Tri-level Positive Airway pressure BY AHMAD YOUNES PROFESSOR OF THORACIC MEDICINE

1. Tri-level Positive Airway pressure BYAHMAD YOUNESPROFESSOR OF THORACIC MEDICINE Mansoura Faculty of Medicine

2. TRI-Level has three pressure levels: • IPAP = (pressure during inspiration); • EPAP = (pressure during expiration); • EEPAP = (pressure at the end of expiration). • The pressure support here is the difference between IPAP and EPAP. • When the patient expires, the pressure is initially reduced to the EPAP in order to support exhalation maximally. • In the further course of the expiration, the pressure is raised across a flat increase to the pressure at the end of the expiration (EEPAP) for an optimal splint of the upper airways.

3. The difference between IPAP and EPAP defines the tidal volume.

4. Bi-level versus tri-level PAP • Due to the additional reduction of the EPAP below the EEPAP, a lower average pressure is required than with the BI-Level pressure variant maintaining the same therapeutic efficacy. • The Tri-Level pressure variant additionally provides the option of setting the pressure at the end of exhalation (EEPAP) separately. If obstructions occur, the phase at the end of exhalation is particularly critical. Obstructions can be prevented by the EEPAP.

5. TRI-Level pressure • This allows IPAP and EPAP to be selected up to 4 hPa lower than for an equally efficient therapy using the Bi-Level option. • The TRI-Level pressure variant allows a particularly comfortable breathing sensation and lower therapy pressures with comparable therapeutic efficacy.

6. Auto-Tri-Level • The auto-TriLevel principleby Weinmann combines two proven types of therapy – auto-CPAP and BiLevel – into a synthesis that offers the most therapy effectiveness. Your benefits with these products: • Therapeutically effective maximum and mean pressures that are lower than BiLevel with the same tidal volume for fewer side effects such as leakage. • It‘s like a new titration every day – adjusts to patient‘s high variability . • Effortless titration and monitoring .

7. Auto Tri-Level • With the auto Tri-Level pressure variant, the therapy device continuously adapts the IPAP, EPAP and EEPAP pressure levels to the patient’s requirements. • The auto-Tri-Level principle by Weinmann combines two proven types of therapy – auto-CPAP and Bi-Level – into a synthesis that offers the most therapy effectiveness. • Differentiation into obstructive and central events is possible only if you set a pressure difference between IPAP and EPAP of at least 6 hPa. • If rising airway resistance is detected, the therapy device raises the EEPAP within adjustable limits EEPAP min and EEPAP max. If there are no obstructions, the therapy device gradually decreases EEPAP again.

8. Auto Tri-Level • You can set the pressure difference (PDIFF) between IPAP and EPAP depending on the requirement for ventilation support eg. Prisma ST30 with volume compensation. • The therapy device is also able to adapt the pressure difference up to PDIFF max automatically: 1- in intermittent phases with reduced respiration from a duration of about 2 minutes, the pressure difference increases to a maximum of PDIFF max. 2- with normal respiration, the pressure difference gradually drops back to the minimum PDIFF. • As EEPAP rises, the device ensures there is a pressure difference which allows a pleasant feeling when breathing.

9. Auto Tri-Level • During a timed-breath phase, the therapy device increases the pressure difference for each breath to at least 6 hPa and to a maximum of PDIFF max. • To ventilate a patient with permanent hypoventilation at least during the night, you need to titrate PDIFF to an adequate value eg. Prisma 30 with volume compensation. • Reduce PDIFF max if the patient is awoken by excessive pressure differences or reacts with reflexive glottal occlusions. • With this mode variant, it is possible to differentiate between obstructive and central apneas. This enables the therapy device to react with the correct pressure modifications.

10. Auto Tri-Level • Patient respiration and adaptation of pressure level is assessed cumulatively over periods of approximately 2 minutes’ duration. In certain cases, the therapy device reacts immediately • With the combination of the auto Tri-Level principle and the automatic trigger WM trak, this device delivers the greatest effectiveness, reliability and breathing comfort – simply the fastest therapy results. • Particularly for cases of complicated SDB, SOMNOvent auto-S, convinces with its intelligent combination of automatic Bi-Level S therapy and auto-CPAP.

11. SOMNOvent CR • Respiratory disturbances are detected based on the analysis of actual minute ventilation, flow profile and snoring. • The minute ventilation is compared with the average minute ventilation in a moving window • The treatment mode is called anticyclic modulated ventilation (ACMV). • Device which combines automatic CPAP and adaptive servo-ventilation proved to effectively suppress all types of upper airway obstructions, such as snoring, obstructive apneas and hypopneas. Moreover, central respiratory disturbances including periodic breathing were deleted , and sleep quality improved. The results did not differ whether or not patients suffered from cardiovascular diseases.

12. SOMNOvent CR • It automatically adapts the positive airway pressure at the end of the expiration, as this period of the breathing cycle is critical for the opening of the upper airways. This component represents the automatic CPAP mode which has proven effective in the treatment of OSAS. In periods of normal breathing the expiratory pressure is relieved. • The device applies varying tidal volumes which are defined by the difference between IPAP and EPAP (pressure level in the early expiration period). Thus, periodic breathing is overcome by increasing the tidal volume during central hypopneas and decreasing it during hyperventilation.

13. SOMNOvent CR • The end expiratory positive airway pressure (EEPAP) varies automatically due to the level of the upper airway obstruction • Mandatory breaths are applied if there is complete cessation of the airflow due to central apneas. The back-up frequency has been designed to avoid inducing hypoventilation.

14. Prisma AcSV • In the AcSV mode, ventilation is performed following the anti-cyclic servo-ventilation method in combination with automatic pressure adjustment for treating obstructions in the upper airways. • There are two possible pressure variants in the AcSV mode. 1-TRI-Level AcSV 2-BI-Level AcSV

15. 1-TRI-Level AcSV • TRI-Level has three pressure levels: IPAP , EPAP and EEPAP. • The pressure support here is the difference between IPAP and EPAP. This pressure support is continually adjusted depending on the patient's ventilation needs (principle of adaptive servo-ventilation). • When the patient expires, the pressure is initially reduced to the EPAP in order to support exhalation maximally. In the further course of the expiration, the pressure is raised across a flat increase to the pressure at the end of the expiration (EEPAP) for an optimal splint of the upper airways. • Due to the additional reduction of the EPAP below the EEPAP, a lower average pressure is required than with the BI-Level pressure variant maintaining the same therapeutic efficacy.

16. 2-BI-Level AcSV • The classic BI-Level pressure profile includes a constant pressure level during expiration for splinting the upper airways (EPAP = EEPAP). • With the BI-Level pressure variant, the IPAP (pressure during inspiration) and the EPAP (pressure during expiration) are attained during one breathing cycle. • The pressure support PDIFF here is the difference between IPAP and EPAP (=EEPAP). • This pressure support is continually adjusted depending on the patient's ventilation needs (principle of adaptive servo-ventilation). • The EPAP is the pressure which keeps the upper airways open and thus prevents obstructions.