PAP Download Interpretation and Case-Based Discussion. Loretta Colvin, APRN-BC Nurse Practitioner Clayton Sleep Institute

Transcription

1 PAP Download Interpretation and Case-Based Discussion Loretta Colvin, APRN-BC Nurse Practitioner Clayton Sleep Institute

2 Objectives Review PAP adherence report elements Incorporate PAP report data into clinical assessment Identify PAP machine technology variations in reporting

3 Conflict of Interest I have no conflicts of interest to disclose

4 Adherence Assessment Considerations

5 Availability Data Assessment 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

6 Patient Assessment Do subjective and objective reports agree? If not, which do you believe or how do you assess further?

7 Recommendation ALWAYS view detailed data for issues Patient issues Not improving, Not tolerating, Report issues AHI, leak, pressure Data issues QUESTION technology when appropriate

8 Data Access 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

9 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)

10 Adherence Data Data card USB or SD card Modem External Internal Viewing machine screens Typically basic usage available

11 Data Downloads 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 + + +

12 Modems Upload schedule Patient transmission? Data transmission F&P Respirionics ResMed Icon System One S9 & AirSense Fixed time Pt initiated / set S9 Fixed time (1-4 pm PST) (9 am CST) q 24 hours AirSense HALO Yes Yes No Cellular signal Cellular signal Cellular signal 30 days stored Blue tooth avail. S9 external External External AirSense internal USB removed SD card stays SD card stays

13 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

14 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

15 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

16 Report Components

17 Key Components F&P Respironics ResMed Icon System One S9 / AirSense Pressure Average & Average & Median & 90 th percentile 90 th percentile 95 th percentile Leak Total Total Unintentional >40-50 L/min high >40-50 L/min high >24 L/min high Custom date range + Change screens + Initial screen +/- Count back days Detailed Summary & detailed report Summary only, not on detailed Reports -Summary + Summary + Summary + Detailed + Detailed + Detailed + Customized

18 Comfort Features Pressure relief Humidifier Chamber Heated Tubing F&P Icon Respironics System One ResMed S9 / AirSense SensAwake Flex / Flex+ EPR S9 0-6 AS 0-8 Boost L-M-H degrees

19 Cases

20 Pressure Relief

21 ResMed EPR Baseline AHI 11 Titration - 9 cm recommended EPR 3 acts similar to mini- Bilevel

22 Fisher & Paykel SensAwake CPAP 9 orders sent to DME DME left SensAwake on AHI 2.9 on report

23 Another Example SensAwake

24 Respironics SystemOne Cflex + PSG AHI 120 s Low sats 60 s AHI 31

25 Leak

26 F&P Icon Infosmart Is leak acceptable? (group) > 50 is high

27 F&P Icon Another Example

28 ResMed S9 EasyCare Online Is this OK? (group) Below 24 is OK for ResMed (excessive leak)

29 SystemOne - Encore Anywhere What s happening? (new patient returns for first CPAP f/u)

30 Respironics (cont)

31 Another Case Example What happened?

32 Case Example (cont) Full Face Mask Nasal Interface

33 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

34 AHI

35 Case #1 Baseline AHI 12 CPAP 10 recommended Patient complains machine turning itself off What next?

36 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

37 Case #2 Minimum pressure too low Events reduce at high pressure Leak may be acceptable (for high pressure) depending on mask Maxed Pressure Residual Events Normal Leak

38 Case #3 Baseline AHI 135 SpO2 58% CPAP 14 AHI 1.8 SpO2 86% Supine/REM

39 Summary Report 2 week

40 Trend Report AHI 33.9 VS Index % large leak

41 Detailed View CPAP 14 AHI 51 OA 45 Leak 40 (FFM 12 cm) 0.3% large leak

42 Detailed Report Different Night AHI 1.2 Leak 42

43 Home Oximetry

44 Case #3 Discussion

45 Case #4 Routine Appointment

46 Baseline

47 Day 1 and 2 (x 1 weeks)

48 2 weeks later

49 Case #4 Discussion

50 Case #5 Compliance Report

51 Case #5 Therapy Report

52 Case #6 Detailed Report AHI 20 AHI 11 AHI 0.2

53 Case #7 51 year old male w/snoring, EDS, HTN BMI 29.9 m/kg 2, 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

54 Case #7 Details

55 Case #7 Min Pressure Dropped

56 Machine and Patient Discrepancy?

57 Modem Case Example DOT driver with Respironics SystemOne Comes in for f/u No data for past 3 weeks on printed report What happened?

58 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 selfmonitoring

59 Patient Self-Monitoring Patient log Machine data monitoring On screens Online

60 Humidifier

61 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

62 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

63 Using Technology Always Pay Attention! (especially after upgrades)

64 Customized Patient Report Needs 2 nd identifier such as DOB for medical record

65 Data Reporting

66 Pressure Reporting Pressure change min 12 max 15 not reflected in text data

67 Look for Details Last settings reported apap settings changed midreporting period

68 Usage Data without AHI or Pressure

69 Insurance Communication

70 Questions Thanks to Ann Cartwright, PA and Neil Freedman, MD for providing cases.