PAP Download Interpretation and Case-Based Discussion filePAP Download Interpretation and Case-Based...
Transcript of PAP Download Interpretation and Case-Based Discussion filePAP Download Interpretation and Case-Based...
PAP Download Interpretation
and Case-Based DiscussionLoretta Colvin, APRN-BC
Nurse Practitioner
Clayton Sleep Institute
Objectives
• Review PAP adherence report elements
• Incorporate PAP report data into clinical
assessment
• Identify PAP machine technology
variations in reporting
Conflict of Interest
• I have no conflicts of interest to disclose
Adherence Assessment
Considerations
Data Assessment • Availability
– Software (Internet access, back-up options)
– Data transfer tools (Modem, card)
• Strengths
– Augments patient story
• Weaknesses
– Relies on manufacturer development,
communication and support
– wide variation in options
Patient Assessment
• Do subjective and objective reports agree?
• If not, which do you “believe” or how do
you assess further?
Recommendation
• ALWAYS view detailed data for issues
– Patient issues
• Not improving, Not tolerating,
– Report issues
• ↑ AHI, ↑ leak, ↑ pressure
• Data “issues”
• QUESTION technology when appropriate
Direct data from
machine display
screen
Data card
download in clinic
Modem
transmitted
DME creates
download and
sends to clinic
Pros: - Back-up when
no card (ex:
older machines)
- Back-up if no
computer
available
- You control the
data
- Can bring up
any report/time
range you chose
- Can access data
from anywhere
and at anytime
- Patient does not
have to bring
equipment
- DME does
the work for
you
Cons: - Limited data
available for
review
- Requires skilled
personnel to
download
- Relies on patient
to bring
machine/card
- DME must
“assign” the
modem to your
clinic
- Potential modem
glitches and
failures
- DME controls
what data
you get
- More
paperwork
and people
involved
Data Access
Software options
Web-Based PC Based
Fisher & Paykel Infosmart Web Infosmart
ResMed AirView(renamed from EasyCareOnline)
ResScan(Screens look very different)
Respironics EncoreAnywhere Encore Pro
Tip – update your PC Based programs to most current version
when any new machine is released (ex: AirSense)
• Data card
• USB or SD card
• Modem
• External
• Internal
• Viewing machine screens
• Typically basic usage available
Adherence Data
F&P
Icon
Respironics
System One
ResMed
S9 / AirSense
Data card USB SD SD
Office card download + + +
Home card download for clinician view
+ + -
Home download for patient viewing
- +SleepMapper
+MyAir (AS)
SleepSeeker (S9)
Modem download + + +
Data Downloads
F&P
Icon
Respirionics
System One
ResMed
S9 & AirSense
Upload schedule
•Fixed time(9 am CST)
•Pt initiated / set
•q 24 hours
•S9 Fixed time (1-4 pm PST)
•AirSense HALO
Patient transmission?
•Yes •Yes •No
Data transmission
•Cellular signal
•30 days stored
•External
•USB removed
•Cellular signal
•Blue tooth avail.
•External
•SD card stays
•Cellular signal
•S9 external
•AirSense internal
•SD card stays
Modems
Data “Pearls” for ResMed
• AirView (formerly Easy Care Online)– Cannot set range for historical detailed data
– Select BOTH compliance & summary for more data
– “Clock time” summary view not printable – hover mouse on screen
• AirSense– Modem: HALO (hour after last off) delay with AM appts
– Conveniently displays last night usage on machine screens
• S9– Detailed report – use card in ResScan, not modem
– SleepSeeker does not interface with clinician data view
• S8– Only stores 6 months, only downloads in ResScan
– Stores mini-card out of machine
Data “Pearls” for Respironics
• EncoreAnywhere
– DME must grant access for online script changes
– Custom “day” cut-points (helpful for shift work)
– SleepMapper requires DME to link office to patient
• System One
– Internal clock stays at noon cut-off for “day”, changes
can only be done in EncoreAnywhere report
• Respironics M-series and Legacy
– Lose card, lose data
Data “Pearls” for Fisher & Paykel
• InfoSmart web
– Change to settings screens to get custom date range
and click “generate” tab
– Reports may need to be “fit to window” for printing
• Icon
– USB easily inserts backwards in computer
– Home download allows office view w/o pt account set-up
– Screen display less user friendly
– Basic mode available for “low tech” patient screens
Report Components
F&P
Icon
Respironics
System One
ResMed
S9 / AirSense
Pressure Average &
90th percentile
Average &
90th percentile
Median &
95th percentile
Leak Total
>40-50 L/min high
Total
>40-50 L/min high
Unintentional
>24 L/min high
Custom date range
+Change screens
Detailed
+Initial screen
Summary & detailed report
+/-Count back days
Summary only,
not on detailed
Reports -Summary
+ Detailed
+ Summary
+ Detailed
+ Customized
+ Summary
+ Detailed
Key Components
F&P
Icon
Respironics
System One
ResMed
S9 / AirSense
Pressure relief
SensAwake Flex / Flex+ EPR
Humidifier
Chamber
0-7 0-5 S9 0-6
AS 0-8
Heated Tubing
Boost L-M-H 1-2-3 60 – 86 degrees
Comfort Features
Cases
Pressure Relief
ResMed EPR
• Baseline AHI 11
• Titration - 9 cm
recommended
• EPR 3 acts
similar to “mini-
Bilevel”
Fisher & Paykel SensAwake
• CPAP 9 orders
sent to DME
• DME left
SensAwake on
• AHI 2.9 on report
Another Example – SensAwake
Respironics SystemOne Cflex +PSG
AHI 120’s
Low sats 60’s
“AHI” 31
Leak
F&P Icon – Infosmart
• Is leak acceptable? (group)
> 50 is high
F&P Icon – Another Example
ResMed S9 – EasyCare Online
• Is this OK? (group)
Below 24 is
OK
for ResMed
(excessive
leak)
SystemOne - Encore Anywhere• What’s happening? (new patient returns for first CPAP f/u)
Respironics (cont)
What happened?
Another Case Example
Nasal
Interface
Full
Face
Mask
Case Example (cont)
Worsened Variable Leak
• Patient received replacement mask
seal for FFM, worsened variable leak
begins after seal received
• Inspect equipment
• Patient sent wrong seal, inserted it
over existing seal
AHI
Case #1
• Baseline AHI 12
• CPAP 10
recommended
• Patient
complains
machine turning
itself off
• What next?
Case #1
• “Auto off” was activated
• Machine turning itself off when not detecting airflow (leak)
• Ramping with each restart
• Events noted at low pressures
• Resolved with mask re-fit
Normal Leak
Maxed Pressure
Residual Events
Case #2
• Minimum
pressure
too low
• Events
reduce at
high
pressure
• Leak may
be
acceptable
(for high
pressure)
depending
on mask
Case #3• Baseline
– AHI 135
– SpO2 58%
• CPAP 14
– AHI 1.8
– SpO2 86%
– Supine/REM
“Summary Report” 2 week
“Trend Report”
• AHI 33.9
• VS Index
525.5
• 0.6%
large leak
Detailed View
• CPAP 14
• AHI 51
• OA 45
• Leak 40
(FFM 12 cm)
• 0.3% large
leak
Detailed Report Different Night
• AHI 1.2
• Leak 42
Home Oximetry
Case #3 Discussion
Case #4 Routine Appointment
Baseline
Day 1 and 2 (x 1 weeks)
2 weeks later
Case #4 Discussion
Case #5 “Compliance Report”
Case #5 “Therapy Report”
Case #6 “Detailed Report”
AHI 20 AHI 11 AHI 0.2
Case #7• 51 year old male
w/snoring, EDS, HTN
• BMI 29.9 m/kg2, weight
213 lbs, height 5’11”
• Home Sleep Test
performed
– RDI 13.7 events/hour
– Nadir oxygen 83%
• Auto PAP min 6 max 14
• Patient feels “horrible”– Foggy
– Headaches
– Worse than baseline
Case #7 Details
Case #7 Min Pressure Dropped
Machine and Patient
Discrepancy ?
Modem Case Example
• DOT driver with Respironics SystemOne
• Comes in for f/u
• No data for past 3 weeks on printed report
• What happened?
Respironics DOT modem • Assess last
machine usage
• May not transmit if no usage
• If concerned about modem, “test” by allowing to run for 1 min then transmit
• When in doubt, start self-monitoring
Patient Self-Monitoring
• Patient log
• Machine data monitoring
– On screens
– Online
Humidifier
Case Example
• Patient calls complaining of nasal and
mouth dryness on CPAP 12 using full face
mask.
• Reports humidifier set at 5
• What do you do? (Group)
– Change humidifier setting
– Do not change humidifier setting
– Ask more questions
Case Example – next steps
• Determine machine brand
• Verify no significant mask leak
• Use your cheat sheet for humidifier settings range
• Max varies based on machine (5-8) and tubing
• Patient vs. algorithm adjustment ?
• Can you walk a patient through changing it?
• Role for add-on equipment? (ex: heated tubing)
• Remember “quirk” for Respironics heated tubing
Using Technology
Always Pay Attention!
(especially after upgrades)
Customized Patient Report
Needs 2nd identifier
such as DOB for
medical record
Data Reporting
Pressure Reporting
• Pressure change
min 12 max 15 not
reflected in text data
Look for Details
Last settings
reported
aPAP settings
changed mid-
reporting period
Usage Data without AHI or Pressure
Insurance Communication
Questions
Thanks to Ann Cartwright, PA and Neil Freedman, MD
for providing cases.