Who, What, Why, and When Gary Hamilton, BS, RRT Clinical Specialist ResMed.
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Transcript of Who, What, Why, and When Gary Hamilton, BS, RRT Clinical Specialist ResMed.
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Bilevel Titrations:Who, What, Why, and When
Gary Hamilton, BS, RRTClinical Specialist
ResMed
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Employed by ResMed Own stock options of ResMed
Disclosures
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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 patientoutcomes by proper utilization of bilevel and its settings
Course Objectives
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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
CPAP Intolerance- next step Bilevel
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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
Comfort vs Ventilation
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Bilevel- Can I get it paid for OSA?
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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)
Difference between Cpap and Bilevel
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Bilevel Breath Cycle Values That Tools Can Impact
Patient Flow
Delivered Pressure IPAP
EPAP
Exhalation
Trigger
Cycle
Inhalation
Pressure support ( P)
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OSA Airway problem
CompSA Airway and Ventilation problem
Cheyne-Stokes Ventilation problem
COPD Ventilation problem
Neuromuscular Ventilation problem
What If It Is Not Just an Airway Problem?
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Can I get Bilevel paid for when it not OSA?
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CompSA or Cheyne-Stokes
Tools Available in Bilevel for Specific Diseases
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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)
Tools for CompSA and/or Cheynes Stokes
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CompSA and the Apneic Threshold
Central apneas occur
CompSA patient not treated
CompSA patient on Servo
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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)
Gives Support Only When Needed
VPAP Adapt SV
Patient Flow
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COPD
Tools Available in Bilevel for Specific Diseases
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Lung tissue destroyed Elasticity of lungs
disappearing Poor functioning
diaphragm Reliance on accessory
muscles Air trapping
Tools For COPD- What are the problems?
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Desaturations During REMin COPD Patient
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Tools for COPD- Problems on Bilevel
• Auto-PEEP• Missed
triggers• Work of
breathing
• Expiratory time
• Lung 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)
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Very High Quick to trigger 2.4 L/min
High More sensitive 4 L/min
Med Default 6 L/min
Low Less sensitive 10 L/min
Very Low Slow to trigger 15 L/min
Bilevel Tools- Sensitivity Adjustments
Very High Quick to cycle 50% of peak flow
High More sensitive 35%
Med Default 25%
Low Less sensitive 15%
Very Low Slow to cycle 8%
Adjustable Trigger Sensitivity
Patient Flow
EPAP
Adjustable Cycle Sensitivity
Patient Flow
EPAP
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Bilevel Tools - Time cycle inspiration
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
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Rise Time◦ For comfort◦ Will affect how pressure “feels” to pt
Bilevel Tools – Ti Control
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Bilevel Tools- Sine Wave
Square Wave Easy-Breathe
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Neuromuscular and Obesity HypoventilationRestrictive Patients
Tools Available in Bilevel for Specific Diseases
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Bilevel Tools- Asynchrony in Restrictive Patients
Premature cycling creates asynchrony• Lungs physically restricted
• Paralysis or muscles deteriorated
Occurs in restrictive patients
“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
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Bilevel Tools- Restrictive Diseases
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.
) 4.8.4 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
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Bilevel Tools- Increasing the Inspiratory Time
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Bilevel Tools- When You Need to Ventilate
PS 5 PS 10 PS 15 PS 20
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iVAPS – (ResMed) Intelligent Volume Assured Pressure Support
Bilevel Tools for Ventilation-VAPS
AVAPS (Philips) Average Volume Assured
Pressure Support
• Can assure Tidal Volume while the patient is sleeping• Is Servo Controlled
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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 ]
SpO2
REM Onset
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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
Conclusion