Transcript Home NIV
Home NIV: Aims and Targets Dan Adler, St.Gallen 2012 Aims of home NIV are: To improve QoL and symptoms related to hypercapnia (questionnaires) To improve nocturnal SpO2 and correct nocturnal hypoventilation (nocturnal SpO2/PtCO2) To ensure that leaks are minimal, and estimated VE is adequate (What information can we get from built-in softwares? Can we trust this information?) To improve quality of sleep (Do we really need PSG during NIV? Is there a surrogate marker for inspiratory effort and for cortical arousal?) Why should we monitor NIV during sleep? Patients on HMV admitted (yearly) to monitor NIV. 20 OHS patients in stable condition admitted to monitor NIV 55% with PVA 40% with periodic breathing under NIV 48 patients admitted for a scheduled control in a phase of clinical stability. 41/53 patients presented any abnormality (leaks, desaturation dips or continuous desaturation) No IE during day NIV trial/ IE very frequent finding during sleep 30 COPD patients in stable condition (no overlap syndrome), ~1/3 patients complained of severe dyspnea immediately after interruption of NIV in the morning. PVA found in all patients using PSG and subjective improvement of sleep quality after setting NIV with a predefined approach Rabec, ERJ 2009; Guo Chest 2007; Fanfulla Respiratory Medicine 2007; Adler Sleep and Breathing 2011 Presentation outline: Basic Monitoring PG/PSG SRI Questionnaire+ “Geneva” Questionnaire SpO2/PtCO2 monitoring Built-in software Respiratory events classification Setting NIV using PSG When should you organize a PG/PSG under NIV? New Tools: PTT (pulse transit time) PWA (pulse wave amplitude) SRI: The Severe Respiratory Insufficiency Questionnaire SRI questionnaire: Disease specific measure of health-related quality of life in patients receiving HMV. Windisch W, J Clin Epidemiol 2003;56:752 English Version French Version: www.isplf.org 8 domains: respiratory complaints, social functioning, sleep, anxiety, social relationships, well-being and physical functioning+ SRI summary scale Windisch, Breath 2011 NIV has a major impact on HRQL N= 137 patients: COPD, restrictive disease, OHS, NMD SRI tot SF36 physical SF36 mental SRI is more sensitive than SF36 to detect HRQL changes in this specific population Windisch, ERJ 2008 SRI too long for routine clinical practice? Windisch, ERJ 2008 If NIV is intended to improve sleep, we should aim at maximal comfort during the night 8 item VAS assessing sleep, comfort, perception of synchronisation, airflow, leaks, noise. Janssens, Respir Med, 2008; Adler Sleep and Breathing 2011 Basic Monitoring: SpO2 monitoring is certainly not enough during NIV Desaturation drops Sustained desaturation > 10min Both patterns are non-specific for the underlying mechanism leading to desaturation Janssens, Thorax 2010 Poor correlation between diurnal PaCO2 and mean nocturnal PtCO2 Sn= 3/(3+18)= 14.3% Paiva, ICM 2009 Normal values of nocturnal oximetry do not allow to exclude nocturnal hypoventilation Nocturnal SpO2 is not a surrogate marker of PCO2 CO2 60 CO2 35 2012 JIVD abstracts: Lamia and Muir, Niguyen-Baranoff and Rabec Transcutaneous CO2 monitoring can replace arterial PCO2 during NIV 3 modern PtCO2 monitor were compared After correction of the technical drift Storre, Respir Med, 2011 Transcutaneous CO2 monitoring can replace arterial PCO2 during NIV Gazométrie Gazométrie Gazométrie Gazométrie PtCO2 adequately reflects PaCO2 during NIV Advantages: Non-invasive No sleep disruption Continuous Storre, Respir Med, 2011 Built-in Software: What can we trust? Many recent home ventilators have built-in software which allows monitoring of items such as: Compliance Leaks Vt, MV, RR % of triggered cycles % of spontaneous expiration ( cycling) AHI Pasquina, Respiration 2012 Built-in Software + Monitoring system Normal Leaks Hypoventilation? Residual obstructive events? PB ? Rabec. ERJ 2009 Built-in software: Validation of leaks and MV on a bench test R=0.947 P<0.001 R=0.959 P<0.0001 Bias: 0.7 L/min, not relevent! Rabec, ERJ 2009 Built-in software: Leaks in a non hermetic system are intentional. What are we talking about? Total leak mesured Total leak mesured Leak above “intentional ones” Contal, Chest 2012 Built-in software: Software estimation vs mesured leaks on a bench test. . “All ventilators are equal but some ventilators are more equal than others…” Only 3 ventilators had narrow limits of concordance! Contal, Chest 2012 Built-in software: Vt software estimation vs mesured Vt For most ventilators,Vt is underestimated Underestimation is worst with higher pressures Vt estimation is little affected by leaks Contal, Chest 2012 Built-in software: Is set pressure reliable? A= Effective PT product S= Surface of ideal PTP A/S ratio A Battisti, Chest 2005 Wide differences between pressurization capatilities in home ventilators Battisti, Chest 2005 Low % of spontaneous inspirations in very severe COPD Ineffective efforts? RR 14/ min Neural RR 24/min Correction of IE using PSG to set NIV Neural RR= Effective RR Adler, Sleep and breathing 2011 Built-in Software: Summary Daily/Weekly/etc… use -- Respiratory rate Accurate Leaks Accurate only in some ventilators Vt Underestimation of Vt in most ventilators Pressure Wide variations in pressurization capabilities. Knowledge of the technical performance of your device is essential! http://www.antadir.com/fr/professionnel AHI No validation. In progress… % Triggered cycles No formal validation. Usefull in clinical pratice (controlled vs spontaneous ventilation). % of spontaneous expiration No formal validation. The final touch… Janssens, Thorax 2010 Leaks Gonzalez-Bermejo, Thorax 2010 Upper airways closure “central” “Obstructive” Gonzalez-Bermejo, Thorax 2010 PB under NIV Gonzalez-Bermejo, Thorax 2010 Use PSG+SpO2/PtCO2 to adapt NIV settings Type d’asynchronies identifiées Modification du paramétrage proposée Apnées ou hypopnées obstructives Augmentation de l’EPAP ou si mauvaise tolérance augmentation de la FR Hypoventilation Augmentation de l’aide inspiratoire et/ou augmentation de la FR back-up Respiration périodique Baisse de l’aide inspiratoire si normocapnie (ASV?) ou augmentation de la FR si hypercapnie Auto-déclenchement Corriger la fuite et éventuelle modification du trigger inspiratoire Double-déclenchement Augmentation du temps inspiratoire ou de l’aide inspiratoire Effort non-récompensé Correction de l’air-trapping: diminution de l’aide inspiratoire, augmentation du trigger expiratoire et éventuellement augmentation de la PEEP ou high BURR Pente de pressuriation concave Augmentation de la pente de pressurisation Adler, Sleep and Breathing 2011 New tools for NIV monitoring at home? PTT: Pulse Transit Time PWA: Pulse Wave Amplitude Basic knowledge: PTT changes with intrathoracic pressure swings Basic knowledge: PWA reduction is a surrogate marker of cortical arousal in healthy subjects and in OSA PTT: Smith ,Thorax, 1999 PWA: Delessert, Sleep 2010 Obstructive or central event? Luo, Chest 2009 PTT as a marker of inspiratory effort during NIV Contal , ERJ 2012 PTT as effective as Peso for classification of respiratory events during NIV Contal, ERJ 2012 Pulse Wave Amplitude Reduction: A surrogate marker of EEG-MA during NIV? EOG A B EEG Chin Pressure Flow Thx & Abd mvt SpO2 PWA Adler, submitted PWA Sn and PPV to detect EEG-MA related to respiratory events during NIV 2474 respiratory events under NIV were analysed in 10 patients. Sensitivity 89.1% and PPV 87% to detect EEG-arousal related to a respiratory event under NIV Adler, submitted Home NIV: Aims and Targets HRQOL. SRI questionnaire Nocturnal PtCO2 monitoring is mandatory. Diurnal ABG is not a surrogate marker Nocturnal SpO2 is not a good surrogate marker Trust your built-in software only if it has been independently validated. Use of PG/PSG only in special situations. In this case, take advantage of the sleep study to adapt the NIV settings while the patient is asleep. New ambulatory tools may be available in a near future. PWA is a surrogate marker of arousal related to respiratory events under NIV PTT for classification between central and obstructive respiratory events under NIV