PAP Download Interpretation and Case-Based Discussion Loretta Colvin, APRN-BC Nurse Practitioner Clayton Sleep Institute
Objectives Review PAP adherence report elements Incorporate PAP report data into clinical assessment Identify PAP machine technology variations in reporting
Conflict of Interest I have no conflicts of interest to disclose
Adherence Assessment Considerations
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
Patient Assessment Do subjective and objective reports agree? If not, which do you believe or how do you assess further?
Recommendation ALWAYS view detailed data for issues Patient issues Not improving, Not tolerating, Report issues AHI, leak, pressure Data issues QUESTION technology when appropriate
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
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)
Adherence Data Data card USB or SD card Modem External Internal Viewing machine screens Typically basic usage available
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 + + +
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
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
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
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
Report Components
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
Comfort Features Pressure relief Humidifier Chamber Heated Tubing F&P Icon Respironics System One ResMed S9 / AirSense SensAwake Flex / Flex+ EPR 0-7 0-5 S9 0-6 AS 0-8 Boost L-M-H 1-2-3 60 86 degrees
Cases
Pressure Relief
ResMed EPR Baseline AHI 11 Titration - 9 cm recommended EPR 3 acts similar to mini- Bilevel
Fisher & Paykel SensAwake CPAP 9 orders sent to DME DME left SensAwake on AHI 2.9 on report
Another Example SensAwake
Respironics SystemOne Cflex + PSG AHI 120 s Low sats 60 s AHI 31
Leak
F&P Icon Infosmart Is leak acceptable? (group) > 50 is high
F&P Icon Another Example
ResMed S9 EasyCare Online Is this OK? (group) Below 24 is OK for ResMed (excessive leak)
SystemOne - Encore Anywhere What s happening? (new patient returns for first CPAP f/u)
Respironics (cont)
Another Case Example What happened?
Case Example (cont) Full Face Mask Nasal Interface
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
AHI
Case #1 Baseline AHI 12 CPAP 10 recommended Patient complains machine turning itself off What next?
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
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
Case #3 Baseline AHI 135 SpO2 58% CPAP 14 AHI 1.8 SpO2 86% Supine/REM
Summary Report 2 week
Trend Report AHI 33.9 VS Index 525.5 0.6% large leak
Detailed View CPAP 14 AHI 51 OA 45 Leak 40 (FFM 12 cm) 0.3% large leak
Detailed Report Different Night AHI 1.2 Leak 42
Home Oximetry
Case #3 Discussion
Case #4 Routine Appointment
Baseline
Day 1 and 2 (x 1 weeks)
2 weeks later
Case #4 Discussion
Case #5 Compliance Report
Case #5 Therapy Report
Case #6 Detailed Report AHI 20 AHI 11 AHI 0.2
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
Case #7 Details
Case #7 Min Pressure Dropped
Machine and Patient Discrepancy?
Modem Case Example DOT driver with Respironics SystemOne Comes in for f/u No data for past 3 weeks on printed report What happened?
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
Patient Self-Monitoring Patient log Machine data monitoring On screens Online
Humidifier
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
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
Using Technology Always Pay Attention! (especially after upgrades)
Customized Patient Report Needs 2 nd identifier such as DOB for medical record
Data Reporting
Pressure Reporting Pressure change min 12 max 15 not reflected in text data
Look for Details Last settings reported apap settings changed midreporting period
Usage Data without AHI or Pressure
Insurance Communication
Questions Thanks to Ann Cartwright, PA and Neil Freedman, MD for providing cases.