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Bilevel Titrations:

Bilevel Titrations:. Who, What, Why, and When Gary Hamilton, BS, RRT Clinical Specialist ResMed. Disclosures. Employed by ResMed Own stock options of ResMed. Course Objectives. By the end of this session, you should be able to : Identify when a CPAP may not be the device of choice

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Bilevel Titrations:

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  1. Bilevel Titrations: Who, What, Why, and When Gary Hamilton, BS, RRT Clinical Specialist ResMed

  2. Disclosures • Employed by ResMed • Own stock options of ResMed

  3. Course Objectives By the end of this session, you should be able to: • Identify when a CPAP may not be the device of choice • Recognize different uses of bilevel and the different disease states it is applicable to • Describe what tools are available to: • Increase tolerance and compliance • Treat the disease and/or disorder • Understand how to impact patientoutcomes by proper utilization of bilevel and its settings

  4. CPAP Intolerance- next step Bilevel Why patients fail CPAP: • CPAP is uncomfortable • Patient may feel CPAP is uncomfortable at higher pressures despite pressure relief features • COPD patients have trapped air/pressure in their lungs, which may increase their work of breathing • Patient may need higher levels of ventilatory support CPAP cannot provide

  5. Comfort vs Ventilation Why make the switch from CPAP to Bilevel? Patient Comfort: • Cannot tolerate CPAP • On a high CPAP pressure and cannot tolerate it Ventilation: • Obstructive disease • Restrictive disease • Neuromuscular disease

  6. Bilevel- Can I get it paid for OSA?

  7. Difference between Cpap and Bilevel • Comfort/compliance features • Cpap • Lower pressure • Ramp • Pressure relief (Cflex or EPR) • Waveform (sine vs square) • Bilevel • Ramp • Pressure relief (Ipap and Epap) • Waveform • Rise time • Trigger sensitivity • Cycle sensitivity • Ti control (controlling the time in inspiration or expiration) • Pressure support ( muscle unloading)

  8. Bilevel Breath Cycle Values That Tools Can Impact Inhalation Trigger Cycle Patient Flow Exhalation Delivered Pressure IPAP EPAP Pressure support ( P)

  9. What If It Is Not Just an Airway Problem? • OSA Airway problem • CompSA Airway and Ventilation problem • Cheyne-Stokes Ventilation problem • COPD Ventilation problem • Neuromuscular Ventilation problem

  10. Can I get Bilevel paid for when it not OSA?

  11. CompSA or Cheyne-Stokes Tools Available in Bilevel for Specific Diseases

  12. Tools for CompSA and/or Cheynes Stokes • ST device • Is back-up rate machine (E0471) • Fixed rate – time controlled • Not very comfortable- little synchrony • Square wave- ventilates • Servo ventilator • Is back-up rate machine (E0471) • Should be more comfortable- tries to sync with pt • Sine wave- not trying to ventilate • Very automatic (servo)

  13. CompSA and the Apneic Threshold CompSA patient on Servo CompSA patient not treated Central apneas occur

  14. Gives Support Only When Needed The ASV algorithm automatically adjusts the magnitude of pressure support breath by breath to: • Provide minimal, comfortable support during the over-breathing phase (hyperpnea) or during normal breathing • Increase support during the under-breathing phase (hypopnea or apnea) VPAP Adapt SV Patient Flow

  15. COPD Tools Available in Bilevel for Specific Diseases

  16. Tools For COPD- What are the problems? • Lung tissue destroyed • Elasticity of lungs disappearing • Poor functioning diaphragm • Reliance on accessory muscles • Air trapping

  17. Desaturations During REMin COPD Patient

  18. Tools for COPD- Problems on Bilevel • May have difficulty exhaling on CPAP • Extends their inspiratory time • Asynchrony • Increases their work of breathing • Cycling problems (getting into exhalation) • Auto-PEEP • Missed triggers • Work of breathing Delayed cycling = Decrease in Decreased expiratory time = Increase in • Expiratory time • Lung emptying

  19. Bilevel Tools- Sensitivity Adjustments Adjustable Trigger Sensitivity Adjustable Cycle Sensitivity Patient Flow Patient Flow EPAP EPAP

  20. Bilevel Tools - Time cycle inspiration Problem: Patient requires longer expiratory time (i.e. COPD) Solution: Best option – Shorten Ti Max time Additional options – Select higher cycle sensitivity, Select faster rise time

  21. Bilevel Tools – Ti Control • Rise Time • For comfort • Will affect how pressure “feels” to pt

  22. Bilevel Tools- Sine Wave Easy-Breathe Square Wave

  23. Neuromuscular and Obesity HypoventilationRestrictive Patients Tools Available in Bilevel for Specific Diseases

  24. Bilevel Tools- Asynchrony in Restrictive Patients “However, premature cycling may also have detrimental effects on patient-ventilator synchrony. Premature cycling is simply when the ventilator terminates the breath while the patient requires a long inspiratory period.” Gentile. Respir Care 2011

  25. Bilevel Tools- Restrictive Diseases An early fall in the absolute flow rates may trigger the transition to EPAP prematurely. Certain devices provide a minimum IPAP time to ensure that IPAP lasts long enough to allow delivery of an adequate tidal volume. )4.8.4 Minimum IPAP duration (if available) may be increased if the device cycles from IPAP to EPAP prematurely (eg,in restrictive chest wall disorders). Level A – Consensus Berry. J Clin Sleep Med 2010

  26. Bilevel Tools- Increasing the Inspiratory Time

  27. Bilevel Tools- When You Need to Ventilate PS 5 PS 10 PS 15 PS 20

  28. Bilevel Tools for Ventilation-VAPS • iVAPS – (ResMed) • Intelligent Volume Assured Pressure Support • Can assure Tidal Volume while the patient is sleeping • Is Servo Controlled AVAPS (Philips) Average Volume Assured Pressure Support

  29. The iVAPS Algorithm: Example Alveolar ventilation drops patient moves into REM sleep iVAPS rapidly increases PS until target Va is reached REM Onset Ventilation [– AV–MV –TargetAV ] Pt. Flow PS SpO2

  30. Conclusion • CPAP may not be the device of choice for specific patients • Diagnoses will be a big determinant of what PAP machine will be appropriate for the patient • Goals of therapy will tell you what machine you should use • Stabilize airway • Hypoventilate the patient • Ventilate the patient • Bilevel offers a greater amount of tools to: • Increase comfort of patient • Increase compliance of patient • Increase the chances of the therapy goals being met • Tools available • Wave forms • Time cycling • Sensitivity adjustments • Servo algorithms

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