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Guidelines to CPAP & Bi-Level device pressure titration in adults

Guidelines to CPAP & Bi-Level device pressure titration in adults. Belgian Society of Sleep Technologists. Normal procedure. Conducted over 2 polysomnographic nights: The first night is to establish a reliable baseline diagnostic for OSAS. The second night to initiate & titrate nasal CPAP.

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Guidelines to CPAP & Bi-Level device pressure titration in adults

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  1. Guidelines to CPAP & Bi-Level device pressure titration in adults Belgian Society of Sleep Technologists Jo Tiete - CHL

  2. Normal procedure Conducted over 2 polysomnographic nights: • The first night is to establish a reliable baseline diagnostic for OSAS. • The second night to initiate & titrate nasal CPAP. Jo Tiete - CHL

  3. Night 1 • Document sleep apnea at least while sleeping in supine position. • In all stages, but most significantly in REM sleep (REM atonia). • Sleeping on the side can lead to a false negative diagnostic result. Jo Tiete - CHL

  4. Night 2 • CPAP titration procedure to specify the lowest pressure, wich abolishes apneas, hypopneas, snoring & arrousals (RERA). • Also in all stages, specially REM & at least in supine position. • Note: REM is almost always more prominent in last third part of the night. Jo Tiete - CHL

  5. Split Night procedure • If documented > 30 apneas with desats >= 4% from baseline after 3 hours after LOFF.  Initiate CPAP ! Jo Tiete - CHL

  6. Split Night procedure • If related with OSAS appearance of: • Bradycardia < 40 beats/min. • PVC (Premature Ventricular Contraction) couplets or bigeminy. • Sinus bradycardia > 2.5 seconds. • SAO2 < 75 %.  Initiate CPAP ! Jo Tiete - CHL

  7. Split Night procedure • At least 3 hours of CPAP titration & treatment is needed. • Research indicate that up to 49 % is inadequatly titrated in split studies because of lack in time! • If fail to titrate adequatly: new full PSG titration. Jo Tiete - CHL

  8. nCPAP titration • Explain procedure to patient! Fit the mask. • Start with 3 to 4 cm H2O till sleep onset. • Increase with 1 or 2 cm every 5 to 15 min. till 10 cm H2O. • If necessary, increase with 0.5 to 1 cm above 10 cm H2O every 15 to 30 min. • 15 to 18 cm H2O is max, except very rare cases! ( tear off mask during sleep). Jo Tiete - CHL

  9. nCPAP titration • If « sensation of not getting enough air » start with more than 4 cm H2O: • Common with nasal congestion. • Severe obesitas. • Prior chronic CPAP treatment. • Richards et all: up to 40 % nasal congestion, dry nose & sore throat with CPAP device. Jo Tiete - CHL

  10. nCPAP titration • If claustrophobia or anxiety: • You will need even more time to explain, prepare & calm down subject. • In this case increase pressure very sloooooooowly! • Sleeptech workload: • explaining, preparing & educating of patient. Jo Tiete - CHL

  11. nCPAP titration • To control therapeutic pressure is correct: • Reduce slightly pCPAP & watch for respiratory events or arrousals to re-appear. • If pressure is set too high: • Discomfort. • Awakenings. • Hypnogram fragmentation. • Oral leak & noise (gasping). • Appearance of central apneas. Jo Tiete - CHL

  12. nCPAP titration • If obst. or mixt. apneas are converted to central apneas of the Cheyne-Stokes type (periodic breathing): • Test with upward pressure. • If no luck: leave at pressure to stop obstructive events. • Central apneas in REM without desats or arrousals don’t need higher pressure. Jo Tiete - CHL

  13. nCPAP titration • If central apneas (not Cheyne-Stokes type) with arrousals: • Investigate for preceding snorings/airflow limitation or UARS: • Then try with higher pressure. • Investigate for arrousal because of too high pressure and/or mouthleak: • Then try with lower pressure. Jo Tiete - CHL

  14. nCPAP titration • If high pressure is necessary to maintain airway patency, but not tolerated: • Do a temporary pressure reduction with slow increase. • If several attempts to do so are not succesfull, change to Bi-Level. • If CPAP not supported because of nasal congestion: use heated humidifier or topical vasoconstrictor spray. Jo Tiete - CHL

  15. nCPAP titration • If high mouth leaks: • Try with heated humidifier. • And/or Shin strap. • If still no succes: • Switch to Bi-Level. • Or use a full face mask. Jo Tiete - CHL

  16. nCPAP titration • Not uncommon: first a succesfull titration, but after position change, respiratory events reappearing. • Even when CPAP is succesfully titrated, many causes can lead to the inability to tolerate CPAP. • Therapeutic failure to CPAP is estimated to be 20 to 30 %. Jo Tiete - CHL

  17. Bi-Level tiration • From start only: • if severe pulmonary reasons & asked by physician. • Indications: • CPAP not tolerated. • COPD(Chronic Obstructif Pulmonary Disease). • Hypoventilation. • High mouth leak with humidifier & shin strap. • Other pneumological diseases (ex: scoliosis). Jo Tiete - CHL

  18. Bi-Level tiration • Increase both IPAP & EPAP till no more obstructive apneas. • Then increase IPAP only, till no more hypopneas, snoring or RERA’s. • If these events still persists, increase EPAP by 0.5 to 1 cm. • In alveolar hypoventilation: lower the EPAP to increase tidal volume. Jo Tiete - CHL

  19. Alter subject position • If CPAP or bi-level pressure not tolerated: • The bed will be elevated by 30 degrees. • Use lateral sleep position (tennis ball, pillow). Jo Tiete - CHL

  20. Oxygen therapy • If despite of good titration, SAO2 < 90% then: • Start with 1 liter O2 inline CPAP. • Maximum 4 to 5 liters O2 (ask your doctor!). • If > 3 liters O2 use of humidifier recommended. • Slooowly increase O2 till SAO2 > 90%. • Danger: fire, CO2 retention, mucosa irritation & epistaxis (nose bleeding). • pCPAP + Oxyconcentrator !!! Jo Tiete - CHL

  21. Auto-/Smart (or stupid)-CPAP • Subject excluded for auto-titration are: • Congestive heart failure. • COPD and daytime hypoxemia. • Hypoventilation syndrome. • NO snorers (ex:UPPP)… auto-CPAPSound algorithm don’t detect any abnormallity! Jo Tiete - CHL

  22. Auto-/Smart-CPAP • Auto-CPAP is not indicated in Split night procedure, but sometimes used for an attended polysomnography. • Some auto-CPAP devices have proven their utility for the Cheyne-Stokes type apneas (Resmed CS). Jo Tiete - CHL

  23. Adherence & follow-up • Education, education, education… • Review subject after CPAP initiation within 3 months. • Follow-up, control & adjustment on yearly basis. • Change deteriorated consumables (mask,…). • At least 4.5 hours PAP use/night. Jo Tiete - CHL

  24. Sleeptech experience • Important: • A trained staff for CPAP use & titration. • Good understanding: in respiratory physiology, anatomy and sleep & respiratory disorders. • Higher compliance succes rates with well trained sleeptechs. Jo Tiete - CHL

  25. My CPAP Evolution Theory: Homo Erectus • Rather small brain. • Big mouth, good flux. • Big thorax volume. • Small abdomen. • No fat, but muscles! (…had to run for the dinausaur!). • No need for CPAP !!! Jo Tiete - CHL

  26. NASA: send this picture in space • Clean & ideal drawing of Homo Sapiens. • But if extra-terrestrial life should visit the earth one day, they will find ... Jo Tiete - CHL

  27. This ! • No brain difference. • Smaller mouth & fatty dubbel shin. • Smaller thorax. • Huge abdomen. • A lot of fat, rare muscles (don’t run anymore!). • Don’t survive without CPAP device!!! Jo Tiete - CHL

  28. Thank you for your attention. tiete.jo@chl.lu

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