevel and its settings

4 Why patients fail CPAP:  CPAP is uncomfortable  Patient may feel CPAP is uncomfortable at higher pressures despite pressure relief features  COPD patients have trapped air/pressure in their lungs, which may increase their work of breathing  Patient may need higher levels of ventilatory support CPAP cannot provide

5 Why make the switch from CPAP to Bilevel? Patient Comfort:  Cannot tolerate CPAP  On a high CPAP pressure and cannot tolerate it Ventilation:  Obstructive disease  Restrictive disease  Neuromuscular disease


7  Comfort/compliance features ◦ Cpap  Lower pressure  Ramp  Pressure relief (Cflex or EPR)  Waveform (sine vs square) ◦ Bilevel  Ramp  Pressure relief (Ipap and Epap)  Waveform  Rise time  Trigger sensitivity  Cycle sensitivity  Ti control (controlling the time in inspiration or expiration)  Pressure support ( muscle unloading)

8 Patient Flow Delivered Pressure IPAP EPAP Exhalation Trigger Cycle Inhalation Pressure support ( P)

9  OSA Airway problem  CompSA Airway and Ventilation problem  Cheyne-Stokes Ventilation problem  COPD Ventilation problem  Neuromuscular Ventilation problem

10 Can I get Bilevel paid for when it not OSA?


12 Tools Available in Bilevel for Specific Diseases

13  ST device ◦ Is back-up rate machine (E0471) ◦ Fixed rate – time controlled ◦ Not very comfortable- little synchrony ◦ Square wave- ventilates  Servo ventilator ◦ Is back-up rate machine (E0471) ◦ Should be more comfortable- tries to sync with pt ◦ Sine wave- not trying to ventilate ◦ Very automatic (servo)

14 Central apneas occur CompSA patient not treated CompSA patient on Servo

15 The ASV algorithm automatically adjusts the magnitude of pressure support breath by breath to: ◦ Provide minimal, comfortable support during the over- breathing phase (hyperpnea) or during normal breathing ◦ Increase support during the under-breathing phase (hypopnea or apnea) VPAP Adapt SV Patient Flow

16 Tools Available in Bilevel for Specific Diseases

17  Lung tissue destroyed  Elasticity of lungs disappearing  Poor functioning diaphragm  Reliance on accessory muscles  Air trapping


19 Auto-PEEPAuto-PEEP Missed triggersMissed triggers Work of breathingWork of breathing Expiratory timeExpiratory time Lung emptyingLung emptying Decreased expiratory time = Increase in Delayed cycling = Decrease in May have difficulty exhaling on CPAP Extends their inspiratory time Asynchrony Increases their work of breathing Cycling problems (getting into exhalation)

20 Very HighQuick to trigger2.4 L/min HighMore sensitive4 L/min MedDefault6 L/min LowLess sensitive10 L/min Very LowSlow to trigger15 L/min Very HighQuick to cycle 50% of peak flow HighMore sensitive35% MedDefault25% LowLess sensitive15% Very LowSlow to cycle8% Adjustable Trigger Sensitivity Patient Flow EPAP Adjustable Cycle Sensitivity Patient Flow EPAP

21 Problem: Patient requires longer expiratory time (i.e. COPD) Solution: Best option – Shorten Ti Max time Additional options – Select higher cycle sensitivity, Select faster rise time

22  Rise Time ◦ For comfort ◦ Will affect how pressure “feels” to pt

23 Square Wave Easy-Breathe

24 Tools Available in Bilevel for Specific Diseases

25 Premature cycling creates asynchrony Occurs in restrictive patients Lungs physically restricted Paralysis or muscles deteriorated “However, premature cycling may also have detrimental effects on patient-ventilator synchrony. Premature cycling is simply when the ventilator terminates the breath while the patient requires a long inspiratory period.” Gentile. Respir Care 2011

26 An early fall in the absolute flow rates may trigger the transition to EPAP prematurely. Certain devices provide a minimum IPAP time to ensure that IPAP lasts long enough to allow delivery of an adequate tidal volume. ) Minimum IPAP duration (if available) may be increased if the device cycles from IPAP to EPAP prematurely (eg, in restrictive chest wall disorders). Level A – Consensus Berry. J Clin Sleep Med 2010


28 PS 5PS 10 PS 15PS 20

29  iVAPS – (ResMed)  Intelligent Volume Assured Pressure Support  AVAPS (Philips)  Average Volume Assured Pressure Support Can assure Tidal Volume while the patient is sleeping Is Servo Controlled

30 The iVAPS Algorithm: Example Alveolar ventilation drops ◦ patient moves into REM sleep ◦ iVAPS rapidly increases PS until target Va is reached Pt. Flow PS Ventilation [– AV –MV –TargetAV ] SpO 2 REM Onset

31  CPAP may not be the device of choice for specific patients  Diagnoses will be a big determinant of what PAP machine will be appropriate for the patient  Goals of therapy will tell you what machine you should use ◦ Stabilize airway ◦ Hypoventilate the patient ◦ Ventilate the patient  Bilevel offers a greater amount of tools to: ◦ Increase comfort of patient ◦ Increase compliance of patient ◦ Increase the chances of the therapy goals being met  Tools available ◦ Wave forms ◦ Time cycling ◦ Sensitivity adjustments ◦ Servo algorithms

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