“SMART” Technologies Why are they so scary? They’re not so smart without YOU!

1. “SMART” TechnologiesWhy are they so scary?They’re not so smart without YOU! Pamela Minkley RRT, RPSGT, CPFT Make Sleep a Priority March 2013

2. It’s critical to understand how things work, not just “know how to do it”

3. What makes us breathe?The stimulus to breatheawake and asleep

7. Respiratory Physiology During Sleep • Stimulus to breathe not the same as awake • Response to hypercarbia & hypoxemia blunted • Physiology varies NREM vs REM • Cardiovascular changes effect gas delivery and exchange • Respiratory and cardiovascular disease disrupt normal physiology • Some pathologic breathing patterns come and go throughout the sleep period.

8. Normal Awake Stimulus to Breathe • Hypercapnia • PaCO2 changes quickly • HCO3 changes slowly • Both affect the pH of the blood • Hypoxia • SaO2 and PaO2 • Carotid and aortic bodies • Stretch, “J”, and other receptors

9. Behavior Metabolic** Metabolic Inactive Non-metabolic Metabolic Metabolic Active Transitional Sleep* Stage 2 Slow Wave Sleep REM Sleep Irregular Periodic Regular Regular Irregular Regular Major Influence on breathing Rare Absent Absent Often Frequent Absent Pattern of breathing Mild Decrease Decreased Variable Present Mild Decrease Mod. Decrease Central Apneas/Hypopneas Phasic Phasic Phasic Phasic Paradoxical Phasic Response to metabolic stimuli Chest wall movement * Transitional sleep refers to the period of sleep between wakefulness and continuous stage I sleep or established stage II sleep. ** The metabolic regulation during the transition between sleep and wake is affected by an upward shift in pCO2 set point and the gain of the pCO2 response. Physiologic Changes in Respiratory Control with Sleep

10. Identify these breathing patterns. Opioids A D Biots OSA B CSR How did you do it?How would a computer do it? C CA

11. What do you see on the PSG? O S A Note square wave pattern of OSA recovery breathing. Different from CSR. Oximetry patterns. OSA Normal CSA How would you “explain” that to a computer?

12. Triangular Paradoxical Central or obstructive hypopnea? Likely response to CPAP? How would a computer know what to do?

13. PAP Therapy: Decision Making Tree OSA Hypoventilation CSA Central Events Don’t breathe at all or pattern is mixed up Impaired Gas Exchange Oxygen drops/Carbon Dioxide rises Obstructive Events Try to breathe but can’t get enough in What would this look like on a PSG? HST? Therapy download? What would this look like on a PSG? HST? Therapy download? What would this look like on a PSG? HST? Therapy download?

14. Hypoventilation would look like THIS! Volume and flow change slowly over time inhypoventilation, ASV algorithmic target will gradually lower and not trigger a response THEN: autoSV Advanced delivers CPAP pressure only

15. AVAPs Algorithm < 1 cmH2O / min increase IPAP Setting Pressure Desired Volume Volume Not a breath by breath change to stabilize the breathing pattern like aSV Delivers a targeted tidal volume. Focus is on ventilation not stabilizing the breathing pattern.

16. PAP Therapy: Decision Making Tree OSA Hypoventilation CSA Central Events Don’t breathe at all or pattern is mixed up Impaired Gas Exchange Oxygen drops/Carbon Dioxide rises Obstructive Events Try to breathe but can’t get enough in What would this look like on a PSG? HST? Therapy download? What would this look like on a PSG? HST? Therapy download? What would this look like on a PSG? HST? Therapy download?

17. Hypoventilation Periodic Breathing OSA Opioid CSA Central Hypopneas OpioidCSA TraumaCSA The Bucket Theory Let’s talk about breathing during sleep

18. Complex Sleep Apnea Components OSA Central SDB Hypoventilation Obstructive apneas Obstructive hypopneas Noninvasive Ventilation Periodic Breathing CSR CPAP APAP BiLevel Central Apnea Central Hypopnea Auto Servo Ventilation Volume Assured Pressure Support with Rate

19. PAP Therapy: Decision Making Tree OSA Hypoventilation CSA Obstructive Events Open the Airway Impaired Gas Exchange Ventilate Central Events Stabilize Breathing Pattern CPAP APAP Bi-level Volume Assured Pressure Support w/Rate Auto Servo Ventilation

20. BiPAP autoSV AdvancedTheory of OperationServo Ventilation Algorithm Algorithms to match the pathologies

21. CPAP Auto CPAP cmH20 cmH20 PAP Therapy for Patients with OSA • CPAP • One level of pressure on inspiration and exhalation • Device may have the option to provide pressure relief in early exhalation • Auto titration therapy • Device pressure is adjusted based on airway dynamics and device algorithm

22. cmH20 Bi-Level cmH20 Auto SV Flow pattern could look different depending on position and spontaneous vs machine breath. Why? How would this graphic look for AVAPS? PAP Therapy for Patients with OSA/SDB • Bi-level therapy • One level of pressure on inspiration and lower level of pressure on expiration. PS the same every breath • Auto Servo Ventilation • Device pressure is adjusted based on airway dynamics, patient respiratory effort and flow and device algorithm. PS varies according to need.

23. PAP Therapy for Patients with CSR CO2 waxing and waning with under and over ventilation Airflow Pressure Support CO2 Stable , Breathing pattern stable, Patient breathes on own with normal variability PatientAirflow

24. What therapy would you need for each breathing pattern shown? A D Biots OSA Most patients will bring a unique mix of breathing patterns! B CSR C CA

25. Involuntary/Autonomic Control Upper airway compromise Respiratory Control Issues

26. Auto Servo VentilationTheory of Operation Auto EPAP with Servo Ventilation Algorithm

27. Auto EPAP Algorithm Leak Tolerance Patient Not Responsive Sophisticated Three Layered Algorithm: Safety Net Exceptions Primary Function Pro Active Analysis

28. Servo Ventilation Algorithm 4 Minutes On a breath by breath basis flow and/or volume is captured Peak flow or volume is monitored over a moving 4 minute window As 1 breath is added, the initial breath falls off (“rolling 4 minute window”) At every point within this 4 minute period an Average Peak Flow is calculated The Peak flow target is established around that average and is based on the patient’s needs

29. Servo Ventilation Algorithm – Normal Breathing IF: Peak flow is at target THENASV delivers CPAP pressure only I wonder what hypoventilation would look like?

30. Hypoventilation would look like THIS! Servo Ventilation Algorithm – Normal Breathing IF: Peak flow changes slowly over time like hypoventilation, target will gradually lower and peak flow will be at target THEN: autoSV Advanced delivers CPAP pressure only

31. Servo Ventilation Algorithm – Decreased Flow IF: Peak flow falls below target THEN: autoSV Advanced increases pressure support • Aggressive, quick changes meet peak flow target • Flow or volume target is conservative…Over ventilation is avoided

32. Assured Volume Algorithm < 1 cmH2O / min increase IPAP Setting Pressure Desired Volume Volume Automatically adjusts the pressure support level to maintain a consistent tidal volume • IPAP will automatically increase or decrease to meet Vt target • SLOW increases, not breath by breath (conservative increases) • Assured tidal volume (aggressive pressure support) Not a breath by breath change to stabilize the breathing pattern like aSV Delivers a targeted tidal volume. Focus is on ventilation not stabilizing the breathing pattern.

33. H S S S H OA OA Auto EPAP - Life is all about compromise! 25 Max pressure EPAPmax 15 EPAPmin 5 S = Snore H = Hypopnea OA = Obstructive apnea Pearl SV algorithm works ‘on top’ of Auto EPAP The higher the EPAP, the less “space” the ASV algorithm has to work

34. Complicated X The Complex Sleep Apnea Bucket List

35. What do you see?

36. What do you see? AM060606

37. What do you see? Proportionate changes in flow and effort. Likely central in nature

38. What do you see? AM060606

40. Identify these breathing patterns. Opioids A D Biots OSA B CSR How did you do it?How would a computer do it? Was it easier this time? C CA

41. What do you see on the PSG? O S A Note square wave pattern of OSA recovery breathing. Different from CSR. Oximetry patterns. OSA Normal CSA How would you “explain” that to a computer?

42. Triangular Paradoxical Central or obstructive hypopnea? Likely response to CPAP? How would a computer know what to do?

43. BiPAP autoSV AdvancedTerms and Definitions Key aSV terms and concepts (because this seems to be a problem for us)

44. Terms you need to understand • EPAPmin • The EPAP will not drop below this pressure • EPAPmax • The EPAP will not go above this pressure even if events are detected • Max pressure • The maximum pressure the device will deliver even if the algorithm indicates a pressure increase is needed • Peak Inspiratory Pressure (PIP) • The maximum pressure reached on inspiration to deliver the pressure support determined by the algorithm • PSmin • The minimum amount of pressure support delivered each breath (i.e. minimum difference between the EPAP and the PSmin setting) • PSmax • The maximum amount of pressure support that can be delivered (i.e. maximum difference between the EPAP and the PIP) Note: This value may limit the amount of Inspiratory pressure delivered

45. Let’s take a look at these terms graphically 25 Auto EPAP - Looks like Auto CPAP! Max pressure EPAPmax PSmax 15 cm H2O 15 PSmax PSmin 3 cm H2O PSmin Auto EPAP EPAPmin 5 We will discuss this more when we talk about titration

46. Let’s take a look at these terms graphically 25 Auto EPAP - Looks like Auto CPAP! Max pressure EPAPmax PSmax PSmax 10 cm H2O 15 PSmin 0cm H2O PSmin Auto EPAP EPAPmin 5 We will discuss this more when we talk about titration

47. Understanding what “success” looks like

48. ASV Stabilizes Ventilation after an arousal. This is the intended response and does NOT require an adjustment in settings!

49. Titration goals Pearl Exquisitely designed algorithms in partnership with your clinical experience, knowledge and observations AND a clear definition of “success” results in SUCCESSFUL THERAPY 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. It is likely each titration will be somewhat unique

50. Titration Protocol Titration Goals: Airway management, stabilize breathing patterns by monitoring patient’s response and adjusting user set parameters if needed for optimal therapy efficacy and adherence