Monitoring: gas exchange, poly(somno)graphy or device in-built software?

Transcription

1 Monitoring: gas exchange, poly(somno)graphy or device in-built software? Alessandro Amaddeo Noninvasive ventilation and Sleep Unit & Inserm U 955 Necker Hospital, Paris, France Inserm Institut national de la santé et de la recherche médicale

2 Monitoring: gas exchange, P(S)G or device in built software? How to monitor NIV/CPAP efficacy? Pulse oximetry and carbon dioxide Built-in software P(S)G Follow up timing

3 The aim of NIV or CPAP is to correct nocturnal gas exchange: before PtcCO 2 SpO 2

4 After CPAP... PtcCO2 SpO 2

5 Pulse oximetry Since oxygen desaturations are a major determinant of adverse neurocognitive and cardiovascular consequences, pulse oximetry should be included in the monitoring of NIV or CPAP efficacy Janssens JP, Borel JC, Pépin JL; SomnoNIV Group. Thorax But what could we miss?

6 Differents events may cause oxygen desaturation

7 Child with congenital myopathy

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9 Nocturnal hypercapnia without hypoxemia SpO 2 (%) Patients N=50 PtcCO 2 < 50 mmhg N=29 PtcCO 2 > 50 mmhg N=21 SpO 2 threshold at 90% SpO 2 > 90% 49 (98%) 28 (56%) 21 (42%) SpO 2 90% 1 (2%) 1 (2%) 0 (0%) SpO 2 threshold at 92% SpO 2 > 92% 46 (92%) 28 (46%) 18 (36%) SpO 2 92% 4 (%) 3 (6%) 1 (2%) SpO 2 threshold at 95% SpO 2 > 95% 30 (60%) 18 (36%) 12 (24%) SpO 2 95% 21 (42%) 14 (28%) 7 (14%) Paiva et al. Intensive Care Med 2009;35:1068

10 Normal daytime blood gases and normal nocturnal SpO 2 do not exclude nocturnal hypercapnia Daytime PaCO 2 Patients with nocturnal PtcCO 2 < 50 mmhg n=29 (%) Patients with nocturnal PtcCO 2 > 50 mmhg n=21 (%) PaCO 2 < 45 mmhg 29 (48%) 18 (36%) PaCO 2 45 mmhg 0 (0%) 3 (6%) Paiva et al. Intensive Care Med 2009:35:1068

11 Pulse oximetry & PtcCO 2 The pros Simple and easy to do even at home Low cost Easy to interprete Limits Lack of specificity in identifying residual sleep disordered breathing Lack of sensitivity if oxygen supplementation Events without desaturation are not taken into account (microarousals)

12 Monitoring: gas exchange, P(S)G or device in built software? How to monitor NIV/CPAP efficacy Pulse oximetry and carbon dioxide Built-in software P(S)G Follow up timing

13 Built-in software or integrated PG Respiratory frequency Airflow Pressure Leaks

14 Leaks Unintentional Leaks Airflow Total Leaks Pressure Vte

15 Objective compliance Date Daily use Date

16 8 month-old girl with Down syndrome (6 kg) Resmed S9 set at 7 cmh 2 O Registered compliance 32 min/night (real use 9 hours/night) Intermittent flow recording

17 Manufacturer s recommandations S9- VAuto S9-VPAP ST Stellar 100/150 PR1 REMstar pro/auto PR1 BIPAP ST/AVAPS BIPAP A30/A40 TRILOGY Icon Modes and minimal recommended weight Every mode > 30 Kg Every mode > 13 Kg Every mode > 13 Kg Every mode > 30 Kg Every mode > 18 Kg Mode ST+AVAPS > 20 Kg Every mode > 10 Kg Every Mode ST+AVAPS > 20 Kg mode > 5 Kg Every mode > 30 Kg

18 Monitoring NIV in a glimpse Date IPAP EPAP RR % of spont Trigger

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21 Automatic detection of apnea/hypopnea Integrated and automatic AHI

22 Variable definitions of obstructive apnea AASM 2012 S9 series (ResMed) PR One BIPAP (Philips) Flow reduction 90% 75 % 80% Event duration 2 cycles > 10 sec > 10 sec Characteristics Persistance or increase in inspiratory effort Upper airway obstruction If persistant flow is detected no impulsations are needed to qualify the apnea

23 Variable definitions of central apnea AASM 2012 S9 series (ResMed) PR One BIPAP (Philips) Flow reduction 90% 75 % 75 % Event duration 20 sec or 2 respiratory cycles and associated with desaturation ± microarousal 10 sec 10 sec Characteristics No respiratory effort <1yr: < 90% of respiratory flow + bradycardia No upper airway obstruction

24 Variable definitions of hypopnea AASM 2012 S9 series (ResMed) PR One BIPAP (Philips) Flow reduction 30% 50% 40% Event duration 2 cycles 10 sec 10 sec Characteristics Associated with a desaturation and/or microarousal/arousal

25 Integrated SpO 2 SpO 2 Airflow

26 Built-in software The pros Low cost Easy Detailed information about objective compliance and treatment efficacy Limits Weight limits for pediatric patients Automatic analysis not always accurate or reliable

27 Monitoring: gas exchange, P(S)G or device in built software? How to monitor NIV/CPAP efficacy? Pulse oximetry and carbon dioxide Built-in software P(S)G Follow up timing

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29 Respiratory events during NIV Unintentional leaks Patient ventilator asynchonies Decrease in ventilatory drive Upper airway obstruction with decrease in ventilatory drive Upper airway obstruction Mixed events NM disease (n=13) 31 ± 38% n=7 38 ± 46% n=9 8 ± 16% n=6 11± 23% n=5 4± 7% n=6 0 ± 0% n=0 Lung disease (n=11) 37 ± 41% n=8 50 ± 39% n=10 4 ± 8% n=5 8 ± 12% n=5 16 ± 18% n=7 0.1 ± 0.1% n=1 OSAS (n=15) 17 ± 31% n=6 11 ± 24% n=6 17 ± 33% n=10 20 ± 34% n=7 16 ± 25% n=9 9 ± 26% n=8 Total population (n=39) 27 ± 36% n=21 33 ± 40% n=25 10 ± 23% n=21 11 ± 28% n=17 12 ± 10% n=22 3 ± 16% n=9

30 Consequences of respiratory events Respiratory events / h * Total population No clinical consequences DS3% AA AA+DS3% Respiratory events / h * * Neuromuscular disease No desaturation or autonomic arousal 3% desaturation # 0 UL AS UAO+DV UAO DV Mixed 0 UL AS UAO+DV UAO DV Mixed D Lung disease 100 OSAS Respiratory events / h * UL AS UAO+DV UAO DV Mixed Respiratory events / h UL AS UAO+DV UAO DV Mixed # Autonomic arousal Autonomic arousal + 3% desaturation

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32 Number of respiratory events/polygraphy

33 Consequences of respiratory events

34 Poly(somno)graphy The pros Gold standard for monitoring NIV or CPAP Precise monitoring of treatment efficacy and characterisation of respiratory events Limits Time consuming, expensive and technically demanding Difficult to interprete

35 Monitoring: gas exchange, P(S)G or device in built software? How to monitor NIV/CPAP efficacy? Pulse oximetry and carbon dioxide Built-in software P(S)G Follow up timing

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37 61 NIV/CPAP sleep studies in 45 children median age 8.3 yrs ( yrs)

38 Conclusion (1) The best strategy to monitor NIV/CPAP therapy has not been validated but P(S)G remains the gold standard The combination of simple tools like SpO 2 + PtcCO 2 + built-in software may efficiently screen which patient would require a P(S)G

39 Conclusion (2) Patients are at greater risk of residual respiratory events during the 1 st months of treatment Nocturnal gas exchange and integrated built-in software should be performed at 1 and 3 months after NIV/CPAP initiation and then every 6 months A P(S)G should be performed after 2-3 months of treatment and then 1/year