1145 pap modalities (das)(update) - chest italy...examples of common cpap devices fisher &...
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PAP Modalities
Aneesa M. Das, MD FCCPThe Ohio State University
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Financial Disclosures:UptoDate Royalties
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Positive Airway Pressure (PAP) Modalities• CPAP• APAP• Bilevel• Advanced bilevel modalities
– Bilevel ST, Adaptive Servo Ventilation, Volume Assured Pressure Support
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CPAP
• Continuous Positive Airway Pressure
• CPAP delivers pressurized air at a constant pressure through a mask to keep the airway open during inhalation.
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UpToDate.com
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CPAP Acts as an Airway Stent
0 cm H20
5 cm H20
10 cm H20
15 cm H20
Richard Schwab, M.D. UPENN
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+ ++ +
+ ++
++
+
Positive airway pressure
Positive intrathoracic pressure
Traction on airway
Splinting of airway
Increased lung volume
Decreased venous return
Decreased afterload
Increased cardiac output
Effects of PAP
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Adherence With CPAP– Definition of adherence
• > 4 hours/night on 70% of nights
– Adherence probably about 50 - 60%• Patients overestimate nightly use.
– Adherence patterns are determined early
– Few clear predictors of adherence:• Daytime sleepiness• More severe disease
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CPAP: Complications
Ø RhinorrheaØNasal congestion or
drynessØ EpistaxisØ Skin abrasions/rashes
Ø Chest discomfortØ ClaustrophobiaØAir swallowingØ InconvenientØ “Not sexy”
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Examples of Common CPAP Devices
Fisher & Paykel
Icon
ResmedAirsense
RespironicsDreamstation
DeVilbissIntelliPaP
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Common CPAP Interfaces: Masks
Nasal Nasal Pillows Full Face
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APAP
• Auto Positive Airway Pressure• (autotitrating positive airway pressure)• APAP works similarly to CPAP but the pressure
can adjust within a range of pressures to maintain an open airway
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APAP Download
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Bilevel
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Antonescu-Turcu et al. Respir Care. 2010 Sep; 55(9): 1216–1229.
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Can bilevel in spontaneous mode treat central sleep apnea?
A. YesB. No
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Can bilevel in spontaneous mode treat central sleep apnea?
A. YesB. No
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Bilevel Spontaneous vs Spontaneous Timed
Flow
Bilevel SPressure
Central Apnea
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Bilevel Spontaneous vs Spontaneous Timed
Flow
Bilevel STPressure
Central Apnea
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Which of the following PAP modalities should be avoided in patients with hypoventilation?
A.Bilevel STB.Volume Assured Pressure Support
(VAPS)C.Bilevel SD.Adaptive Servo Ventilation (ASV)
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Which of the following PAP modalities should be avoided in patients with hypoventilation?
A.Bilevel STB.Volume Assured Pressure Support
(VAPS)C.Bilevel SD.Adaptive Servo Ventilation (ASV)
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Hypoventilation Central Sleep Apnea with
Periodic Breathing
Central Sleep Apnea with
HypoventilationBilevel S YES NO NO
Bilevel ST YES YES YES
Adaptive Servo Ventilator (ASV)
NO YES NO
Volume Assured Pressure Support (VAPS)
YES NO YES
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Adaptive Servo Ventilation (ASV)
Maintains a the patient’s recent flow/ventilation by adjusting the pressure support, and providing a backup rate
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Theory of Operation
2. Peak Flow/Minute Ventilation is reduced below target ▬► IPAP is increased
Flow
Pressure
3. Peak Flow/Minute Ventilation is increased ▬► IPAP is decreased
Breath by breath, the algorithm adjusts pressure support if….
1. Peak Flow/Minute Ventilation is at target ▬► No additional* IPAP is given
2.1. 3.
Adaptive Servo Ventilation
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Warning:
ASV is currently contraindicated in patientswith predominant central sleep apnea (CSA)and reduced left ventricular ejection fraction(LVEF ≤45%).
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Volume Assured Pressure Support (VAPS)• Designed to maintain a preset target ventilation by
monitoring ventilation, adjusting the pressure support, and providing a backup breath automatically
• Non-inferior to Bilevel-ST in management of: – obesity hypoventilation syndrome– chronic obstructive pulmonary disease– neuromuscular disease
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Volume Assured Pressure Support (VAPS)• AVAPS (volume assured pressure support;
Respironics)– targets expiratory tidal volume
• iVAPS (intelligent volume assured pressure support ResMed)– targets alveolar ventilation (minute ventilation minus
dead space ventilation)
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Selim et al. CHEST 2018; 153(1):251-265
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Device Type Mechanism Main Indications
CPAP Continuous positive pressure to stent open airway
OSA
Bilevel S Inspiratory and expiratory pressures to augment breaths that are patient initiated
OSA, hypoventilation
Bilevel ST (timed mode)
Inspiratory and expiratory pressures to augment breaths that are patient or device initiated if patient rate falls below set rate
CSA, hypoventilation,
Adaptive Servo Ventilator (ASV)
Maintains a the patient’s recent flow/ventilation by adjusting the pressure support, and providing a backup rate
CSA
Volume Assured Pressure Support (VAPS)
Maintains a set target ventilation by adjusting the pressure support, and providing a backup rate
hypoventilation
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