How to Do PAP Therapy: VAPS, Trilogy

Transcription

1 Workshop: Non- Invasive Ven?la?on October 9, 2014 How to Do PAP Therapy: VAPS, Trilogy Lisa F. Wolfe Associate Professor of Medicine Northwestern University Feinberg School of Medicine Chicago, Illinois

2 Objec?ves Why is my sleep apnea different then his? Central Sleep Apnea is not all the same Hyperpnea vs Hypopnea Diagnosis Major groups Screening RAD s vs NIV - MV Treatment Hands (Fingers) on

3 Central Sleep Apnea Hyperpnea Disorders of loop gain instability. Small CO2 gap puts pa?ents at risk Diure?cs Autonomic imbalance Sensor Gain Hyperpnea drives apnea Compensatory in the sezng of alkalosis Plant gain Shamim Nema?, Journal of Applied Physiology 1 July 2011Vol. 111no. 1, P.55-67

4 Central Sleep Apnea Hypopnea Disorders of ven?latory failure Large CO2 gap puts pa?ents at risk Diaphragma?c Failure CNS failure to control ven?la?on Hypercapnea is found earliest during sleep Ozsancak A. Chest. 133(5): , 2008 May. Day?me Hypercapnea In ability to augment Ve when needed Day?me Symptoms Loss of ven?latory drive Slow wave sleep Loss of accessory muscle tone REM sleep Loss of gravita?onal support Supine Posi?on

5 Central Sleep Apnea: Hypopnea Common Diagnosis Neuromuscular disease ALS Muscular Dystrophy Spinal Muscular Atrophy Many Many More.. Spinal Cord Injury Chiari Malforma?on Kyphoscoliosis Severe phrenic nerve injury Indica3ons for Non- Invasive Ven3la3on Na?onal Coverage Determina?on Any of the following would be sufficient to ini?ate NIV FVC <50% Measured upright or supine MIP >- 60 Measured upright or supine PO <88% for >5 mins on a recording las?ng at least 2 hours PaCO2 >45

6 RAD s vs HMV Respiratory Assist Device Descrip?on: Home based Ven?lator Support Devices Pressure cycled modes only Advantages Less expensive Commonly used and available Disadvantages No baieries No alarm hook ups Home based Mechanical Ven3la3on Descrip?on: Home based Ven?lator Support Devices Pressure and Volume cycled Modes as well as Mouth Piece Ven?la?on (MPV) Advantages Provide Day?me Support with baieries Portable Day?me modes (MPV) Assist breath stacking and cough Hospital Alarm Hook ups Disadvantages Very Expensive Many ins?tu?ons have no support for the devices

7 RAD Modes Spontaneous All pa?ents with NMD should have a back up rate Spontaneous/Timed May be problema?c because Ti?me is not assured in each breath Pressure Control Inspiratory?me is guaranteed with both device and pa?ent triggered breaths Volume Assured Pressure Support increases pressures to meet pa?ent needs in an automated fashion Thanx to Doug McKim

8 SeZng Op?ons SeAngs for NIV Pressure V Time Curve for NIV B Trigger The point at which the device switches from EPAP to IPAP. Nega?ve pressure or flow signals the device. E Cycle The point at which the device switches from EPAP to IPAP. Drop in inspiratory flow signals the device Can be independently adjusted to op?mize synchrony P r e s s u r e A B C Time G D E F A H B C

9 SeZng Op?ons SeAngs for NIV C Rise The rate at which pressure changes from EPAP to IPAP. Fast is more comfor?ng in those with significant air hunger Diaphragm failure Slow may be more comfor?ng in upper airway spas?city Bulbar disease F Fall Not adjustable on devices in the US. Pressure V Time Curve for NIV Pressure G D E C F A B A B Time H C

10 SeZng Op?ons SeAngs for NIV Pressure V Time Curve for NIV H - Respiratory Rate G Inspiratory Time Addressed differently in each mode and with each device P r e s s u r e A B C G D E F A B C Let s Talk About Modes Time H

11 SeZng Op?ons: Ti in ST/ PC mode Respironics ST A total inspiratory?me (Ti) is set on the device however, the pa?ent only receives this guaranteed?me during the apnic breaths. During spontaneous breaths the Ti is not employed. PC A total inspiratory?me (Ti) is set on the device and is guaranteed and fixed as the Ti?me during both apnic and spontaneous breaths. Resmed ST- The Ti?me applies to every breath spontaneous or device delivered due to apnea. The Ti is set with a window of Ti minimum and Ti maxiumum. The breath cannot end before the Ti min The breath cannot con?nue aner the Ti max If the Ti min is short essen?ally al breaths are spontaneous If the Ti min is long then this is analogous to PC mode.

12 SeZng Op?ons: Ti in ST/ PC mode Respironics Forced min Resmed Forced max ST Mode Pressure S Time D S D S= spontaneous D = device delivered breath PC Mode Pressure Time Ti Min Ti Max Pressure Time S D S

13 SeZng Op?ons:Back Up Rate ST Mode Advantages Most widely available May be the only device available in hospitals or nursing homes Very comfortable for those with normal muscle strength Less likely to cause hyperinfla?on in COPD Disadvantages May contribute to premature cycling and a short shallow breathing paiern in those with neuromuscular disease PC Mode Advantages May help to prevent rapid shallow breathing in neuromuscular disease Disadvantages Fixed Ti?me may be uncomfortable This could be beier with Ti control Limited availability This may be changing: Respironics: Trilogy / V60 ResMed: Stellar N Engl J Med 1997; 337:

14 SeZng Op?ons: Ti in ST/ PC mode Why would a Ti extension be helpful in NMD? (All theory for now) Longer Ti?me will help recruit basilar atelectasis This will improve lung compliance This will in- turn reduce work of breathing A more open lung has improved cough strength and sputum clearance

15 Why should inspiratory time be preserved? Tidal Volume V t α (I- E) X Ti R

16 SeZng Op?ons: Auto Modes Why add an Auto Titra?ng mode, when classically Bi- Level ST has been used to treat all central apnea pa?ents? Before using an auto?tra?ng device ask yourself: o Why should I consider an auto algorithm? ü To compensate for NREM to REM differences in ven?la?on. ü To address processes that are likely to change from night to night. o What algorithm is used by this device? ü Servo Ven?la?on ü Average Volume Targeted Ven?la?on o What pa?ents will benefit from this therapy? ü Match the right device to the right pa?ent Don t use auto modes to set it and forget it

17 SeZng Op?ons: Auto Modes for NMD AUTO MODES TO USE In the US op?ons include: Volume Assured Pressure Support Devices Respironics : AVAPS average volume assured pressure support ResMed: ivaps - Intelligent Volume Assured Pressure Support AUTO MODES TO AVOID Anything with the name Auto, it may seem that they have the ability to provide ven?la?on but they dont VPAP auto Bipap auto Aflex auto

18 Consider VAPS func?onality REM to NREM changes Worsening disease PAP/ pressure intolerance Monitored PAP ini?a?on is not available Severe aerophagia 8 Volume = cc/ kg IDBwt IPAP = cwp Time

19 How to set up your VAPS AVAPS 1. Choose a mode: S/ST/PC 2. Choose an EPAP 1. In NMD minimize EPAP 3. Choose a goal Target Tidal Volume 1. For the average pa?ent set at 8 cc/ kg ideal body weight based on height. 2. For those with: bulbar disease, s?ff chestwall, pressure intolerance set at 6 cc/ kg ideal body weight based on height. 4. Set IPAP minimum and maximum 1. For de- condi?oning set the IPAP min low 2. For most set the IPAP min close to the target 5. Set Rate/ Ti / Rise IVAPS 1. Choose an EPAP 1. In NMD minimize EPAP 2. Set back up rate 1. Usually from Set a target alveolar volume based on height (see IVAPS calculator) 4. Set Pressure Support min and max 1. For de- condi?oning set the PS min low 2. For most set the PS min close to the target 5. Set trigger/cycle/ rise/ Timin/ Timax 6. Learned targets is an op?on***

20 Does VAPS make a difference? Sleep quality O2 satura3on Max CO2 Avg. CO2 Mixed group of NMD pa?ents VAPS seems to have made everything worse??? J. Jaye et al Eur Respir J 2009; 33:

21 Does VAPS make a difference? COPD OBESITY Similar improvements with both PS and AVAPS All studies have been done in ST mode Crisafulli, E. Lung (2009) 187: Murphy, PB Thorax 2012;67:

22 Does VAPS make a difference? Thorax August 2012 Vol 67 No 8 So why use it? Most labs are not as aggressive with their ini?al?tra?on In progressive disease things change to fast to keep up Many pa?ents have NO access to a lab If you choose to advance therapy at home without a lab this speads the process and reduces the paperwork

23 Consider Mechanical Ven?la?on modes Tradi3onal Modes Common NIV Modes: Spontaneous Spontaneous / Timed Pressure Control Timed Uncommon NIV Modes: Assist Control SIMV SIMV (PC/PS) New Modes New AVAPS mode AVAPS AE Sip or Kiss mode ven?la?on

24 Consider Mechanical Ven?la?on modes AVAPS - AE This adds the ability to set auto modes for BOTH: EPAP based on an algorithm to resolve upper airway obstruc?on PS based on an algorithm to assure, on average adequate?dal volume Back up rate is monitored with a goal based on alert rate**** Kiss Ven3la3on Day?me ven?la?on support Used for Relief of acute dyspnea Improve speech Improve swallow Assist with cough Assist with clearing sinuses

25 Consider Mechanical Ven?la?on modes Kiss Ven3la3on Recommended sezngs thanx to Doug McKim and Carole LeBlanc MPV : ON Tidal Volume (Vt) : larger than pa?ent s spontaneous Vt, enabling LVR to maximum insuffla?on capacity (MIC) within 2-3 stacked breaths Breath Rate (BPM) : 0 if the pa?ent has sufficient ven?lator free breathing?me (VFBT) and up to 12 if more dependent Inspiratory Time : 1.2 to 1.5 seconds (adjust as per comfort and desired pa?ent peak inspiratory flow (PIF); PIF will be dependent on Vt Flow Paiern : Ramp or Square (adjust as per comfort) PEEP : 0 cmh20 Low Inspiratory Pressure : 1-2 cmh20 High Inspiratory Pressure : up to 70 cmh20 (for op?mal LVR). To allow for LVR up to MIC Apnea and Circuit Disconnect alarms MUST be enabled if pa?ent has limited ven?lator free breathing?me or if close monitoring is required. Informed consent is recommended for alarm sezngs

26 How to hit the buions Press the up buion to access the menu Choose the primary or secondary sezng and adjust as needed

27 How to hit the buions

28 How to hit the buions Hit the knob and double check bu\ons for 10 seconds to access the menus Hit the i bu\on to get mask info

29 IVAPS Calculator C:\Documents and SeZngs\sleepmd\Local SeZngs \Temp\Temporary Directory 1 for ResMed%20iVAPS %20SeZngs%20Calculator_RevisedFinalDran[1].zip \ResMed ivaps SeZngs Calculator_RevisedFinalDran.mht Input the height Set the back up rate a smidge higher then you think and lower then spontaneous Then pick either a vt/kg ideal body weight OR specific vt goal Then hit calculate to get the Alveolar volume (Va) to input on eth device sezngs

30 Conclusions Auto Modes that include Vt and back up rate considera?ons offer new and interes?ng op?ons They are beier set up to treat those with NMD. They are beier posi?oned to address hypoven?la?on as compared to previous studies but the studies have not yet been performed. Expanding NIV op?ons in homes has occurred will RT s and hospitals have not been able to keep pace. It will be a challenge for physicians to feel comfortable with these devices remains essen?al.