1 / 28

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

Guidelines to CPAP & Bi-Level device pressure titration in adults. Belgian Society of Sleep Technologists. 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.

ronna
Télécharger la présentation

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

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Guidelines to CPAP & Bi-Level device pressure titration in adults Belgian Society of Sleep Technologists Jo Tiete - CHL

  2. 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. Jo Tiete - CHL

  3. 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. Jo Tiete - CHL

  4. 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. Jo Tiete - CHL

  5. Split Night procedure • If documented > 30 apneas with desats >= 4% from baseline after 3 hours after LOFF.  Initiate CPAP ! Jo Tiete - CHL

  6. Split Night procedure • 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 ! Jo Tiete - CHL

  7. 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. Jo Tiete - CHL

  8. 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). Jo Tiete - CHL

  9. 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. Jo Tiete - CHL

  10. 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. Jo Tiete - CHL

  11. 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. Jo Tiete - CHL

  12. 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. Jo Tiete - CHL

  13. 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. Jo Tiete - CHL

  14. 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. Jo Tiete - CHL

  15. 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. Jo Tiete - CHL

  16. 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 %. Jo Tiete - CHL

  17. 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). Jo Tiete - CHL

  18. 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. Jo Tiete - CHL

  19. 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). Jo Tiete - CHL

  20. 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 !!! Jo Tiete - CHL

  21. 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-CPAPSound algorithm don’t detect any abnormallity! Jo Tiete - CHL

  22. 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). Jo Tiete - CHL

  23. 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. Jo Tiete - CHL

  24. 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. Jo Tiete - CHL

  25. 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 !!! Jo Tiete - CHL

  26. 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 ... Jo Tiete - CHL

  27. 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!!! Jo Tiete - CHL

  28. Thank you for your attention. tiete.jo@chl.lu

More Related