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David Wolfe Crouse Hospital Upstate Medical University

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  • David Wolfe

    Crouse Hospital

    Upstate Medical University

  • Alphabet Soup

    CPAP

    BPAP

    IPAP

    PS

    EPAP

    APAP

    ASV

    AVAPS

    iVAPS

    OSA

    RLS

    PLMD

    OHS

    EDS

  • Making it Simpler

    CPAP/BPAP airway

    A/i VAPS lung (hypercapnic)

    ASV brain (normo/hypocapnic)

  • OHS Criteria

    Chronic daytime hypercapnia (PaCO2 >

    45 mm Hg)

    in obese patients (BMI > 30 kg/m2)

    after ruling out any other causes of

    hypoventilation

  • OHS Signs and Symptoms

    Hypoxemia

    Dyspnea

    EDS

    Morning headache

    Depression

    As many as 90% of OHS patients also

    have OSA.

  • OHS Indications

    Headaches and somnolence after CPAP

    treatment

    Continuous O2 saturation < 90%

    DOE

  • OHS Untreated

    Pulmonary HTN

    R heart failure

    Polycythemia

  • Treatment of OHS

    Weight loss

    NIV

  • Bilevel PAP (BPAP)

    EPAP

    IPAP

    PS difference between EPAP and

    IPAP

    EPAP = 6, IPAP = 14

  • Rise Time

    Time it takes to change from the

    expiratory pressure setting to the

    inspiratory pressure setting.

  • BPAP

  • iVAPS

    intelligent Volume-Assured Pressure

    Support

    Under-achievers

    Targets alveolar ventilation by adjusting

    to patients RR and adjusting PS.

  • iVAPS - Alveolar Ventilation

    Targets and maintains alveolar ventilation instead of E or VT Delivers required ventilation at the alveoli (gas

    exchange) Compensates for the air that travels through the

    conducting airways

    Maintains VA with fluctuating RR Normal anatomical deadspace ~1/3 (?) of VT With respiratory disorders, as RR , wasted

    deadspace volume

    Estimating anatomical deadspace maintains consistent ventilation at the alveolar level, even with RR fluctuations

  • iVAPS

    Rate and alveolar ventilation targets are

    set for the patient

    Responding to the patients breathing

    changes, it automatically adjusts

    pressure support

    Provides an intelligent back-up rate

    Helps reduce the need for frequent f/u

  • iVAPS

    COPD - hyperinflation

    OHS

    Neuromuscular Disorders

    Restrictive Diseases

  • iVAPS

    Set-up manually or Learn Targets

    (learned during set-up) feature

    Learned/Set Target Patient Rate =

    Spontaneous Respiratory Rate

    Learned/Set Target VA (height) =

    Required VA

    iVAPS constantly monitors & estimates

    pts VA in relation to target VA ventilation.

  • Automatically adjusts PS to achieve &

    maintain target VA, varying speed of

    response as required.

  • If VA is far from target, PS adjusts

    quickly.

  • As VA gets close to target, PS gently

    levels off.

  • Maintains stable VA automatically during

    changes in respiratory mechanics (i.e.

    REM sleep transition, postural change).

  • Back-up rate = 2/3 of the patients

    spontaneous breathing rate

  • Unable to trigger the device, back-up

    rate provides breaths at the target

    patient rate.

  • iVAPS

    The PS and back-up rate work to

    balance efficacy and pt. comfort.

  • BiPAP AVAPS

    Average Volume Assured Pressure

    Support

    Increases pressure quickly to maintain

    target VT, but slow enough to keep

    patient asleep.

    Averages VT and

    changes PS

    gradually (several

    minutes).

  • AVAPS

    Automatically adapts to changing patient

    needs and disease progression

    Maintains optimal patient comfort

    Improves efficacy of ventilation

  • AVAPS

    Digital Auto-Trak Sensitivity algorithm:

    Allows clinicians to achieve optimum

    patient/ventilator synchrony.

    Recognizes & compensates for leaks

    Automatically adjusts its variable trigger and

    cycle thresholds

  • AVAPS Settings

    Target VT set to ideal body

    weight 8 ml/kg

    Set IPAP limits

    Max: 25 cm H2O (depends on pt pathology)

    Min: EPAP + 4 cm H2O

    Set RR: 2-3 BPM < resting RR

    Set Ti

    Adjust rise time for pt comfort

  • AVAPS

    As pt effort decreases, PS increases to

    maintain target VT.

    IPAP level will not rise above IPAP Max.

    As pt effort increases, PS decreases.

    IPAP will not fall below IPAP Min.

  • AVAPS

  • Trilogy

    AVAPS AE

    Forced oscillation technique

    AVAPS rate

    Dual prescriptions

    Passive (AVAPS) or active exhalation

    port

  • For OHS

    BPAP and AVAPS improved:

    Oxygenation

    Sleep quality

    QOL

    AVAPS greater improvement in

    ventilation than BPAP.

    Storre et al, Chest, 2006

  • OHS. Compared to BPAP . . .

    Nocturnal ventilation with AVAPS,

    lowered TcCO2 by 3 mmHg.

    AVAPS:

    Impaired sleep quantity and architecture.

    Subjectively poorer sleep.

    Janssens et al, Respir Med, 2009

  • Adaptive/Automatic Servo

    Ventilation

    Over-achievers

    Treats: CSA

    Complex SA

    Mixed apnea

    Periodic breathing

    How: EPAP - keeps airways open

    PS increases VT (IPAP = EPAP + PS)

  • AirCurve 10 (VPAP Adapt SV)

    90% of recent ventilation.

    Automatically adjusts PS.

    Min PS and Max PS restrict PS range.

    EPAP adjusted to eliminate OEs.

    Mandatory breaths delivered at pts

    recent spontaneous breath rate:

    timed backup rate automatically

    calculated to match pts needs.

  • ASV

    Add diagram . . .

  • ASV Auto

    Automatically adjusts EPAP.

    Analyzes the state of patients upper airway on a breath-by-breath basis.

    Min and Max EPAP restricts EPAP range.

    Delivers (titrates) EPAP within the allowed range according to obstruction degree.

    EPAP changes based on:

    Inspiratory flow limitation

    Snoring

    OAs

  • ASV Auto

  • Breath Phase Mapping

  • PS

    PS trigger points set automatically,

    based on patient respiratory flow

    measurement.

    ResMed recommends Max PS to be

    15 cm H2O.

  • Backup Rate

    Uses breath phase mapping.

    Provides a timed backup rate

    synchronized with pts breathing.

    If deviation from the target ventilation:

    First, adjusts PS.

    Second, if necessary, adjusts backup rate

    From a backup that matches the pts recent

    rate,

    Towards the built-in 15 BPM default backup.

  • Ramp

    Set at 5 - 45 min

    ASV

    Start EPAP to set EPAP

    Min PS to PS range (Min PS and Max PS)

    ASVAuto

    Start EPAP to Min EPAP (EPAP range)

    Min PS to

    PS range

  • BiPAP autoSV

    Targets peak flow (over time period):

    Flow = Volume/Time

    Hypopnea/apnea, pt flow decreases . . .

    device flow increases.

    Increases flow first, then backup rate.

  • BiPAP autoSV Advanced

    Auto EPAP

    Automatically distinguishes between clear

    airway and obstructed apneas.

    Advanced backup rate

    Timing of backup rate delivery calculated to

    encourage spontaneous breathing at pts

    own natural rate.

    Synchronous with pts breathing.

  • BiPAP autoSV Advanced contd

    Servo Ventilation algorithm

    Monitors peak flow & s PS breath by

    breath to stabilize breathing pattern.

    Establishes a target peak flow.

    Rapidly normalizes unstable breathing

    pattern.

  • BiPAP autoSV Advanced contd

    Bi-flex technology

    Provides pressure relief:

    During exhalation.

    At critical transition points from

    Exhalation to inhalation

    Inhalation to exhalation.

  • BiPAP autoSV Advanced

    Suggested Titration Protocol

    EPAPmin = 4 cm H2O

    4 cm H2O (or pt comfort) known CPAP < 10

    6-8 cm H2O (or pt comfort) known CPAP > 10

    EPAPmax = 15 cm H2O

    PSmin = 0 cm H2O

    PSmax = 20 cm H2O

    Max pressure = 25 cm H2O

    Rate = auto

    Bi-Flex = to pt comfort

  • Set It and Forget It?

    Increase EPAPmin for obstructive events.

    Adjust Bi-Flex and/or increase PSmin for

    patient comfort.

    Increase PSmax for central events

    Inadequate breathing rate?

    Set rate to minimum 8-10 bpm or 2 below

    resting RR

    Set I-time = 1.5 seconds

    Wait 20 minutes after change.

  • ASV through March 2015

    CSA/CSB due to HF consistently

    demonstrated that ASV decreases CA

    frequency.1,2,3

    ASV improved LVEF.1,4

    ASV impact on mortality and QOL

    uncertain (not been studied).

    1. Pepperell et al, Am J Respir Crit Care Med, 2003

    2. Oldenburg et al, Eur J Heart Fail, 2008

    3. Fietze et al, Sleep Med, 2008

    4. Sharma et al, Chest, 2012

  • May 2015 press release

    Cautioned against ASV use in pts with

    symptomatic chronic HF & LVEF 45%.

    risk appears to be in LVEF < 30%.

    EPAP not adjusted much not a lot of

    obstruction.

    EPAP was not auto.

    No difference in exercise capacity or

    QOL.

  • Confusing?

    Present settings:

    EPAP = 8 cm H2O

    IPAPmin = 10 cm H2O

    IPAPmax = 25 cm H2O

    New settings to EQUAL present settings?

    EPAPmin

    EPAPmax

    PSmin

    PSmax

    Max pressure

  • Confusing? No!

    Present settings on ASV:

    EPAP = 8 cm H2O

    IPAPmin = 10 cm H2O

    IPAPmax = 25 cm H2O

    New settings to EQUAL present settings?

    EPAPmin = 8 cm H2O

    EPAPmax = 8 cm H2O

    PSmin = 2 cm H2O

    PSmax = 17 cm H2O

    Max pressure = 25 cm H2O

  • Quick Takeaways

    AVAPS targets TV

    iVAPS targets VA

    AVAPS AE has auto-EPAP

    i/AVAPS - underachievers

    ASV overachievers

    ASV Auto tracks (minute) ventilation

    BiPAP AutoSV tracks peak flow

  • End of Quiz . . . No Bonus Questions

    Now, do YOU have any questions?