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Advanced Titration Opportunities for the Sleep Lab

Advanced Titration Opportunities for the Sleep Lab. Kevin C. R ush BS, BA, RRT, RPSGT. Disclaimer. I am a full-time paid employee of Philips Respironics. Objectives. Discuss the “state” of the in-lab sleep center. Identify diagnoses that are candidates for advanced titrations.

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Advanced Titration Opportunities for the Sleep Lab

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  1. Advanced Titration Opportunities for the Sleep Lab Kevin C. Rush BS, BA, RRT, RPSGT

  2. Disclaimer I am a full-time paid employee of Philips Respironics.

  3. Objectives Discuss the “state” of the in-lab sleep center. Identify diagnoses that are candidates for advanced titrations. Differentiate complex sleep disorders from patients suffering from respiratory failure. Examine the clinical challenges around ASV. Can we do something about chronic respiratory failure in the sleep lab? Explore best practices in titrating advanced studies. Review reimbursement challenges around providing advanced equipment in the home.

  4. State of the Union in the in-lab Sleep Center Influx of home sleep testing in many cases dominating over 50% of the testing in sleep centers. More and more patients go “straight to auto CPAP” without being able to have their titration in the lab. Decreased reimbursement for in-lab tests, many cases more than a 50% cut. Increased labor to “fight” on behalf of patients to bring them into the lab for medically necessary tests. Unbearable regulations from insurance payers and hospital policies to diagnose patients and maintain their therapy outcomes. Increased volume of patients needing help and care, many time creating non-revenue generating visits.

  5. Bottom line, you have to do more with less!!!

  6. Does your life remind you of this?

  7. “If you aren’t in over your head, how do you know how tall you are?” T.S. Elliot

  8. It’s a great day to be a sleep tech!!!!!!!

  9. Challenge # 1 My patient is needing high CPAP pressures or is uncomfortable with the CPAP therapy.

  10. Pathology of the Sleep Lab/Respiratory Department Obesity Hypo-Ventilation Neuro- Muscular Disorders OSA Central/ Periodic Breathing COPD Restrictive Thoracic Disorder Complex Sleep Apnea

  11. Thechallenge… • After the end of the first year, 371 patients withOSA*: • 34%usedtheirCPAPonanightlybasis(regularusers) • 32.3% had not used it atall • 33.7% had used it onlyintermittently • Four-yearfollow-uprevealedthatabouttwothirdsoftheOSA patientsdidnotusetheCPAPmachine *Sarrell, E.M.Treatment compliance with continuous positive airway pressure device among adults with obstructivesleepapnea(OSA):howmanyadheretotreatment?.Harefuah.2013Mar;152(3):140-4,184,183. **2016Philipsblinded,incentivizedsurveyofU.S.SleepPhysicians(n=180)

  12. Long-term CPAPadherence • Acomprehensive systematic literature review over 20 years* • 82 papers met study inclusion/exclusioncriteria. • TheoverallCPAPnon-adherenceratebasedona • 7 hours per night sleep time frame adherence was 34.1%. • No significant improvement over the timeframe. • Behavioral intervention improved adherence rates by 1 hour per night onaverage. • The“lowrateofadherenceisproblematic,andcallsintoquestion theconceptofCPAPasgold-standardoftherapyforOSA.” *Rotenberg et al. Trends in CPAP Adherence over Twenty Years of Data Collection: Aflattenedcurve.JournalofOtolaryngology-HeadandNeckSurgery (2016) 45:43

  13. What do we know from Research? • In a landmark study, 54% of patients were found to be inconsistent users of CPAP2. The effectiveness of CPAP is in question when used inconsistently. • Skipping CPAP for two or more nights within the first week of treatment signals potential non-adherence and emphasizes the need for close follow-up during this period of time1 • The first week to month of home therapy appears to be the most critical phase for intervention and securing long-term compliance.2 • Bi-level is an effective salvage therapy for approximately 50% of patients who do not tolerate and/or respond to CPAP3 1 Weaver, TE and Grunstein, RR. Proc Am Thorac Soc 2008;5:173-178. 2 Kribbs, N., and et al. Am Rev Respir Dis 1993;147:887-895. 3. Szumstein, et al., ATS/ALA Abstract , 1999

  14. Why has CPAP adherence become a challenge? 20% of patients are easy to follow and comply 60% are Challengers 20% of patients never accept therapy

  15. Common Problems with CPAP Therapy Rosenthal, L.; Sleep, 2005

  16. Why has PAP adherence become a challenge? 20% of patients are easy to follow and comply 60% are Challengers OUR Target Increase efficiencies & help this group increase compliance 20% of patients never accept therapy

  17. Solution: BiPAP Rescue Titration Ava Rush aka “Captain America”

  18. BiPAP – the alternative for non-adherent CPAPpatients

  19. BiPAP Rescue Research Studies

  20. BiPAPRescue BiPAPis an effective salvage therapy forabout 50%of patients who do not tolerate CPAP therapy or for whom CPAP is not effective in treating OSA. There is a decline in BiPAPuse over 6 months in patients whoinitially accept BiPAPas salvage therapy forOSA1. 1Szumstein, S., Is Bilevel Positive Airway Pressure (BPAP) an Effective SalvageTherapyforObstructiveSleepApnea(OSA)PatientsWhoFail CPAP Therapy? ATS/ALAABSTRACT1999

  21. If the patient is uncomfortable or intolerant of high pressures on CPAP, the patient may be tried on BiPAP. If there are continued obstructive respiratory events at 15 cm H2O of CPAP during the titration study, the patient may be switched to BiPAP(consensus). Clinical Guidelines for the Manual Titration of Positive Airway Pressure in Patients with Obstructive Sleep Apnea, Positive Airway Pressure Titration Task Force of the American Academy of Sleep Medicine, The Journal of Sleep Medicine, CA Kushida, A Chediak, RB Berry et al, Journal of Clinical Sleep Medicine, Vol. 4, No. 2, 2008

  22. Insp Insp Exp Exp CPAP IPAP Pressure Needed throughout breath EPAP Unnecessary Pressure Delivered One Breath One Breath CPAP BiPAP PFL POH POA

  23. Clinical Validation:CPAP vs. BiPAP for Treatment of OSA Patients having difficulty acclimating to CPAP may benefit from BiPAPtherapy after conventional rescue protocols have failed. • At 30 days: • 45% of BiPAPpatients used > 4 hours/night • 33% of CPAP patients used > 4 hours/night • At 90 days: • 54% of BiPAPpatients used > 4 hours/night • 32% of CPAP patients used > 4 hours/night • P. Gay, et. al Sleep 2005:28; A210

  24. BiPAP Rescue Titration Keys

  25. BiPAP Titration Keys: • Do a CPAP titration first (if possible). If you need to move to BiPAP for comfort, start with a delta of 1 cmH2O and begin your BiPAP titration. • Switch to BiPAP, EPAP and IPAP will be equal to your CPAP pressure. • Increase EPAP by 1 cmH2O for OA. • Increase IPAP by 1 cmH2O for OH and snoring.

  26. BiPAP Rescue Reimbursement Keys

  27. Moving to BiPAP: -Coverage for a RAD without backup rate (E0470) is covered for patients with OSA who meet criteria A-C above (which qualifies them for CPAP), in addition to criterion D. -Criterion D: A single level(E0601) positive airway pressure device has been tried and proven ineffective based on a therapeutic trial conducted in either a facility or in a home setting.

  28. Challenge # 2 My patient is suffering from Complex Apnea, Periodic Breathing, Idiopathic CSA, or drug induced CSA.

  29. Pathology of the Sleep Lab/Respiratory Department Obesity Hypo-Ventilation Neuro- Muscular Disorders OSA Central/ Periodic Breathing COPD Restrictive Thoracic Disorder Complex Sleep Apnea

  30. Baseline Polysomnogram

  31. CPAP Titration Study

  32. CPAP Titration – Development of Central Events

  33. That is a Bear! 8/25/18 Goshen, CT

  34. PB / Cheyne Stokes Respiration

  35. Other CSA

  36. Possible treatment options: 1 Dernaika T et.al; Chest 2006 s;130(4)129 (7 out of 10 resolved Pilot Study) 2 Adult Sleep Apnea Task Force, AASM, ; Journal of Clinical Sleep Medicine 2009; 5(3) • Over-titration!!!! Lower the CPAP pressure. • CPAP + Time on Therapy to reset chemoreceptors for patient1 • Must qualify with RDI > 5 with symptoms of OSA or RDI >15 without symptoms 2 • 30-45 day trial on CPAP then follow up with patient on EDS, if improved keep on CPAP • No improvement in daytime sleepiness after 30-45 days, try alternatives • CPAP + Medications (Drugs to stabilize the RR - Acetazolamide, Theophyline, Benzodiazepines) • Increase CO2 by adding O2 or mechanical deadspace to CPAP (See Dr. Robert Thomas from the Beth Israel Deaconess Medical Center) • Auto Servo Ventilation / BiPAP with a b/u rate

  37. Possible treatment options: 1 Dernaika T et.al; Chest 2006 s;130(4)129 (7 out of 10 resolved Pilot Study) 2 Adult Sleep Apnea Task Force, AASM, ; Journal of Clinical Sleep Medicine 2009; 5(3) • Over-titration!!!! Lower the CPAP pressure. • CPAP + Time on Therapy to reset chemoreceptors for patient1 • Must qualify with RDI > 5 with symptoms of OSA or RDI >15 without symptoms 2 • 30-45 day trial on CPAP then follow up with patient on EDS, if improved keep on CPAP • No improvement in daytime sleepiness after 30-45 days, try alternatives • CPAP + Medications (Drugs to stabilize the RR - Acetazolamide, Theophyline, Benzodiazepines) • Increase CO2 by adding O2 or mechanical deadspace to CPAP (See Dr. Robert Thomas from the Beth Israel Deaconess Medical Center) • Auto Servo Ventilation / BiPAP with a b/u rate

  38. Possible treatment options: 1 Dernaika T et.al; Chest 2006 s;130(4)129 (7 out of 10 resolved Pilot Study) 2 Adult Sleep Apnea Task Force, AASM, ; Journal of Clinical Sleep Medicine 2009; 5(3) • Over-titration!!!! Lower the CPAP pressure. • CPAP + Time on Therapy to reset chemoreceptors for patient1 • Must qualify with RDI > 5 with symptoms of OSA or RDI >15 without symptoms 2 • 30-45 day trial on CPAP then follow up with patient on EDS, if improved keep on CPAP • No improvement in daytime sleepiness after 30-45 days, try alternatives • CPAP + Medications (Drugs to stabilize the RR - Acetazolamide, Theophyline, Benzodiazepines) • Increase CO2 by adding O2 or mechanical deadspace to CPAP (See Dr. Robert Thomas from the Beth Israel Deaconess Medical Center) • Auto Servo Ventilation / BiPAP with a b/u rate

  39. Solution: Auto Servo Ventilation Titration

  40. AutomaticServoVentilation Treatment for complicated breathing patterns such as: Central apnea/Complex Apnea – b/u Rate OSA - EPAP Periodic breathing such as CSR - ASV 44

  41. Theory of Operation 2. 3. 1. * Can be set with minimum pressure support (BiLevel) Pressure

  42. 3/4 minutes Theory of Operation Target

  43. Backup Breath Target Pressure

  44. BiPAP autoSV™ : Automatic Servo Ventilation SV Pressure Support

  45. Example of back up machine breaths

  46. ASV Titration Keys

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