Guidelines to CPAP & Bi-Level device pressure titration in adults

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Guidelines to CPAP & Bi-Level device pressure titration in adults Powered By Docstoc
					         Guidelines to
CPAP & Bi-Level device pressure
      titration in adults




        Belgian Society of Sleep Technologists

 8-Feb-12              Jo Tiete - CHL            1
           1. Normal procedure

Conducted over 2 polysomnographic nights:

 The first night is to establish a reliable
  baseline diagnostic for OSAS.
 The second night to initiate & titrate nasal
  CPAP.


8-Feb-12            Jo Tiete - CHL               2
Night 1
 Document sleep apnea at least while
  sleeping in supine position.
 In all stages, but most significantly in REM
  sleep (REM atonia).
 Sleeping on the side can lead to a false
  negative diagnostic result.



8-Feb-12            Jo Tiete - CHL               3
Night 2
 CPAP titration procedure to specify the
  lowest pressure, wich abolishes apneas,
  hypopneas, snoring & arrousals (RERA).
 Also in all stages, specially REM & at least
  in supine position.
 Note: REM is almost always more
  prominent in last third part of the night.


8-Feb-12            Jo Tiete - CHL               4
           2. Split Night procedure
a) If documented > 30 apneas with desats >=
   4% from baseline after 3 hours after
   LOFF.
 Initiate CPAP !




8-Feb-12            Jo Tiete - CHL            5
             Split Night procedure
b) If related with OSAS appearance of:
      Bradycardia < 40 beats/min.
      PVC (Premature Ventricular Contraction) couplets or
       bigeminy.

      Sinus bradycardia > 2.5 seconds.
      SAO2 < 75 %.
 Initiate CPAP !
8-Feb-12                     Jo Tiete - CHL                  6
           Split Night procedure
 At least 3 hours of CPAP titration &
  treatment is needed.
 Research indicate that up to 49 % is
  inadequatly titrated in split studies because
  of lack in time!
 If fail to titrate adequatly: new full PSG
  titration.


8-Feb-12            Jo Tiete - CHL                7
           3. nCPAP titration
 Explain procedure to patient! Fit the mask.
 Start with 3 to 4 cm H2O till sleep onset.
 Increase with 1 or 2 cm every 5 to 15 min.
  till 10 cm H2O.
 If necessary, increase with 0.5 to 1 cm
  above 10 cm H2O every 15 to 30 min.
 15 to 18 cm H2O is max, except very rare
  cases! ( tear off mask during sleep).

8-Feb-12            Jo Tiete - CHL              8
              nCPAP titration
   If « sensation of not getting enough air »
    start with more than 4 cm H2O:
     – Common with nasal congestion.
     – Severe obesitas.
     – Prior chronic CPAP treatment.


   Richards et all: up to 40 % nasal congestion,
    dry nose & sore throat with CPAP device.

8-Feb-12              Jo Tiete - CHL             9
               nCPAP titration
 If claustrophobia or anxiety:
 You will need even more time to explain,
  prepare & calm down subject.
 In this case increase pressure very
  sloooooooowly!
 Sleeptech workload:
     – explaining, preparing & educating of patient.


8-Feb-12                Jo Tiete - CHL                 10
                   nCPAP titration
   To control therapeutic pressure is correct:
     – Reduce slightly pCPAP & watch for respiratory
       events or arrousals to re-appear.
   If pressure is set too high:
     –     Discomfort.
     –     Awakenings.
     –     Hypnogram fragmentation.
     –     Oral leak & noise (gasping).
     –     Appearance of central apneas.

8-Feb-12                    Jo Tiete - CHL         11
                nCPAP titration
   If obst. or mixt. apneas are converted to
    central apneas of the Cheyne-Stokes type
    (periodic breathing):
     – Test with upward pressure.
     – If no luck: leave at pressure to stop obstructive
       events.
   Central apneas in REM without desats or
    arrousals don’t need higher pressure.

8-Feb-12                 Jo Tiete - CHL                    12
                   nCPAP titration
   If central apneas (not Cheyne-Stokes type)
    with arrousals:
     – Investigate for preceding snorings/airflow
       limitation or UARS:
           » Then try with higher pressure.
     – Investigate for arrousal because of too high
       pressure and/or mouthleak:
           » Then try with lower pressure.


8-Feb-12                      Jo Tiete - CHL          13
                nCPAP titration
   If high pressure is necessary to maintain
    airway patency, but not tolerated:
     – Do a temporary pressure reduction with slow
       increase.
     – If several attempts to do so are not succesfull,
       change to Bi-Level.
   If CPAP not supported because of nasal
    congestion: use heated humidifier or topical
    vasoconstrictor spray.
8-Feb-12                 Jo Tiete - CHL                   14
               nCPAP titration
   If high mouth leaks:
     – Try with heated humidifier.
     – And/or Shin strap.
   If still no succes:
     – Switch to Bi-Level.
     – Or use a full face mask.



8-Feb-12                  Jo Tiete - CHL   15
            nCPAP titration
 Not uncommon: first a succesfull titration,
  but after position change, respiratory events
  reappearing.
 Even when CPAP is succesfully titrated,
  many causes can lead to the inability to
  tolerate CPAP.
 Therapeutic failure to CPAP is estimated to
  be 20 to 30 %.
8-Feb-12            Jo Tiete - CHL            16
                4. Bi-Level tiration
   From start only:
     – if severe pulmonary reasons & asked by
       physician.
   Indications:
     –     CPAP not tolerated.
     –     COPD(Chronic Obstructif Pulmonary Disease).
     –     Hypoventilation.
     –     High mouth leak with humidifier & shin strap.
     –     Other pneumological diseases (ex: scoliosis).
8-Feb-12                   Jo Tiete - CHL              17
           Bi-Level tiration
 Increase both IPAP & EPAP till no more
  obstructive apneas.
 Then increase IPAP only, till no more
  hypopneas, snoring or RERA’s.
 If these events still persists, increase EPAP
  by 0.5 to 1 cm.
 In alveolar hypoventilation: lower the EPAP
  to increase tidal volume.
8-Feb-12            Jo Tiete - CHL           18
           5. Alter subject position
   If CPAP or bi-level pressure not tolerated:
     – The bed will be elevated by 30 degrees.
     – Use lateral sleep position (tennis ball, pillow).




8-Feb-12                 Jo Tiete - CHL                    19
                6. Oxygen therapy
   If despite of good titration, SAO2 < 90%
    then:
     –     Start with 1 liter O2 inline CPAP.
     –     Maximum 4 to 5 liters O2 (ask your doctor!).
     –     If > 3 liters O2 use of humidifier recommended.
     –     Slooowly increase O2 till SAO2 > 90%.
   Danger: fire, CO2 retention, mucosa
    irritation & epistaxis (nose bleeding).
     – pCPAP + Oxyconcentrator !!!
8-Feb-12                    Jo Tiete - CHL              20
         7. Auto-/Smart (or stupid)-
                    CPAP
   Subject excluded for auto-titration are:
     –     Congestive heart failure.
     –     COPD and daytime hypoxemia.
     –     Hypoventilation syndrome.
     –     NO snorers (ex:UPPP)… auto-CPAP Sound
           algorithm don’t detect any abnormallity!


8-Feb-12                   Jo Tiete - CHL             21
           Auto-/Smart-CPAP

 Auto-CPAP is not indicated in Split night
  procedure, but sometimes used for an
  attended polysomnography.
 Some auto-CPAP devices have proven their
  utility for the Cheyne-Stokes type apneas
  (Resmed CS).


8-Feb-12          Jo Tiete - CHL          22
           8. Adherence & follow-up
 Education, education, education…
 Review subject after CPAP initiation within
  3 months.
 Follow-up, control & adjustment on yearly
  basis.
 Change deteriorated consumables
  (mask,…).
 At least 4.5 hours PAP use/night.
8-Feb-12            Jo Tiete - CHL          23
           9. Sleeptech experience
   Important:
     – A trained staff for CPAP use & titration.
     – Good understanding: in respiratory physiology,
       anatomy and sleep & respiratory disorders.
   Higher compliance succes rates with well
    trained sleeptechs.



8-Feb-12                Jo Tiete - CHL              24
      My CPAP Evolution Theory:
           Homo Erectus
                            Rather small brain.
                            Big mouth, good flux.
                            Big thorax volume.
                            Small abdomen.
                            No fat, but muscles!
                             (…had to run for the
                             dinausaur!).

                            No need for CPAP !!!
8-Feb-12        Jo Tiete - CHL                   25
NASA: send this picture in space
                         Clean & ideal drawing
                          of Homo Sapiens.
                         But if extra-terrestrial
                          life should visit the
                          earth one day, they
                          will find ...




8-Feb-12     Jo Tiete - CHL                      26
           This !
                       No brain difference.
                       Smaller mouth &
                        fatty dubbel shin.
                       Smaller thorax.
                       Huge abdomen.
                       A lot of fat, rare
                        muscles (don’t run
                        anymore!).
                       Don’t survive without
                        CPAP device!!!
8-Feb-12   Jo Tiete - CHL                   27
Thank you for your attention.

        tiete.jo@chl.lu

				
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