Bi-Level Therapy: Boosting Comfort & Compliance in Apnea Patients

Transcription

1 Bi-Level Therapy: Boosting Comfort & Compliance in Apnea Patients

2 Objectives Describe nocturnal ventilation characteristics that may indicate underlying conditions and benefits of bilevel therapy for specific SDB patients Understand qualification criteria for bilevel therapy, recognize settings and understand the benefits of monitoring therapy efficacy

3 Pulmonary Ventilation Main Headline Goes Here

4 What Is Ventilation? The 2 basic functions of the Respiratory System are: 1. Ventilation (movement of air into and out of the lungs) 2. Respiration (gas exchange at the alveoli) O 2 The volume of gas in the lungs at any instant depends mainly on: 1. Activity of muscles of inspiration and expiration 2. The mechanics of the lungs and chest wall CO 2 3. Ventilation central control DifferenceBetween Ventilation & Respiration

5 Mechanics of the Lung and Chest Wall Compliance ease of stretch or distend Elastance ease of recoil or return to original shape Resistance impedance of gas flow through airway or tube

6 Normal Breathing During Sleep Non-Rapid Eye Movement (NREM) Rapid Eye Movement (REM) Divided into multiple stages Breathing (Vt & RR) irregular blood pressure & heart rate Loss of muscle tone (atonia) eye movement Ventilatory response further reduced Muscles relaxed, not paralyzed McNicholas WT, Phillipson EA. UK, Saunders 2002

7 Ventilation Changes During Sleep Decreased respiratory drive with a small fall in ventilation and rise in carbon dioxide (CO2) Small reductions in tidal volume are compensated by an increase in breath rate Alterations in respiratory system mechanics o Increased upper airway resistance o Altered chest wall mechanics Depressed arousal responses to chemical stimuli Becker HF et al. Am J Respir Crit Care Med 1999

8 Hypoventilation

9 Hypoventilation Alveolar hypoventilation is defined as insufficient ventilation leading to hypercapnia, (PaCO 2 45mmHg). It may be an acute or chronic and is caused by several mechanisms Alveolar hypoventilation may be acute or chronic and may be caused by several disorders. Night time and Daytime Hypoventilation Respiratory insufficiency patients have an additional 10 15% drop in ventilation at sleep onset (SO) o Further reduction in REM sleep (10 20%), due to falling tidal volumes not counteracted by increased respiratory rate Becker HF et al. Am J Respir Crit Care Med 1999

10 Hypoventilation in COPD Patients

11 Hypoventilation & COPD Hypoventilation is not uncommon in patients with severe COPD, therefore it is a marker of disease severity. Hypoventilation in COPD involves multiple mechanisms, including: o o o Decreased responsiveness to hypoxia and hypercapnia Increased Ventilation-Perfusion mismatch leading to increased dead space Decreased diaphragmatic function due to fatigue and hyperinflation Alveolar hypoventilation in COPD usually does not occur unless the forced expiratory volume in 1 second (FEV 1 ) is less than 1L or 35% of the predicted value. Gold Report 2017

12 Pathophysiology of COPD Diaphragm flattening Muscle weakness Air trapping Intrinsic PEEP Dyspnea Elastic recoil Work of breathing Ventilatory muscle failure Ventilation ATS/ERS Standards for the diagnosis and mgt. of COPD, 2004 PaCO 2

13 Overlap Syndrome

14 Overlap Syndrome Consists of both: o o o Upper airway obstruction (OSA) during sleep Nocturnal hypoventilation (COPD) Approximately 10% of sleep apnea patients may have some degree of COPD* May demonstrate prolonged hypoxemia during sleep SpO 2 often does not recover between episodes of repetitive apnea If left untreated, morbidity and mortality much higher than for either disease process alone * Douglas NJ. Sleep Disorders 1998

15 Benefits of Bilevel Therapy Main Headline Goes Here

16 Bilevel Therapy Bilevel positive airway pressure, commonly referred to by the trademarked names BiPAP, is a form of NIV (Non invasive Ventilation) that uses a time-cycled or flow-cycled change between two different applied levels of positive airway pressure (IPAP and EPAP)* * Kushida CA et al. J Clin Sleep Med 2008

17 How Does Bilevel Work? Prevents nocturnal hypoventilation and hypoxia o Cardiovascular consequences Improves ventilation (gas exchange) o o o Reduces nocturnal CO 2 levels Increases nocturnal O 2 levels Improves daytime blood gases Stabilizes upper airway Rests respiratory muscles Decreases daytime sleepiness by correcting sleep architecture o Comfort & Compliance Reduces arousals due to SDB and associated sleep fragmentation *. Antonescu-Turcu A & Parthasarathy S. Respir Care 2010

18 Bilevel Provides a Breath with Two Pressures IPAP Pressure during inspiration. Give appropriate volume of air. Decrease work of breathing. Reduce level of CO 2 in arterial blood (PaCO 2 ). Breath Cycle Pressure delivery matches the breath cycle (breathe in, breathe out). Settings in the breathe cycle can be adjusted to meet patient needs. Normal I:E ratio is 1:2 (you exhale twice as long as you inhale) EPAP Pressure during expiration. Keeps airway open. Improves oxygenation.

19 Consider Using Bilevel When Patient is not tolerating high pressure settings 1 Events persist at 15 cm H 2 O 2 Patient complains of not being able to exhale despite expiratory pressure relief (EPR ) feature 1 Patient has history of ventilatory insufficiency such as chronic obstructive pulmonary disease (COPD), restrictive lung disease, or obesity hypoventilation syndrome (OHS) 1 Must be a 4 cm H 2 O difference between IPAP and EPAP to be considered bilevel therapy 2 1. Gay P et al. Sleep Kushida CA et al. J Clin Sleep Med 2008

20 Bilevel Modes of Therapy S Spontaneous (S) IPAP and EPAP S/T PAC VAuto Spontaneous Timed (S/T) IPAP and EPAP Backup Rate Spontaneous Timed (S/T) IPAP and EPAP Backup Rate / Ti VAuto with Fixed Pressure Support (PS) Max IPAP and Min EPAP PS ASV/ ASVAuto Adaptive Servo-ventilation targeting recent minute ventilation Min and Max PS EPAP / Auto EPAP ivaps Intelligent Volume Assured Pressure Support Min and Max PS EPAP

21 Bilevel Therapy & COPD Severe hypercapnic COPD patients (PaCo2 > 53 mm Hg) discharged after an acute exacerbation (AECOPD) and treated with home oxygen therapy and home mechanical ventilation (HOT + HMV) will experience a 51% reduction in risk of hospital readmission or death. Patients on HOT-HMV definitely experienced better outcomes 1 The addition of long-term NIV to standard treatment improves survival of patients with hypercapnic, stable COPD when NIV is targeted to greatly reduce hypercapnia 2 1. Murphy PB et al. J Am Med Assoc Kohnlein T et al. Lancet Respir Med 2014

22 Bilevel Therapy & COPD COPD patients who use (NPPV) immediately following a hospital admission due to an acute exacerbation (AECOPD) with hypercapnic respiratory failure would have lower hospital readmissions and lower mortality 1 The addition of NIV to optimal standard therapy has beneficial effects in the HRQoL (Health-Related Quality of Life) of stable hypercapnic COPD patients; with the improvement in dyspnea (breathlessness) being the major determinant of HRQoL changes 2 1.Galli JA et al. Respir Med Tsolaki V et al. Respir Med 2008

23 Bilevel Therapy & NMD Early treatment with NPPV prolongs survival and reduces decline of FVC% in ALS 1 For patients with Duchenne muscular dystrophy, the use of NIV for twenty-four hour should be considered as a safe alternative because its use may obviate the need for tracheostomy 2 Noninvasive ventilation improves sleep quality and breathing in subjects with respiratory muscle weakness 3 1. Carratu P et al. Orphanet Journal of Rare Diseases McKim DA et a. Can Respir Bourke SC et al. Eur Respir J 2002

24 Synchrony Features and Benefits

25 Synchrony Challenges NIV patients often remain ineffectively treated: 40% of NIV patients experience asynchrony in 10% or more of their breaths Patients can experience o Discomfort o Ineffective ventilation o Treatment refusal Epstein SK. Respir Care 2011

26 Asynchrony Asynchrony Discomfort Compliance Accessory Muscle Use Ineffective Treatment Work of Breathing

27 1. Transition to Inspiration: Trigger Sensitivity Settings You would change to MORE sensitive (High): If the patient is having difficulty triggering the therapy (i.e., breaths are not being sensed, due to: Upper airway obstruction AutoPEEP Weak respiratory muscles Increased circuit resistance EPAP Flow Trigger Sensitivity Very High High Medium Low Very Low IPAP The higher the sensitivity level, the smaller the patient effort required to trigger the device You would change to LESS sensitive (Low): If the device is too sensitive to the patient, causing auto-triggering. Auto-triggering or noticeable extra triggering may be due to cardiac oscillations.

28 Qualification Criteria Main Headline Goes Here

29 Qualification Criteria

30 Qualification Criteria

31 RAD Guidelines January 2017

32 RAD Guidelines