titrating asv and niv - wisleep.org › titrating_asv_and_niv.pdfqualifying-hypoventilation covered...
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Titrating ASV and
NIVUNDERSTANDING VENTILATION
MARLA VAN LANEN RRT, RPSGT, RST
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Objectives
Explain the difference between ASV and NIV
Explain manufacturer differences
Patient selection with volume or pressure support assisted
PAP
Successful titration strategies
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CPAP
Continuous Positive Airway Pressure
Used to treat obstructive sleep apnea
Splints the airway open with air pressure
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Bilevel
Positive airway pressure
Duel pressures
Inhalation=IPAP
Exhalation=EPAP
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When to Use BiLevel
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When CPAP is
Uncomfortable/Pressure too high
Standard guidelines for CPAP titration
Switch to Bilevel once pressure beyond 15cmH20
Higher pressures increase leaks
Mask needs to be tighter at higher pressures
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Underlying Lung Disease
Restrictive disorder (neuromuscular disease)
Obesity hypoventilation
COPD
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Using iVAPS/AVAPs
Ensures appropriate ventilation for the patients needs
Adjusts automatically to maintain a set tidal volume or
alveolar ventilation
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Manufacturer Types
IVAPS=Resmed
Intelligent Volume Assisted Pressure Support
AVAPS=Respironics
Average Volume Assured Pressure Support
Also called BiPAP AVAPS
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Tidal Volume
The amount of air inhaled or exhaled in a single breath
Measured in CC or ML
Abbreviation Vt
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Gas Exchange
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Alveolar Ventilation
Targets alveolar ventilation which takes into account the
anatomical deadspace.
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Restrictive Lung Disease
Difficult time maintaining the inhalation phase for
adequate ventilation
Caused by physical restriction of the lungs or
neuromuscular weakness
Use settings to make triggering a breathe easier
Adjust cycle time to allow for a longer breath
Slower Rise time
Increases tidal volume and improves gas exchange
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Obesity Hypoventilation
Regular BiLevel may be enough
Ventilation in insufficient to support adequate
oxygenation
Due to large BMI
Increased weight on chest does not allow adequate
chest expansion during sleep
Especially true in REM
Commonly also have OSA
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Setting the Tidal Volume/Minute
volume
Set Vt or Minute Volume based on height and weight
6-8ml/kg
Set for patient comfort
Set according physician orders
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Max/Min Pressure Support
Max Pressure support should not need adjustment
Min Pressure support: adjust for comfort or to maintain Vt
Important to monitor Vt and leak
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EPAP
Increase by 1cm for obstructive events
First and foremost maintain the airway
Keep EPAP high enough to allow the pressure support to
work
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Back Up Rate
Count the patient’s resting RR set slightly behind
Useful in neuromuscular patients who need to rest
respiratory muscles
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Examples of Restrictive Lung
Disease
ALS
Muscular Dystrophy
Kyphoscoliosis
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Qualifying Guidelines
Clinical documentation of Neuromuscular disease or
thoracis cage abnormality
PCO2 greater than 45
Pulmonary Function test-FVC is less than 50% predicted
or Maximal Inspiratory pressure is less than 60cmH2O
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Qualifying Guidelines
No diagnostic is needed if qualifying guidelines met
Do all night titration with TcCO2
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Qualifying-Hypoventilation
Covered BIPAP is currently being used
Spirometry shows FEV1/FVC equal to or greater than 70% and FEV1
greater than and equal to 50% of predicted
Either O2 sat is equal to or greater than 88% for 5 minutes of
recording time (not caused by OSA)
Or ABGs worsens by 7mmHg compared to ABGs done to qualify for
BiPAP
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COPD
Chronic Obstructive Pulmonary Disease
Air sacs are damaged and lose their stretch
Exhalation is prolonged
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COPD
Regular Bilevel may be enough
Normal trigger sensitivity
Shorten exhalation time (TI max)
Let out of the exhalation phase sooner
Bilevel assists ventilation and rests the muscles associated
with breathing
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Qualifying Guidelines-COPD
OSA and treatment with CPAP has been considered and
ruled out
PCO2 greater than 52
O2 sat less than or equal to 88% for at least five
continuous minutes during the night that is not caused
by OSA
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ASV
Adaptive Servo Ventilation
VPAP adapt or Auto SV
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Central Sleep Apnea
Cheyne-stokes breathing
Drug induced apnea
High altitude breathing
Complex sleep apnea
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Patient Selection
SERVE-HF
LVEF must be greater than 45
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Cheyne Stokes Breathing Consecutive central apneas and/or central hypopneas
separated by crescendo/decrescendo change in
breathing effort
Cycle length 40 seconds
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Leak
Set mask to calculate appropriate leak value
Make sure leak is acceptable
Change mask or adjust to manage leak
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Baseline settings
Max and min pressure support 15/4
EPAP 4-5
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Adjusting ASV
Increase EPAP by 1cm for OSA
Don’t rush!!!! Wait 20 minutes between changes
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Adjusting EPAP
EPAP plus Max pressure support equal 25
As you increase EPAP be aware that IPAP may
automatically decrease
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Qualifying for ASV
Central sleep apnea
AHI greater than 5
Central apnea greater than 5
EDS
Central apneas are greater than 50% of total events
Complex Sleep Apnea
AHI greater than 5
central apneas are greater than 50% of the total events once
CPAP/BiPAP has been applied
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Questions???
Thank you!