Transcript PAP Titration

PAP Titration
A Physician’s perspective
Navin K Jain, MD
CONFLICT OF INTEREST
None to disclose
OBJECTIVES
• Learn PAP titration protocols
• Learn current practices in PAP titration
• Understand a “good titration
PAP Titration : Survey March 2014
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5 Sleep Disorders Centers
20 technicians (1-9 studies)
84 PAP titrations
Baseline AHI (5-137/hour)
– AHI <10 - 15
– AHI >60 - 16
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PAP
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Fixed pressure CPAP – 34
Auto Titrating CPAP – 35
Fixed Pressure BPAP – 12
Auto Titrating BPAP – 3
ASV – 3
EPR - 31
Masks
– Nasal – 12
– Nasal Pillows – 9
– Full Face – 63
Modes of PAP Titration
• CPAP - Titrate positive pressure throughout recording to determine
single fixed pressure that will eliminate respiratory disturbances
during subsequent nightly usage at home
• BPAP - device may be used when a patient demonstrates difficulty
acclimating to high airway pressure during the expiration phase of
breathing.
– BPAP allows the sleep technologist to separately increase inspiratory
or expiratory pressures during the polysomnography to arrive at two
pressures for subsequent use in the home.
• Servoventilation device (SV) - a computer-controlled valve to adjust
airway pressure breath by breath to maintain steady ventilation.
– Heplful for patients with periodic breathing abnormalities such as
Cheyne Stokes respiration and central apnea seen in heart failure or
patients with complex sleep apnea
Goals of PAP Titration
• Keep the upper airway open (airway
management).
• Stabilize breathing patterns by monitoring the
patient’s response to therapy.
• Adjust user-set parameters as needed for optimal
therapy efficacy and adherence.
The goals should be individualized to
meet the needs of each patient.
Patient Types for PAP Titration
PAP Titration Study
Manual PAP titration during attended PSG is current
AASM standard for :
• Select optimal therapeutic pressure
• Must be administered by well- trained sleep
technologist
• PAP education
• Hands on equipment demonstration
• Careful mask fitting and acclimation to device prior to
titration
• Art and not a cookbook – using clinician’s experience
and judgment
Optimal Pressure
• effective pressure that eliminates SDB events
without creating any untoward pressure
related side effects
– Should be effective in all positions and stages of
sleep
• Lower than Optimal Pressures
– Mouth breathing
– claustrophobia
• Higher than Optimal Pressure
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Air leaks
Mouth breathing
Worsening of nasal congestion
Rhinorrhea
Exacerbating central apnea
Poor tolerance to PAP
• Factors influencing Optimal Pressure
– sleep position,
– Rapid eye movement (REM) sleep,
– sleep duration
– degree of respiratory effort
– the length of the soft palate.
• Factors not affecting optimal pressure
– Severity of AHI
– BMI
Optimal Titration
• The Respiratory Disturbance Index (RDI) is < 5
per hour for a period of at least 15 minutes at
the selected pressure and within the
manufacturer’s acceptable leak limit.
• The SpO2 is above 90% at the selected
pressure.
• Supine REM sleep at the selected pressure is
not continually interrupted by spontaneous
arousals or awakenings.
Good Titration
• The Respiratory Disturbance Index (RDI) is < 10
per hour (or is reduced by 50% if the baseline RDI
was <15) for a period of at least 15 minutes at the
selected pressure and within the manufacturer’s
acceptable leak limit.
• The SpO2 is above 90% at the selected pressure.
• Supine REM sleep at the selected pressure is not
continually interrupted by spontaneous arousals
or awakenings.
Adequate Titration
• The Respiratory Disturbance Index (RDI) is
NOT < 10 per hour, but the RDI is reduced by
75% from baseline.
• Criteria for optimal or good titration is met
but you did NOT get a sample of supine REM
at the selected pressure.
Respiratory Parameters during PAP
Titration
• Airflow sensor – airflow signal generated by PAP
device (because pressure transducer under nares
with mask leads to poor mask seal) – flow signal
• Respiratory effort sensor – RIP belt
• Sampling Rate – minimum 25 Hz; prefer 100 Hz
(to assess artifacts and cardiogenic oscillations)
• Filter settings : LFF 0.1 Hz, HFF 15 Hz.
• Most machines provide a signal reflecting an
estimate of leak
Hypopnea during PAP Titration
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Same definition as during PSG
Different signal source
Oxygen desaturation criteria – 3%, 4% or none
Associated arousal
Educational Program
• Adequate PAP education, hands-on demonstration,
careful mask fitting, and acclimatization
– Done prior to a diagnostic study with high clinical
suspicion of OSA
• Mask fitting goals
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Maximizing comfort
Compensation for nasal obstruction
Minimizing leak
Mask interface – nasal, nasal pillow, full face/ oro-nasal
Accessories – chin strap, heated humidifier
• Acclimatization
– Wearing interface with pressure on prior to lights off
PAP Titration (AASM protocol)
• Start patient on 5 cm H2O (may start higher pressure for higher BMI
or for re-titration studies)
• Increase pressure until respiratory events are eliminated : apneas,
hypopneas, RERAs, and snoring
– Increase pressure at least 1cm H2O, no sooner than ever 5 minutes
(for at least 2 obstructive apneas, or at least 3 hypopneas, or at least 5
RERAs, or at least 3 minutes of loud or unambiguous snoring)
– Exploration pressure – may increase 2-5 cm to overcome upper airway
resistance – to normalize shape of inspiratory flow limitation
– Down Titration – not necessary
• If patient still hypoxic after respiratory events are resolved, do not
increase pressure
• Maximum CPAP pressure – 15 cm H2O
PAP Titration – AASM protocol
Bi-Level PAP
• Patient intolerant or uncomfortable of high
pressure on CPAP
• Continued obstructive events at 15 cm H2O CPAP
during titration study
• Not more effective or superior to CPAP
TITRATION
• Starting pressure 8/4; maximum IPAP – 30 cm
H2O; minimum difference 4; maximum difference
10
Expiratory Pressure Relief
• 20% using CPAP complaints of sensation of
exhaling against a high pressure
• Pressure reduction during expiration (EPR, Cflex) on pressure relief CPAP MAY be more
comfortable for patients requiring higher CPAP
pressure
Adaptive Servo-Ventilation
• Uses an algorithm that varied Pressure
Support to achieve 90% of measured long
term minute ventilation
• Used in management of Central Sleep Apnea,
and Complex Sleep Apnea
• Uses negative feedback loop
Re-Titration Study
• How often – in stable patient
• Things to do before Re-Titration Study
– Clinical evaluation – sleep history
– Mask fitting and Leak
– Review of PAP download
– Auto PAP Trial and adjustment of pressure based
on data
PAP NAP Study
• Previous night sleep restriction
– 1 – 3 hours of sleep
– No napping prior to PAP-NAP
• Mask fitting, desensitization
– Determine best mask for patient, Full Face vs. Nasal vs. Direct Nasal Pillow
– Mask fitting for comfort, lack of leak, lack of pressure points
• Pressure desensitization
• PAP Therapy Hookup
– channel hookup is used, including pressure transducer, snore, PAP therapy
pressure, mask leak, respiratory effort belts, heart rate, pulse oximetry, video
monitoring, and body position S
• PAP Therapy Testing
– 60 to 120 minutes spent in bed with PAP device in place
– Goal is to help patient adapt to PAP therapy sensation
– Pressure changes for comfort, to improve airflow signal, to increase
physiologic exposure, but not to titrate
PAP Titration
Deciding factor for therapy
• Patient – AHI, BMI, gender
• Technician
• Sleep Disorders Center
• Reviewing Physician
Baseline AHI & PAP Titrations
• What AHI one should not titrate?
• In survey of SDC – 15/84 – AHI <10
• Who should get Split Night studies – 16/84
had AHI >60
EPR
• 31/84
• Technicians
– 1/9 (minimum)
– 4/4 (maximum)
• SDC
– 2/18
– 10/11
• Should everyone have EPR
• What Level : 1,2 or 3
PAP Masks
• Full Face – 63
– Quattro – 43
– Simplus – 17
– Others - 3
• Technicians (Full Face mask)
– 8/9 (maximum)
– 1/4 (minimum)
• SDC
– 16/18 (maximum)
– 6/11 (minimum)
• Nasal Pillow- 9 (one technician 3/4)
• Nasal- 12
PAP Mode of therapy
• Fixed Pressure
– 37/ 42 (maximum)
– 2/18 (minimum)
• Auto Titrating
– 3/42 (minimum)
– 16/18 (maximum)
PAP Mode of therapy
• CPAP
– 40/42 Maximum
– 11/19 Minimum
• Bilevel
– 1/42 minimum (1/9 for technician when >5
studies)
– 8/19 maximum (one technician 5/9)
PAP Titration Study
Should we abandon it?