Advanced PAP Therapy: Advanced Algorithms. Gary Hamilton, BS, RRT Clinical Specialist ResMed Corp

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1 Advanced PAP Therapy: Advanced Algrithms Gary Hamiltn, BS, RRT Clinical Specialist ResMed Crp

2 Declaratins/ Cnflicts f Interest Am presently emplyed by ResMed Crp Presently wn stck in ResMed Crp ResMed 2018

3 Curse Objectives By the end f this sessin, yu shuld be able t: T knw when a CPAP may nt be the device f chice Recgnize different uses f Bilevel and the different disease states it is applicable t Knw when serv ventilatin is a viable ptin What diagnses are apprpriate Hw the device actually imprves the patient Knw when VAPs therapy is apprpriate ResMed 2018

CPAP Intlerance Why patients fail CPAP: CPAP is uncmfrtable Patient may feel CPAP is uncmfrtable at higher pressures despite pressure relief features COPD

4 CPAP Intlerance Why patients fail CPAP: CPAP is uncmfrtable Patient may feel CPAP is uncmfrtable at higher pressures despite pressure relief features COPD patients have trapped air/pressure in their lungs, which may increase their wrk f breathing Patient may need higher levels f ventilatry supprt CPAP cannt prvide

5 Nt Just an Airway Prblem OSA Airway prblem COPD Ventilatin prblem Neurmuscular Ventilatin prblem Cheyne-Stkes Ventilatin prblem CmpSA Airway and Ventilatin prblem ResMed 2018

6 Qualificatin Criteria

7 Qualificatin Criteria

8 RAD Guidelines January 2017

9 RAD Guidelines

10 Hw Des Bilevel Wrk? Prevents ncturnal hypventilatin and hypxia Cardivascular cnsequences Imprves ventilatin (gas exchange) Reduces ncturnal CO 2 levels Increases ncturnal O 2 levels Imprves daytime bld gases Stabilizes upper airway Rests respiratry muscles Decreases daytime sleepiness by crrecting sleep architecture Cmfrt & Cmpliance Reduces arusals due t SDB and assciated sleep fragmentatin *. Antnescu-Turcu A & Parthasarathy S. Respir Care 2010 ResMed 2018

EPAP, IPAP and PS IPAP Achieve adequate tidal vlume Get the respiratry rate (RR) belw 25 bpm Decrease the wrk f breathing Pressure Supprt (PS) PS = IPAP - EPAP The greater the

11 EPAP, IPAP and PS IPAP Achieve adequate tidal vlume Get the respiratry rate (RR) belw 25 bpm Decrease the wrk f breathing Pressure Supprt (PS) PS = IPAP - EPAP The greater the PS the greater the ventilatry supprt Care must be taken nt t ver-ventilate Reduce PaCO 2 IPAP = EPAP + PS EPAP Overcme bstructive apneas and hyppneas Imprve xygenatin ResMed 2018

Bilevel Therapy Bilevel psitive airway pressure, cmmnly referred t by the trademarked names BiPAP, is a frm f NIV (Nn invasive Ventilatin) that uses a

12 Bilevel Therapy Bilevel psitive airway pressure, cmmnly referred t by the trademarked names BiPAP, is a frm f NIV (Nn invasive Ventilatin) that uses a time-cycled r flw-cycled change between tw different applied levels f psitive airway pressure (IPAP and EPAP)* * Kushida CA et al. J Clin Sleep Med 2008 ResMed 2018

Cnsider Using Bilevel When Patient is nt tlerating high pressure settings 1 Events persist at 15 cm H 2 O 2 Patient cmplains f nt being able t exhale despite expiratry pressure relief (EPR ) feature

13 Cnsider Using Bilevel When Patient is nt tlerating high pressure settings 1 Events persist at 15 cm H 2 O 2 Patient cmplains f nt being able t exhale despite expiratry pressure relief (EPR ) feature 1 Patient has histry f ventilatry insufficiency such as chrnic bstructive pulmnary disease (COPD), restrictive lung disease, r besity hypventilatin syndrme (OHS) 1 Must be a 4 cm H 2 O difference between IPAP and EPAP t be cnsidered bilevel therapy 2 1. Gay P et al. Sleep Kushida CA et al. J Clin Sleep Med 2008 ResMed 2018

14 ResMed 2018 Hypventilatin in COPD Patients

15 Hypventilatin & COPD Hypventilatin is nt uncmmn in patients with severe COPD, therefre it is a marker f disease severity. Hypventilatin in COPD invlves multiple mechanisms, including: Decreased respnsiveness t hypxia and hypercapnia Increased Ventilatin-Perfusin mismatch leading t increased dead space Decreased diaphragmatic functin due t fatigue and hyperinflatin Alvelar hypventilatin in COPD usually des nt ccur unless the frced expiratry vlume in 1 secnd (FEV 1 ) is less than 1L r 35% f the predicted value. Gld Reprt 2017 ResMed 2018

16 Pathphysilgy f COPD Diaphragm flattening Muscle weakness Air trapping Intrinsic PEEP Dyspnea Elastic recil Wrk f breathing Ventilatry muscle failure Ventilatin ATS/ERS Standards fr the diagnsis and mgt. f COPD, 2004 PaCO 2

17 Effects f Ncturnal Ventilatin in COPD Typical sleep-related desaturatins Due t ncturnal hypventilatin r central apneas Nt assciated with bstructive apneas Greater decrease in alvelar ventilatin leading t pr gas exchange and hypventilatin (patients with impaired lung functin) Wrsening daytime bld gases ResMed 2018

18 Inspiratry flw rate Cycling is Nt One Size Fits All It is paramunt t match the apprpriate flwcycling criterin with the specific underlying pathphysilgy. Patients with bstructive disease require different cycling criteria than thse with acute lung injury r ther frms f lung impairment. NORM Peak flw 100 lpm COPD COPD Peak flw 60 lpm Flw drps t 25% Inspiratry time (sec) Gentile MA. Respir Care 2011

19 Hypventilatin in Neurmuscular Disease (NMD) Patients ResMed 2018

20 Patient presents with bth ncturnal hypventilatin and central apneas Ncturnal Ventilatin in NMD Especially during REM sleep Significant diaphragmatic impairment r severe glbal respiratry muscle weakness Accessry muscles recruited during NREM Muscles may nt be recruited during REM sleep, resulting in falls in SpO 2 and/r sleep fragmentatin ResMed 2018 Graph curtesy f Amanda Piper

21 Central Sleep Apnea and ventilatin VPAP Adapt SV in CPAP Mde CSR Pattern SpO 2 variable 90-98% Pulse rate variable beats per min ResMed 2018

Central Sleep Apnea Central sleep apnea (CSA) is characterized by a lack f drive t breathe during sleep, resulting in repetitive perids f insufficient ventilatin and cmprmised gas exchange These

22 Central Sleep Apnea Central sleep apnea (CSA) is characterized by a lack f drive t breathe during sleep, resulting in repetitive perids f insufficient ventilatin and cmprmised gas exchange These nighttime breathing disturbances can lead t imprtant cmrbidity and increased risk f adverse cardivascular utcmes. CSA is cnsidered t be the primary diagnsis when 50% f apneas are central in rigin Unstable ventilatry cntrl during sleep is the hallmark f CSA. Internatinal Classificatin f Sleep Disrders ICSD3. AASM 2014 Eckert DJ et al. Chest 2007

23 The Apneic Threshld In all individuals, there is a required level f CO 2 in the bdy necessary t drive ventilatin Nt necessarily the same in all healthy individuals and may nt be cnstant ver time PaCO 2 If breathing increases t the pint where the CO 2 drps belw this required level, breathing will cease fr a shrt perid until the CO 2 level has risen again (an apnea will ccur) Mst healthy individuals will have ne r tw central apneas during the night. ResMed 2018

24 The Apneic Threshld Central apneas ccur ResMed 2018

Pathphysilgy f CSA Unstable Ventilatry Cntrl CSA syndrmes are classified in tw grups accrding t the wakefulness CO 2 levels (arterial PCO2). 1. Nrmcapnic spntaneus central sleep apnea/hyppnea.

25 Pathphysilgy f CSA Unstable Ventilatry Cntrl CSA syndrmes are classified in tw grups accrding t the wakefulness CO 2 levels (arterial PCO2). 1. Nrmcapnic spntaneus central sleep apnea/hyppnea. Nrmal r lw arterial PCO 2 when awake and an ver respnse t hypercapnia when asleep Cheyne-Stkes breathing, Idipathic Central Sleep Apnea and Cmplex Sleep Apnea ASV Stabilize ventilatin 2. Hypercapnic central sleep apnea and hyppnea. Abnrmal central pattern generatr utput ( wn t breathe ) Impairment f respiratry mtr utput ( can t breathe ) Assciated with hypventilatin Bilevel mdes that enhance ventilatin Eckert DJ et al. Chest 2007

26 Prevalence f CSA Prevalence f CSA vary greatly between the varius frms Eg: Mst healthy individuals will have peridic breathing n high altitude 1 Idipathic CSA is relatively uncmmn (5% f patients referred t a sleep lab) 2 Treatment-emergent CSA is in apprximately (3-10%) f bstructive sleep apnea titratin studies 3 High prevalence f CSA existing in patient sub-grups 6.5% SDB patients have cmplex sleep apnea 3 24% piate patients exhibit central sleep apnea 4 31% patients with HFpEF have central sleep apnea 5 Mre prevalent in lder individuals than in the middle aged ppulatin 6. CSR-CSA is als mre cmmn in men and extremely rare in pre-menpausal wmen. Overall prevalence in wmen is 0.3% cmpared t 7.8% in men White DP et al. J Appl Physil Malhtra A et al. Clinical Sleep Disrders. LWW Javaheri S et al. J Clin Sleep Med Crrea D et al. Anesth Analg MacDnald M et al. J Clin Sleep Med Bixler EO et al. Am J Respir Crit Care Med 2001

sleep apnea (OSA), central and/r mixed apneas, r peridic breathing. It is intended fr hme and hspital use.

27 Wh Are the Right Patients fr ASV Therapy? ASV Indicatin Fr Use The ASV device is indicated fr the treatment f patients weighing mre than 66 lb (30 kg) with bstructive sleep apnea (OSA), central and/r mixed apneas, r peridic breathing. It is intended fr hme and hspital use. ASV Cntraindicatin ASV therapy is cntraindicated in patients with chrnic, symptmatic heart failure (NYHA 2-4) with reduced left ventricular ejectin fractin (LVEF 45%) and mderate t severe predminant central sleep apnea. ResMed 2018

28 ASV Algrithm in Summary Cmpnents f ASV Devices Aut EPAP Aut + Aut PS + back up = rate ASV OSA Peridic Breathing (HCSB) CSA EPAP: expiratry psitive airway pressure HCSB: Hunter Cheyne-Stkes breathing PS: pressure supprt. Mdified frm Javaheri S et al. Chest 2014

29 1. ASV Creates a Target Ventilatin Target MV is set t 90% f the patient s recent 3 minute average Target MV is cntinually adjusted t reflect changes in patient s wn MV during the night and thrugh varius sleep stages. 3-minute mving windw Flw Pressure ResMed 2018

30 2. ASV Respnds Quickly Stabilizing Ventilatin Prevents under and ver ventilatin by dynamically increasing (fr hyppneas) r decreasing (fr hyperpneas) inspiratry pressure supprt (PS) Flw ressure PS

31 2. ASV Respnds Quickly Stabilizing Ventilatin If the upper airway is cllapsed, n matter hw advanced yur algrithm is, it CANNOT STABILIZE VENTILATION AirCurve 10 ASV : 2 ptins ASV mde Manually set EPAP t prtect airway against cllapse ASVAut mde Use an Aut-adjusting EPAP that is respnsive t Obstructive Apnea predictrs (Flw Limitatin and Snre)

change in EPAP Scenari 2: bstructive apnea Flw drps MVdrps PS

32 ASVAut Respnse t Events Scenari 1: central apnea Flw drps MVdrps PS increases Flw & vent respnd Airway = OPEN PS ventilates patient N change in EPAP Scenari 2: bstructive apnea Flw drps MVdrps PS increases N/little flw & vent Airway = CLOSED OA EPAP increases n next breath

33 Scenari 1: Central Apnea Flw drps- Central Apnea begins Flw respnse t PS increase PS increases t maintain ventilatin Minute ventilatin drps N EPAP change

34 Scenari 2: Obstructive Apnea Flw drps- Obstructive Apnea begins Little/N flw respnse t PS increase PS increases t maintain ventilatin Minute ventilatin drps EPAP increases t reduce ccurrence f bstructins Little/n MV respnse t increased PS

3. ASV Predicts Patient s Needs Algrithm

35 3. ASV Predicts Patient s Needs Algrithm tracks 13 pints in the breath cycle, cntinually and accurately mapping respiratry rate and MV. Predicts when t insert PS and EPAP Easy-Breathe replicates natural wave shape f nrmal breathing ResMed 2018

36 Switch frm CPAP t ASV mde Respiratry pattern beginning t nrmalize SpO 2 stabilizing Less variability in pulse rate

37 Respiratry pattern cmpletely nrmalized SpO 2 stable 94-97% Pulse rate stable beats per min

38 VAPS Therapy Main Headline Ges Here ResMed 2018

39 ResMed 2018 The term VAPS, Vlume Assured Pressure Supprt, refers t hybrid mdes f ventilatin that aim t prvide a minimum level f ventilatin by autmatically varying the level f pressure supprt prvided by the ventilatr.

40 Vlume Assured Therapy The aim f VAPS mde is t adapt the delivered IPAP t changes in lung mechanics t assure a defined pre-set tidal vlume (VT) delivery by autmatically adjusting pressure supprt t achieve ptimal ventilatr supprt. Mre stable ventilatin is achieved while: imprving patient cmfrt reducing wrk f breathing ptimizing patientventilatr interactin prviding adequate levels f treatment pressure ResMed 2018

hypventilatin, and neurmuscular diseases Chrnic

41 Wh is VAPS Suitable Fr? Cntinuus r intermittent ventilatry supprt fr patients weighing mre than 66 punds (30 kg) with respiratry cnditins including COPD, besity hypventilatin, and neurmuscular diseases Chrnic bstructive pulmnary disease Obesity hypventilatin Neurmuscular disease & restrictive cnditins. ResMed 2018

42 Philips- Average Vlume Assured Pressure Supprt Lks at tidal vlume Autmatic back up rate Autmatic Epap in Ventilatr (Trilgy) ResMed- Intelligent Vlume Assured Pressure Supprt Avaps and Ivaps Lks at Minute Ventilatin Autmatic back up rate Autmatic Epap in Ventilatr (Astral) 2017 ResMed I

43 Why G Vaps? Bilevels/pressure supprt very cmfrtable fr patients Flw based- t start the breath and t end the breath Patients are in cntrl f their breathing Negative- they can t guarantee vlumes- just pressure Using a Vaps mde Still cmfrtable fr patient Yet when patient s lung cmpliance is challenged psitinal sleep stage Vlume will still be delivered ResMed 2018

44 Review CPAP may nt be the device f chice fr specific patients Diagnses will be a big determinant f what PAP machine will be apprpriate fr the patient Gals f therapy will tell yu what machine yu shuld use Stabilize airway Ventilate the patient Stabilize the patient s ventilatin Ventilate and guarantee the delivered vlumes And Remember- cnsistent mnitring can uncver prblems nt picked up n- and enable them t be addressed ResMed 2018

45 Questins?

Continuous Positive Airway Pressure (CPAP) and Respiratory Assist Devices (RADs) including Bi-Level PAP

Continuous Positive Airway Pressure (CPAP) and Respiratory Assist Devices (RADs) including Bi-Level PAP Cntinuus Psitive Airway Pressure (CPAP) and Respiratry Assist Devices (RADs), Including Bi-Level PAP Benefit Criteria t Change fr Texas Medicaid Effective March 1, 2017 Overview f Benefit Changes Benefit