CPAP in the treatment of sleep apnea. Titration, fixed and intelligent systems Marc 2015 Josep M Montserrat. Barcelona. Spain
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1. INTRODUCTION 2. TITRATION 3. AUTOMATIC CPAP 4. FOLLOW UP. COMPLIANCE
1. INTRODUCTION 2. TITRATION 3. AUTOMATIC CPAP 4. FOLLOW UP. COMPLIANCE
Upper airway mechanoreceptors Negative pressure Vibration UPPER AIRWAY PATENCY/COLLAPSE BRAIN STEM CENTERS UPPER AIRWAY FACTORS: UPPER AIRWAY MUSCLES ANATOMIC Obesity, retrognatia COLAPSABILYTY Shape Tissue properties Normal breathing
Upper airway mechanoreceptors Negative pressure Vibration UPPER AIRWAY PATENCY/COLLAPSE BRAIN STEM CENTERS UPPER AIRWAY FACTORS: (+) UPPER AIRWAY MUSCLES (-) ANATOMIC Obesity, retrognatia COLAPSABILYTY Shape Tissue properties Apnea
Upper airway mechanoreceptors Negative pressure Vibration + UPPER AIRWAY PATENCY CPAP BRAIN STEM CENTERS UPPER AIRWAY FACTORS: (+) ANATOMIC Obesity, retrognatia UPPER AIRWAY MUSCLES (-) + + COLAPSABILYTY Shape Tissue properties Normal breathing
1. INTRODUCTION 2. TITRATION 3. AUTOMATIC CPAP 4. FOLLOW UP. COMPLIANCE
Step one: 1. Adequate mask 2. Devices: No changes of mask pressure during inspira<on and compensa<on. 3. Sensors or procedures: classical PSG plus: PNT, leaks detec<on, pressure from the devices and from the mask. In case Bi- level transcutaneous CO 2 and EMG Step two: <tra<on Key points: educa2onal, training, pleasant night, short follow- up PSG Simple devices (automa<c CPAP) Step three: treatment and compliance
AIM SUPPRES 1. Apnoeas, hypopnoeas 2. Thoracoabdominal incoordina<on 3. Snoring 4. Flow limita<on NORMALIZE SLEEP
CPAP TITRATION
Flow (L/s) P. eso CPAP cmh 2 O T- A incoordina2on Arousals Yes Yes Yes/Not Not Yes Yes Not Not Montserrat et al. AJRCCM 1995
CPAP TITRATION PSG Diurnal, training and mask adjustment session Apnoea/hypopnoea? Flow limita2on Snoring Sleeping consolidation PSG. Difficult patients Non difficult patients INCREASE THE PRESSURE. ONE cmh 2 O EVERY 5-10 MINUTES But keep calm Sometimes more time is needed because sleep has be to stabilized and transition events can be present Check REM and supine. Increase in needed During last 60 mint check if with less pressure is enough Kushida. JCSM 2008 If ok END OF CPAP TITRATION
EOG EEG ECG A B C EMG Flujo SaO 2 Tórax Abdomen Sumatorio Presión mascarilla 4 6 9 Presión equipo Fuga Posición corporal All night CPAP Leak FUGA A B C Sa0 2
CPAP TITRATION PSG Diurnal, training and mask adjustment session Apnoea/hypopnoea? Flow limita2on Snoring Sleeping consolidation Strollo PJ Jr, Sanders MH, Costan<no JP et al. Split- night studies for the diagnosis and treatment of sleep- INCREASE THE PRESSURE. ONE cmh 2 O EVERY 5-10 MINUTES But keep calm Sometimes more time is needed because sleep has be to stabilized and transition events can be present Check REM and supine. Increase in needed During last 60 mint check if with less pressure is enough Kushida. JCSM 2008 PSG. Difficult patients If ok Non difficult patients Automa2c devices. Split night No leaks. No residual events Analyze the pressure curve If ok END OF CPAP TITRATION disordered breathing. Sleep. 1996 Acceptance of CPAP ranged from 62 to 67%. Lloberes P, Ballester E, Montserrat JM et al. Comparison of manual and automa<c CPAP <tra<on in pa<ents with OSA. Am J Respir Crit Care Med. 1996 Auto- CPAP permits future fixed- level CPAP needs,
Posi<ve Airway Pressure Titra<on Task Force of the American Academy of Sleep Medicine Kushida et al. JCSM 2008 1. In pa<ents with a high clinical suspicion of OSA a Split- Night Study is a possibility. Pa<ents should Receive an adequate prepara<on. 2. Pressure increase 2 cm H20. Diagnos<c part: IAH > 30 3. If problem or doubts beber to follow as a diagnosis study PUBMED. Last 5 years (from 28) SEVERE OSA (IAH > 30): Data from the first 2 hours adequate. Kim. Sleep Breath 2015 (n: 134) Chau. Respirology 2011 (n:180); Khawaja. 2010 JCSM (n:114). Compliance was not different (split vs full PSG) Collen. Sleep Breath.2010. (n:400). Non randomized..
Certain APAP devices may be used in an unattended way to determine a fixed CPAP treatment pressure for patients with moderate to severe OSA without significant comorbidities
AUTOMATIC CPAP TITRATION Multicenter study 360 patients SAHS CPAP RECOMEDATION Automatic CPAP FULL PSG 12 weeks Full PSG (residual events and compliance IAH > 30 Relevent symptoms No severe comorbilities Masa et al. AJRCCM 2004
HAPPY NIGHT Patients initial experience with CPAP treatment and, in particular, the degree of improvement in sleep during CPAP titration may be crucial factors in determining their subsequent use of this treatment modality.
START WITH DAYTIME SETTINGS. If obstruc2ve events increase IPAP/ EPAP 1 cmho 2 / 10-15 min (un2l they disappear START TITRATION Day2me training. Ini2al Sejng New sensors: VE, EMG and TcCO 2 CHECK TcCO 2 SatO 2 EMG If hypoven2la2on increase IPAP 1 cmh2o every 10-15 min. (Max 25-30 cmh2o or pa2ent tolerance) (BUT KEEP CALM) IF V/Q Add O 2 END IF HIPOVENTILATION Obesity, increase CO 2.. Difficult to differen2ate if VE or TcCO 2 are not available If TcCO 2 is normal with acceptable minute ven2la2on END OF CPAP TITRATION (7 cc/kg) Low SatO 2 Add O 2 But if SatO 2 < 90% Check a`er some days Oximetry V/Q mismatch Causes SatO 2 < 90% Hypoven2la2on If at max. pressures (20 cmh 2 O) or pa2ents tolerance the SatO 2 < 90% Consider other op2ons (Oxygen or BI- LEVEL) AASM and SomnoNIV group
1. INTRODUCTION 2. TITRATION 3. AUTOMATIC CPAP 4. FOLLOW UP. COMPLIANCE
Automatic CPAP Device capable of detecting breathing disturbances and to apply the nasal pressure required Normal breathing Apnea Sensors (flow, snoring,...) Event and artifact detection Decision on CPAP change CPAP Patient Upper airway
The performance of an automatic CPAP device can be tested in the bench. (Connecting the A-CPAP with a breathing waveform generator that reproduces SAHS events). Farré et al. AJRCCM 2002
CPAP treatment: Automatic CPAP Intelligent CPAP systems: Automatic CPAP Adapted from Rigau et al. Chest 2006;130; 350-361
Intelligent CPAP systems: Automatic CPAP Different response of auto-cpap devices Isetta et al. ERS Congress 2014
1. INTRODUCTION 2. TITRATION 3. AUTOMATIC CPAP 4. FOLLOW UP. COMPLIANCE
COMPLIANCE Barbé et al. AJRCCM 2010 Martinez-Garcia JAMA 2013
RECOMMENDED INTERVENTIONAL SCHEME PRE- CPAP TITRATION SUPPORT Considera<on of personal and social pa<ent s characteris<cs Adequate Indica<on of treatment and symptoms Assessment of physiological aspects (AHI, CT90 %...) Careful ini<al educa<onal and CPAP and mask training session. Effort to reach pa2ent s awareness of the need of treatment Adequate mask choice SUPPORT DURING CPAP TITRATION (2tra2on is an art) Some<mes a slow increase of pressure is needed depending of the pa<ents Assistance and guidance through the night (awake periods, percep<on of pressure, mask leaks or asynchronies) A number of <mes not all the events can be corrected Pleasant night is probably the most important point Discussion of the procedure and problems in the morning POST- CAP TITRATION FOLLOW- UP The intervals of the visits depend of the side effects, compliance, characteris<cs of the pa<ents and associated diseases. Early detec2on and treatment of side effects is one of the most important points as control during the first weeks Con<nuous educa<onal and psychological support First visit (1-2 weeks): individual face- to- face, group support or teleconsulta<on Second visit (4-6 weeks): individual face- to- face, group support or teleconsulta<on Next visits depend on the pa<ent s characteris<cs, comorbidi<es, side effects, residual symptoms/ events detected and compliance All the procedure can be performed by face to face or groups visits as by videoconferences
Future internet management of domiciliary CPAP treatment: Internet videoconference CPAP training Knowledgement of CPAP issues Isetta et al. Interact J Med Res 2014; 3(1): e6
Future internet management of domiciliary CPAP treatment: Internet videoconference CPAP training Practical assessment scores Isetta et al. Interact J Med Res 2014; 3(1): e6
CONCLUSIONS Application of nasal CPAP is very effective in normalizing breathing and sleep architecture. A-CPAP technology is at present not well defined and the commercially available devices exhibit considerable differences. Split night and automatic CPAP represent an useful option in a high suspicion patients. A-CPAP probably is more costefectiveness There are no data clearly showing that automatic CPAP is better than fixed-cpap for the home treatment of the general OSA population.
IN THE END, the fundamental issue is not whether ambulatory studies are better or worse than PSG, but rather under what conditions use of home studies are appropriate. Large randomized trials of different diagnostic strategies in different groups of patients with collection of concomitant economic information are required to address this important issue. It is unlikely that one diagnostic strategy will be superior in all the different clinical scenarios that are encountered. SLEEP, Vol. 34, No. 6, 2011
Dra Valentina Isetta Prof. Ramon Farré Prof. Daniel Navajas Thanks