The Nuts and Bolts of CPAP Use: Titration, Tracking, Optimization - PDF document

2/13/2018 The Nuts and Bolts of CPAP Use: Titration, Tracking, Optimization Grace Pien, MD, MSCE Division of Pulmonary and Critical Care Department of Medicine Johns Hopkins School of Medicine 16 February 2018 Outline • Optimizing CPAP delivery – PAP systems – Masks – Accessories – Troubleshooting • Understanding and using tracking data – PAP adherence tracking systems – Residual AHI and event detection – Mask leak – Data transmission and review systems – Barriers to using tracking systems in clinical practice – How to use the data 1

2/13/2018 Introduction to CPAP: What to Tell the Patient • Safer than taking a medication • Not a breathing machine – s/he will not die if disconnected from the unit or therapy stopped • Pneumatic splint to open the airway - it is not oxygen • Machine much quieter than snoring - white noise • Use during sleep only • Consider a desensitization program − Get used to it - watch TV with CPAP on − Take pictures of yourself CPAP Units 2018 ResMed AirSense 10 Philips Respironics DreamStation Fisher & Paykel SleepStyle 2

2/13/2018 Travel CPAPs HDM Z1 ResMed AirMini Is This the Future of CPAP? • “MicroCPAP” microblower fluidic pump • About half of capital raised from crowdfunding • Still in prototype form • NOT yet evaluated in clinical trials or by FDA 3

2/13/2018 Cost of CPAP • CPAP machines range from $300 to $800 • More expensive units have compliance/efficacy capability, some have built-in auto-PAP capability • Auto-CPAP: $500 - $900 (no code for Medicare reimbursement) • Bi-level systems: $950 - $1700 • Circuit and mask $75 - $200+ • New CPAP mask every 6 months should be covered • Insurance companies (including BC/BS, US Health Care, Medicare, HMO's, Managed Medicaid, etc) provide coverage CPAP Advancements • Ramp systems • Useful at high CPAP settings • Heated humidification* • Multiple heated humidification systems available • Reduces nasal drying - useful for mouth leaks and patients with sinus problems • Cool passive humidifiers not as effective • Humidifier and CPAP in one unit • Heating coils in tubing • Tubing insulators *AASM practice parameters CPAP/Bilevel pressure. Sleep 29: 375-380, 2006. 4

2/13/2018 CPAP Advancements: Variable Expiratory Pressure • Different manufacturers, different names, different algorithms for pressure reduction • Philips Respironics – C-Flex and A-Flex – Relative drop – C-Flex lowers pressure on exhalation, ramps back up to the prescribed pressure at inhalation – A-Flex (for Auto-CPAP) lowers pressure on exhalation, gradually increases the pressure on inhalation • Resmed – EPR (expiratory pressure relief) – 1, 2 or 3 cm drop during exhalation, increased back to prescribed pressure at inhalation • DeVilbiss – Smartflex – 1, 2 or 3 cm drop during exhalation, separate settings for adjustment during inhalation • Useful in patients with difficulty with exhalation • Equally effective as CPAP • No long term effect on adherence • No difference in cost Auto-CPAP • These units adjust the pressure throughout night rather than delivering one fixed pressure • Optimal CPAP varies during night – Changes in body, head position – Sleep state dependent changes • REM v. NREM; effects of sleep deprivation – Alcohol or sedative effects – Effects of URIs, seasonal allergies – Useful for bariatric surgery patients – Becoming standard with widespred use of HSAT 5

2/13/2018 Auto-CPAP • Noninvasively detects variations of upper airway obstruction and airflow limitation • Hypopneas • Apneas • Snoring • APAP devices automatically increase pressure until flow limitation resolved • Followed by gradual reduction in pressure until flow limitation resumed • Maximum therapeutic range: 4 to 20 cm H 2 O Auto-CPAP: Uses and Limitations •  mean pressure across the night • eg nasal complaints, nosebleeds • Automated titration: in lab or at home • Able to determine appropriate CPAP settings • Allows for fewer technologists if in lab • Inability to recognize central apneas and hypoventilation (may be changing) • More expensive than conventional CPAP • This is changing • No code for medicare reimbursement 6

2/13/2018 Comparison of CPAP with APAP • Meta-analysis of 9 RCTS (282 patients) published between 1996 – 2003 • No significant difference • Reduction in AHI • Daytime sleepiness (Epworth Sleepiness Scale) • Adherence • Significant reduction in mean pressure (2.2 cm water) with APAP • Conclusions: CPAP should remain the primary treatment option for patients with OSA Ayas et al, Sleep 27; 249-253, 2004 Bilevel Positive Airway Pressure • Several different commercially available bilevel systems • Independent regulation of inspiratory (IPAP) and expiratory (EPAP) airway pressures – Lower expiratory pressures – May be useful for patients who have difficulty with exhalation or chest pain with CPAP – Algorithms to adjust pressures are empiric • Increase EPAP or IPAP or both? • Role of IPAP and EPAP in abolishing apneas needs to be studied • Auto-Bilevel PAP systems - how do they work? – The pressure differential between IPAP and EPAP is fixed (lowest setting is generally 4 cm of water) 7

2/13/2018 Bilevel PAP Systems • Similar in weight and size to CPAP units • More expensive than CPAP units • Louder than CPAP? • Studies have not demonstrated improved adherence or efficacy compared to CPAP Reeves-Hoche et al. AJRCCM 151:443-449, 1995 • Reserved for patients who do not tolerate CPAP, especially with • Difficulties with exhalation, mask leaks • Chest pain as a result of lung hyperinflation CPAP Interfaces • Lack of controlled trials demonstrating differences in efficacy between various CPAP interfaces • Nasal interfaces − Nasal masks − Nasal pillows/direct nasal interfaces • Full face masks • Hybrid masks • Oral masks 8

2/13/2018 CPAP Interfaces • Unique mask features • Some require specific headgear • Many are a cushion and frame combo • Quick release clips • Swivel • Location of tubing connector • Additional connection port for oxygen • Gel-like material Nasal Pillow Interfaces ResMed Swift LT Respironics Nuance Gel ResMed Swift FX Innomed Nasal Aire II ResMed Swift FX For Her Bella 9

2/13/2018 Nasal Masks ResMed AirFit N20 Respironics DreamWear ResMed Mirage Activa LT Devilbiss EasyFit ResMed AirTouch F20 ResMed Swift FX Nano Full Face Masks DeVilbiss Quest ResMed Quattro FX for Her Respironics Amara View Fisher Paykel Simplus Respironics Amara ResMed AirFit F20 10

2/13/2018 Hybrid Interfaces Resmed Mirage Liberty Respironics Wisp Other Mask Interfaces Sleepweaver Fisher Paykel Oracle oral interface 11

2/13/2018 CPAP Problems and Adherence • Patient acceptability • Patient acceptability • Patient acceptability • Adherence 50 ‐ 60% • Average nightly use 4.8 hours ‐ not so bad! • Approximately 35% of patients "love" CPAP, 50% struggle with CPAP but eventually tolerate it and about 15% "hate" CPAP and never use it • We are able to track CPAP use CPAP Nasal Gel Pads Gecko Nasal Pad Boomerang Gel Pad Propellaire Gel Pad 12

2/13/2018 CPAP Interface “ Tricks ” • CPAP Mask Fitting Program • History • Dentures, Eyeglasses • Claustrophobia, Mouth Breathing • Physical Exam • Multiple trials before finding correct mask • Close follow-up important CPAP Interface “ Tricks ” • Large masks leak more than snug ones • If in doubt, start with smaller size • Dry skin can reduce mask seal • Stay away from petroleum-based moisturizers • Prescribe heated humidification • Consider nasal steroids • Clean masks with warm, soapy water • No antibacterial soaps 13

2/13/2018 Common Complaints with CPAP • Nocturnal arousals – Change mask interface • Rhinitis, nasal irritation and dryness – Treat with heated humidification ± nasal steroids • Aerophagia – Change body position or mask type • Mask and mouth leaks – Switch mask type/chin strap • Sinusitis – Add heated humidification/?Oracle Common Complaints with CPAP • Chest and back pain (lung hyperinflation) – Consider expiratory pressure relief or bilevel device • Claustrophobia – Switch from a nasal mask to nasal pillows – Desensitization • Difficulty with exhalation – Consider expiratory pressure relief or bilevel device • Severe complications – Case reports: epistaxis, meningitis and pneumocephalus (pituitary surgery) 14

2/13/2018 How To Treat CPAP Tubing Rainout? • Decrease humidification • Can be difficult in winter • Add heated tubing • Not compatible with all PAP units • Tube buddy or snugglehose to keep tubing warm to prevent condensation CPAP Tubing Insulators…or, what is a SnuggleHose? • Fabric tubing covers for CPAP hoses • Decrease condensation from humidifiers • Available in lengths up to 10 feet • SnuggleHose, Tube Buddy, Tubing Wrap, Tender Tubing 15