Transcript AVAPS & AVAPS-AEAuto-titration Modes of Non

AVAPS & AVAPS-AE
Auto-titration Modes of Non-invasive
Ventilation Preliminary Setting Guidelines
Nicholas Dawson, RRT and Bill Moller, RPSGT, RST
Philips Home Health
Philips Home Health , NIcholas Dawson
Educational Objectives
What we will cover today:
• What is AVAPS-AE?
• AVAPS mode; Why do we need it?
• AVAPS & AVAPS-AE Modes; Settings and Range
• AVAPS-AE Suggested settings guidelines in OHS and COPD-OSA
• Summary/Questions
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AVAPS-AE
AVAPS-AE is a auto-titration mode of noninvasive ventilation designed to
treat respiratory insufficiency patients (OHS, COPD and NMD) in the
hospital and homecare environments
• Proven performance of AVAPS
– Maintains targeted Tidal volume
• Auto EPAP
– Maintains patent upper airway at comfortable pressure
• Auto backup rate
– Applies an auto backup rate near a patient’s resting rate
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AVAPS; What is it?
Average Volume Assured Pressure Support
• As name implies, it is simply volume targeted pressure support.
• Auto titrating mode that responds in Inspiratory pressures to changes in
thoracic dynamics to ensure stable tidal volume delivery.
• Considered a “Hybrid” mode since it is both Pressure and Volume
oriented mode of ventilation
• Also used as an ‘adjunct’ or added to other modes of ventilation such as
“S” mode, “S/T” mode or even PC (Pressure Control) mode
• Allows clinician to set operating pressure limits for safety or diagnostic
purposes
• Available in R.A.D. platform, but more fully developed in Trilogy
Ventilator
• Also recently developed in new Omni-Lab Advanced titration device.
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AVAPS: proven effective
• Automatically titrates pressure support
– Changes in body position
– Sleep stage
– Changes in respiratory mechanics
• Delivers average tidal volume
– Throughout course of the night
– Long-term progression = protects/defends resting lung volume.
• AVAPS produces results comparable to sleep lab titration of PS1
– CO2 reduction
– Health-related quality of life
– Sleep quality
1Murphy,
PBThorax thoraxjnl-2011-201081: Published Online First: 1 March 2012 doi:10.1136/thoraxjnl-2011-201081
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AVAPS-AE: Who it treats
• AVAPS-AE is used for patients with complex breathing disorders with or
without OSA component who suffer from Minute ventilation instability.
Etiology can stem from Hypoventilation syndromes to airflow limitation
related to obstructive pulmonary disease. Patients with dynamic I:E
ratios and chronic parenchymal disease with limited reserve lung
volumes can benefit from the auto rate feature alone.
• Many of these patients primarily have COPD and some Hx of Chronic
Respiratory Failure who may be underserved by traditional sleep
therapy modes & methods.
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Who can benefit from AVAPS-AE?
• Neuromuscular disease
• Restrictive thoracic disorders
• COPD with Chronic respiratory failure
• OHS with chronic hypercapnea
• Pulmonary patients that fail to respond to traditional RAD device
therapy
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AVAPS-AE: Adds Auto EPAP option
• Auto EPAP provides airway patency
– Designed for NIV use only
– Patient benefit: lower, more comfortable EPAP pressure
• AVAPS-AE and patient overlap
– ?? ~ 30% of COPD patients have OSA1
– 90% of OHS patients have OSA2
• AVAPS-AE: 1st NIV therapy with Auto EPAP
designed for respiratory insufficiency and respiratory failure patients
1Jelic
International Journal of COPD 2008:3(2)269-275
Chest 2007:131;1624-1626
2Mokhlesi.
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AVAPS-AE: How to use it
• Start with tidal volume selection:
– 8ml/kg IDEAL bw Suggest a range +/- 150mls
• Assess need for EPAP: select a range to monitor or manually titrate
• Choose Pressure support range: (2 methods) new user/existing user
– New user: set Pressure support levels lower e.g. 5/15
– Existing user: take existing Rx IPAP…+10 & -10
• Set back up rate if desired: set to auto for all COPD
• Set comfort settings: Ramp- Rise time- AVAPSrate
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AVAPS-AE: Auto EPAP proactive analysis
Theory of Operation
Device
Pressure
P search
opt
Ptherap
y
Pcri
t
search
Upper
Airway
Resistanc
e
Illustration courtesy of Krames Medical Illustration.
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AVAPS-AE: Auto EPAP proactive analysis
Popt – Optimal Pressure Search
P
(High Pressure Search)
Pressure
opt
EPAP
Popt
P
ther
P
P therapy
crit
P therapy
Critical Pressure Searches
Resistance
EPAP
(Low Pressure Search)
P
therapy
P therapy
Pcrit
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Comparison of Auto EPAP methods
Current PRI Auto EPAP/CPAP
Peak
Flatness
Shape
Roundness
Pressure
Flow
AVAPS-AE
Forced oscillation technique (FOT) at 5 Hz,
1 cm amplitude during EPAP
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Benefits of FOT
• FOT may improve detection of obstructed airways at higher pressure
support levels
– Not affected by high levels of pressure support
– FOT measurements taken at end exhalation (10 brea
Increase in
EPAP by 1
cm H2O s
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FOT – Flow resulting from pressure
FOT signal
Resulting flow
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FOT – Patent vs. obstructed airway
• .
Patent/Normal airway
Resulting flow (low resistance)
Obstructed airway
Resulting flow (higher resistance)
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AVAPS-AE
Maintaining tidal volume and airway patency
PS max
EPAP max
PS min
IPAP
EPAP min
EPAP
Target Vt
Resistance
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Auto
AutoBack-up
Backup rate
Rate
Auto backup rate combined with the tidal volume assurance of AVAPS
provides a minimum level of ventilation
• Auto backup rate is near resting rate
• Comfortable assistance when needed
• No manual adjustments (auto-default
setting)
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Auto Backup rate
Moving breath rate
Bpm
Targeted auto backup rate is
2 bpm below avg.
spontaneous rate
Calculated
Target auto
spontaneous
backup rate
rate
Minimum auto
backup rate
10
Spontaneous breaths
Time
breaths
50 spontaneous
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Auto backup rate
Moving breath rate
Bpm
• The
is reduced
triggers
Thebuffer
auto backup
rateby
is timed
buffered
by
•spontaneous
The patienttriggers
will be to
guided
back
to
the
promote synchrony
targeted backup
rate
with the
device
Target auto
backup rate
Auto backup rate
buffer zone
10
Timed Breaths
Spontaneous Breaths
Time
(Night time session)
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Auto Backup rate: Patient comfort features
• Comfort feature intent: Minimizes patient/device asynchrony
– Rate will not exceed patient’s initial resting
spontaneous rate
– Machine breath delayed if patient is still exhaling
– AVAPS-AE allows patient to terminate a machine delivered breath
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AVAPS-AE suggested settings
OHS*
COPD – OSA*
8 -10 ml/Kg of ideal
bodyweight
8 ml/Kg of ideal
bodyweight
35 cmH2O
30 cmH20
PS Max
19- 35 cmH2O
30 cmH2O
PS Min
14 -19 cmH2O
12 cmH2O
EPAP Max
14 cmH20
14 cm H2O
EPAP Min
4 cmH2O
4 cm H2O
Breath Rate
Auto
Auto
AVAPS Rate
2
N/A
Vt Target
Max P
* AVAPS-AE protocol Dr. N. Hart, Dr. P. Murphy, Lane Fox Respiratory unit, St. Thomas’ Hospital London UK
* AVAPS-AE Multi Center Trial protocol l,Prof Jean François MUIR, France
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AVAPS-AE: Comfort Settings
• Ramp- Sets pressure support back to minimum level setting. Use if
patient sensitive to initial pressures at time of sleep. Can be turned
“OFF” if not desired
• Rise time: setting 1-6 default is 3..lower toward 1 for flow starved
patients, raise toward 6 for NMD
• AVAPS rate: sets speed of response for pressure support changes
while chasing tidal volume
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AVAPS-AE: What to monitor…
• AVAPS-AE will titrate pressure support based upon the tidal volume
target set and the patients dynamic lung compliance or ability to
generate volumes at the given inspiratory pressure support level.
• EPAP can be monitored during ventilation
• Inspiratory flowrates can be monitored for patients who have disease
states that may require variability in inspiratory flow rates.
• Respiratory rate can be set fixed BPM and monitored for flow
challenges with changing I:E ratios or can be set to “auto” and nocturnal
respiratory rate can be monitored and compared to minute ventilation
stability.
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AVAPS-AE
• Proven performance of AVAPS
– Confidence that tidal volume targets are being met
• Auto EPAP
– Auto adjusting EPAP to meet changing patient needs
– Maintains a patent airway
• Auto backup rate
– Maintains a breath rate designed for patient comfort (easy to use)
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