Disclosures. Michael Gunnuscio RPSGT, Bob Chase RRT, Umakanth Khatwa MD

Transcription

1 Disclosures Michael Gunnuscio and Umakanth Khatwa have no financial relationships to disclose. Robert Chase works full time with North Atlantic Medical. Copyright 2014 Boston Children s Hospital 1

2 CPAP Introduction and Mask Fitting Michael Gunnuscio RPSGT Copyright 2014 Boston Children s Hospital 2

3 Prior to CPAP titration scheduled mask fitting Introduction to CPAP therapy Mask trial and fitting Desensitization program Copyright 2014 Boston Children s Hospital 3

4 Mask Fitting 30 min to an hour Education on test procedure and CPAP in general Mask trial Discuss possible challenges Facilitate family support Copyright 2014 Boston Children s Hospital 4

5 CPAP education Ensure understanding of apnea and how CPAP can help Discuss equipment options and maintenance Explanation of sleep study and titration procedures Copyright 2014 Boston Children s Hospital 5

6 Mask Trial Mask choice to allow natural breathing, nasal v. nasal/oral Try several masks to find best size and provide options Demonstrate correct application and adjustment of mask Fitting should be done in sleeping position Fit tested with minimal pressure, leak documented Copyright 2014 Boston Children s Hospital 6

7 Desensitization Determination and Imagination Take home mask wearing open ended Address concerns Start with less effective but more comfortable interface Humidification Expiratory Pressure Relief Recruit support from family and friends Copyright 2014 Boston Children s Hospital 7

8 Mask Fitting Documentation Education provided Masks tried including brand, model, size and leak Masks ranked in order of preference and effectiveness Summary of concerns and possible solutions Copyright 2014 Boston Children s Hospital 8

9 Mask Challenges Complex patients Claustrophobia Cranial facial abnormalities Limited pediatric choices General anxiety Social concerns Copyright 2014 Boston Children s Hospital 9

10 CPAP/BiPAP Titration Umakanth Khatwa, MD Copyright 2014 Boston Children s Hospital 10

11 Positive Airway Pressure (PAP) Therapy Stents open airways Reduces upper airway collapsibility Improves FRC (O2 reserve) Improves gas exchange Restores sleep continuity Reduces work of breathing Copyright 2014 Boston Children s Hospital 11

12 Indication for CPAP in Children Obstructive sleep Apnea Significant residual OSA after A&T Contraindication for T&A Family prefers non surgical treatment Post op management of OSA treatment Milder cases of hypoventilation To improve oxygenation Tracheomalacia (floppy airways) and C Pap Adjusting to Continuous Positive Airway Pressure Copyright 2014 Boston Children s Hospital 12

13 Titration guidelines Adequate PAP education to patient/parent Mask fitting and acclimatization Minimum starting pressure = 5 cw Increase CPAP by 1 cw increment (at least 5 min) < 12 years (1 apnea, 1 2 hypopneas, 3 RERAs, 1 ambiguous event) > 12 years (2 apneas 3 hypopneas, 5 RERAs, 3 ambiguous events) Maximum CPAP pressure < 12 years = 15 cw > 12 years = 20 cw Copyright 2014 Boston Children s Hospital 13

14 Practical consideration In lab titration study Same parameters as diagnostic study Airflow measured by internal sensor (C flow) which can show flow limitation Need to have good ETCO2 / TcCO2 Good SaO2 signals Snore microphone Good belts Copyright 2014 Boston Children s Hospital 14

15 Split night study Usually avoided in young children Short time, tolerance, first night effect Difficult and frightening Allow time for home mask acclimatization Split criteria Should be well established and differs to each patient > 20 obstructive events in 1 hour > 30 in 2 hour At least 2 hour baseline data One REM cycle with supine position if possible Copyright 2014 Boston Children s Hospital 15

16 Guidelines The guidelines should not be followed in cookbook fashion Sleep tech / clinician should combine judgment and experience to apply these recommendations for best possible resultome Copyright 2014 Boston Children s Hospital 16

17 What to look for during CPAP titration Resolution of all apneas Especially IN supine REM if possible Resolution of all hypopneas Resolution of snoring Normalization of oxygenation Improvement in CO2 (< 50 torr) Decrease in sleep fragmentation Copyright 2014 Boston Children s Hospital 17

18 What to watch out for during CPAP titration Mask leak (usually < LPM) Mask discomfort and difficulty sleeping? Re fit, modification, acclimatization C Flow for flow limitation SaO2 and ETCO2 data CPAP emergent central apneas and hypopneas CPAP emergent hypoventilation worsening baseline desaturation, shallow breathing, and or CO2 retention with increasing CPAP pressure Copyright 2014 Boston Children s Hospital 18

19 Contact MD Unable to tolerate CPAP Emergence of central apneas & hypoventilation while on CPAP Worsening desaturation or CO2 while on CPAP Vomiting in mask? Aspiration CPAP pressure requirement > 15 cw Copyright 2014 Boston Children s Hospital 19

20 Successful titration Ideal world Complete resolution of all obstructive apnea, hypopneas and snoring at least pressure possible including in supine REM Oxygenation well above 95% consistently ETCO2 < 50 torr No emergence of central apneas or hypopneas Better sleep maintenance Titration duration at least 4 hours (AASM), but usually > 5 6 hours in children Copyright 2014 Boston Children s Hospital 20

21 Usually what is considered successful titration (AASM) < 12 years: RDI < 2 per hour > 12 years: RDI < 5 per hour 75% reduction in RDI Copyright 2014 Boston Children s Hospital 21

22 Copyright 2014 Boston Children s Hospital 22

23 BiPAP Bi level pressure IPAP EPAP Rate Copyright 2014 Boston Children s Hospital 23

24 Indications for BiPAP Unable to tolerate CPAP too high pressure required on CPAP (> 15 cw) Emergence of central sleep apnea Emergence of hypoventilation Obesity hypoventilation syndrome Neuromuscular disease Copyright 2014 Boston Children s Hospital 24

25 BiPAP guidelines IPAP EPAP Maximum IPAP and Maximum EPAP Back up rate I: E difference at least Titrate both IPAP and EPAP by cw to eliminate obstructions (> obstructive events) Increase IPAP by cw, if CO2 > torrconsistently (> min) Increase rate by if you note or etc Add O2 only if recurrent desaturation < 88% for > 5 minutes (start at 0.25 LPM and titrate as needed). Do not add O2 unless respiratory events are controlled Goal SaO2 > % Goal CO2 < torr Copyright 2014 Boston Children s Hospital 25

26 Bi level pressure BiPAP titration IPAP 8, EPAP 4 At least I:E difference = 4 Maximum I:E difference = 10 Increase IPAP/EPAP by 1 cw 1 obstructive apnea, 2 hypopneas, 3 RERAs Wait at least 5 min before next increase Copyright 2014 Boston Children s Hospital 26

27 Back up rate (ST mode) Central sleep apnea Neuromuscular weakness with hypoventilation Obesity related hypoventilation Severe hypoventilation Copyright 2014 Boston Children s Hospital 27

28 BiPAP, all breaths triggered Copyright 2014 Boston Children s Hospital 28

29 BiPAP not triggered/shallow breaths Copyright 2014 Boston Children s Hospital 29

30 BiPAP triggers, no back up rate Copyright 2014 Boston Children s Hospital 30

31 BiPAP trigger with Back up rate 20 Copyright 2014 Boston Children s Hospital 31

32 TRANSITIONING A CHILD/INFANT TO PAP THERAPY Bob Chase RRT Copyright 2014 Boston Children s Hospital 32

33 PROGRAM OBJECTIVES 1.Increase your awareness of different strategies for successfully aiding a child to use CPA 2.Increase your awareness of the various types of interfaces available for children and several pros and cons of each choice. 3.Increase your ability and understanding of ways to customize a one-size-fits-all interface Copyright 2014 Boston Children s Hospital 33

34 COMMERCIAL SUPPORT/ VESTED INTERESTS 1. This program is strictly a collection of my ideas based upon a long successful history as a practicing respiratory therapist. 2. I have received no outside financial support or suggestions from any company in the development of this program Copyright 2014 Boston Children s Hospital 34

35 PROGRAM GUIDELINES Being Patient Being Persistent Being Creative Knowing your Equipment Copyright 2014 Boston Children s Hospital 35

36 BE Patient Under the age of 2 Spend periods of time each day holding just the mask on (no headgear or tubing) while trying to engage the child in some activity. Once the mask becomes less problematic move on to using the headgear to hold the mask in place. Do this only during the day while awake and with those people the child/infant feels most comfortable with. Copyright 2014 Boston Children s Hospital 36

37 BE Patient Under the age 0f 2 Work towards keeping the mask NOT headgear on for periods up to 60 minutes. Next with the PAP unit set at its lowest pressure of 4 cmh2o try using it during a nap period as this should offer a period when resistance will be at its lowest level. The goal here is to have the child fall asleep with the system engaged even for a short period, remove it as soon as the child wakes up. Copyright 2014 Boston Children s Hospital 37

38 BE Patient Under the age of 2 The major goal is to have the child fall asleep with the system engaged even for a short period of time Continue using it during a napping period for a couple of days. This may take 5 to 7 days to arrive at the point where they can sleep through the entire nap. Once this has been achieved for more than an hour, move on to using it at night. Copyright 2014 Boston Children s Hospital 38

39 BE Persistent This is the key element in successfully transitioning any patient onto PAP Therapy. Children and Infants under the age of 2 In my experience are the most difficult as you can t reason or bribe or cajole them but you can make a game of putting the mask on a stuffed animal and then on them. Go very slow for the first couple of days, but be persistent Copyright 2014 Boston Children s Hospital 39

40 BE Persistent Children 3 and up Can be offered something that they like if they will hold/wear the mask for a period of time The word NO is not an option here and make that clear from the start Entertain them when they wear it watch a favorite program with them, read a favorite story This is a time for tough love tempered with compassion Copyright 2014 Boston Children s Hospital 40

41 BE Persistent Take whatever amount of time you need to reach the goal of wearing just the mask for an hour. The next step is to see if they could go to sleep with the mask on Once they are able to fall asleep with the mask on for several nights then we move on to the next step attaching the tubing and engaging the unit Copyright 2014 Boston Children s Hospital 41

42 Be Creative Here we can take several different approaches Pressure Breathing on a PAP device is initially scary no matter what the age of the person using it We are accustomed to breathing in and out without resistance. PAP therapy allows you to breathe in easily but blocks exhalation at a certain point. The sensation is that you can t get all of the air out of your lung and therefore you can t take a full breath in. Copyright 2014 Boston Children s Hospital 42

43 Be Creative Pressure cont. We normally extend very little effort exhaling until you go onto CPAP The trick is to encourage the person to exhale slowly and with a little effort. This concept is more easily employed with the older child. I would always start with the lowest pressure of 4 cmh2o and gradually over a week move up 1 or 2 cm s of pressure until their target pressure was reached Copyright 2014 Boston Children s Hospital 43

44 Be Creative Modes of PAP Therapy Standard CPAP Auto Adjusting PAP (APAP) Keeps the pressure low with it only increasing in response to a reduction in airflow, corrects the problem then returns back to a lower pressure. BiLevel (BiPAP) Std and Auto Tends to simulate a more natural respiratory pattern. You breathe in at one pressure level and exhale at a lower one. Initially keep pressures as low as possible to encourage compliance, then bring it up to the target level over a couple of weeks. Copyright 2014 Boston Children s Hospital 44

45 Be Creative If a young child can fall asleep with the interface on but takes it off during the night try putting mittens on Copyright 2014 Boston Children s Hospital 45

46 Be Creative Headgear Problems This is the next biggest problem after the mask. Many headgears are all one size and usually too big Copyright 2014 Boston Children s Hospital 46

47 Interfaces PIXIE Great for ages 3 and up No visual blockage Headgear easy to set Be Creative Copyright 2014 Boston Children s Hospital 47

48 Interface Pixie Straps do not loosen or tighten with head movement up or down Be Creative Copyright 2014 Boston Children s Hospital 48

49 Be Creative Interfaces Age 3 and up, Headgear is a problem, no visual obstruction, 3 sizes of masks that are very soft Copyright 2014 Boston Children s Hospital 49

50 Be Creative Interfaces Mini Me 2 Ages 3 mos and up, highly adjustable, very soft gel, sized headgear, vented and non vented.. Cleared for ages 2 and up Copyright 2014 Boston Children s Hospital 50

51 Be Creative Interfaces Mini Me 2 Copyright 2014 Boston Children s Hospital 51

52 Be Creative Interfaces Mini Me Ages 2 and up, 2 point headgear, highly adjustable very soft 2 sizes Copyright 2014 Boston Children s Hospital 52

53 Interfaces Respironics Small Child Be Creative Ages 1 year and up Visual Obstruction Very Soft Gel Copyright 2014 Boston Children s Hospital 53

54 Be Creative Interface I Q Mask One size fits all For a larger older child Visual obstruction No forehead pad Copyright 2014 Boston Children s Hospital 54

55 Be Creative Interface ResMed NANO One size fits all For a larger older child No Visual obstruction No forehead pad Easy on and off Copyright 2014 Boston Children s Hospital 55

56 SleepNet Gel Nasal Mask Interface SleepNet One size fits all For a larger older child No Visual obstruction No forehead pad Easy to adjust the mask configuration Extremely comfortable Copyright 2014 Boston Children s Hospital 56

57 Be Creative Interface ResMed Nasal Avella 3 Sizes For a larger older child No Visual obstruction No forehead pad Over the ear headgear Used when std headgear may present a problem Copyright 2014 Boston Children s Hospital 57

58 Be Creative Chinstraps 1. They can be used to keep the mouth closed when on PAP therapy 2. They are adjustable and reasonably comfortable 3. Can keep the pt from having to use a FFM 4. Can help keeping a headgear from moving Copyright 2014 Boston Children s Hospital 58

59 Be Creative Chinups An alternative to a chinstrap 1. They are easy to apply and remove when you need to keep to keep the mouth closed when on PAP therapy 2. Reasonably comfortable 3. Can keep the pt from having to use a FFM 4. Comes in a thirty unit package Copyright 2014 Boston Children s Hospital 59

60 Be Creative Use featherweight tubing Comes in Std 6 ft length Non heated but can be used with a rainout cover Copyright 2014 Boston Children s Hospital 60

61 Be Creative Free App for Apple or Android Phones 1.Visually presents data about you sleep quality AHI, Leaks, Hrs of Use 2. Highlights any problem and offers suggestions for improvement 3. Offers a short video on improving the problem 4. Takes info from modem, or data card Copyright 2014 Boston Children s Hospital 61

62 Program Evaluation Tool Using the rating scale 5=Strongly Agree through 1 = Strongly Disagree Purpose/Goals Overall purpose/goal of this activity is related to the learning objective The program should increase your awareness of different strategies for successfully aiding a child to use CPAP The program should increase your awareness of the various types of interfaces available for children and several pros and cons of each choice The program should increase your ability and understanding of ways to customize a one size fits all interface Rate the teaching expertise of the presenter Is knowledgeable in in content the content area area Content is consistent with objectives Teaching strategies were consistent with objectives Teaching by presenter was effective Copyright 2014 Boston Children s Hospital 62