Advanced Positive Airway Pressure (PAP) Treatment Modalities Nic Butkov, RPSGT Asante Sleep Center Medford, Oregon.

Advanced Positive Airway Advanced Positive Airway Pressure (PAP) Treatment Pressure (PAP) Treatment

ModalitiesModalities

Nic Butkov, RPSGTNic Butkov, RPSGTAsante Sleep CenterAsante Sleep Center

Medford, OregonMedford, Oregon

Currently-Available PAP ModalitiesCurrently-Available PAP Modalities

CPAPCPAP Bi-level PAP spontaneous (S) modeBi-level PAP spontaneous (S) mode Bi-level PAP spontaneous/timed (S/T) modeBi-level PAP spontaneous/timed (S/T) mode Bi-level PAP timed (T) modeBi-level PAP timed (T) mode Bi-level PAP with pressure control (PC or PAC) modeBi-level PAP with pressure control (PC or PAC) mode Average Volume-Assured Pressure Support (AVAPS™) Average Volume-Assured Pressure Support (AVAPS™)

or Intelligent Volume-Assured Pressure Support or Intelligent Volume-Assured Pressure Support (iVAPS™)(iVAPS™)

Adaptive servo-ventilation (ASV) modeAdaptive servo-ventilation (ASV) mode

Treatment Applications Treatment Applications CPAP for upper airway obstructionCPAP for upper airway obstruction Bi-level S for basic ventilatory supportBi-level S for basic ventilatory support Bi-level S/T for ventilatory support with back-up Bi-level S/T for ventilatory support with back-up

respiratory raterespiratory rate Bi-level PC or PAC for ventilatory support with Bi-level PC or PAC for ventilatory support with

fixed inspiratory timefixed inspiratory time AVAPS or iVAPS for ventilatory support with AVAPS or iVAPS for ventilatory support with

regulation of tidal volumes and back-up rateregulation of tidal volumes and back-up rate ASV for central sleep apneaASV for central sleep apnea

Basic Concepts ofBasic Concepts ofBi-Level PAP TherapyBi-Level PAP Therapy

Expiratory positive airway pressure (EPAP)Expiratory positive airway pressure (EPAP) Provides the baseline PAP levelProvides the baseline PAP level Maintains upper airway patency during expirationMaintains upper airway patency during expiration Prevents alveolar collapse and improves functional Prevents alveolar collapse and improves functional

residual capacity (FRC)residual capacity (FRC) Reduces work of breathing and improves oxygenationReduces work of breathing and improves oxygenation

Inspiratory positive airway pressure (IPAP)Inspiratory positive airway pressure (IPAP) Maintains upper airway patency during inspirationMaintains upper airway patency during inspiration Provides pressure support to augment ventilationProvides pressure support to augment ventilation Decreases work of inspiratory musclesDecreases work of inspiratory muscles

Setting the EPAPSetting the EPAP

The baseline EPAP level is usually kept low (4 – The baseline EPAP level is usually kept low (4 – 5 cwp) unless closed airway apneas are present5 cwp) unless closed airway apneas are present

EPAP can also be increased in select cases to EPAP can also be increased in select cases to help recruit the alveoli and improve oxygenation help recruit the alveoli and improve oxygenation

High EPAP levels may be contraindicated in High EPAP levels may be contraindicated in some patientssome patients

Setting the IPAP for Pressure Setting the IPAP for Pressure SupportSupport

EPAP-IPAP span = pressure support (PS)EPAP-IPAP span = pressure support (PS) A low EPAP-IPAP span (PS of 4 cwp or less) A low EPAP-IPAP span (PS of 4 cwp or less)

offers expiratory relief, but is generally offers expiratory relief, but is generally insufficient for added ventilatory supportinsufficient for added ventilatory support

For patients needing added ventilatory support, For patients needing added ventilatory support, a span of 6 cwp or higher is usually required a span of 6 cwp or higher is usually required (higher PS = higher breath volumes)(higher PS = higher breath volumes)

However, excessive PS may lead to upper However, excessive PS may lead to upper airway instability and may be contraindicated for airway instability and may be contraindicated for some patientssome patients

Timed Inspiration and I:E RatioTimed Inspiration and I:E Ratio Timed inspiration (Ti) is used with some PAP Timed inspiration (Ti) is used with some PAP

modalitiesmodalities When using Ti, it is essential to calculate the When using Ti, it is essential to calculate the

resulting inspiratory to expiratory (I:E) ratio resulting inspiratory to expiratory (I:E) ratio based on the respiratory ratebased on the respiratory rate

For example, at a rate of 12 bpm, each breath For example, at a rate of 12 bpm, each breath cycle is 5 seconds in duration. An inspiratory cycle is 5 seconds in duration. An inspiratory time of 1.66 sec. with an expiratory time of 3.34 time of 1.66 sec. with an expiratory time of 3.34 sec. delivers a 1:2 ratiosec. delivers a 1:2 ratio

Timed Inspiration (cont.)Timed Inspiration (cont.)

Shorter inspiratory times are generally used for Shorter inspiratory times are generally used for patients with obstructive lung conditions, to allow patients with obstructive lung conditions, to allow longer time for expirationlonger time for expiration

Longer inspiratory times are generally used for Longer inspiratory times are generally used for patients with restrictive lung conditions; patients with restrictive lung conditions; however, ihowever, inspiratory time should never exceed nspiratory time should never exceed the length of expiratory timethe length of expiratory time

Timed Inspiration (cont.)Timed Inspiration (cont.) Respironics applies Ti only to machine- Respironics applies Ti only to machine-

delivered breaths in their ST modedelivered breaths in their ST mode ResMed applies minimum and maximum ResMed applies minimum and maximum

inspiratory times limits to inspiratory times limits to allall breaths in their S, breaths in their S, ST, and iVAPS modesST, and iVAPS modes The Min Ti sets the obligatory Ti baselineThe Min Ti sets the obligatory Ti baseline The Max Ti allows for longer inspiratory times based The Max Ti allows for longer inspiratory times based

on the patienton the patient’’s own breath cycle s own breath cycle In PC or PAC mode, In PC or PAC mode, fixed Ti is applied to all fixed Ti is applied to all

breathsbreaths

Setting the TiSetting the Ti Ti settings are based on clinical indicators, Ti settings are based on clinical indicators,

making certain that appropriate I:E ratios are making certain that appropriate I:E ratios are maintainedmaintained

When applied only to machine-delivered When applied only to machine-delivered breaths, Ti is set relative to the back-up ratebreaths, Ti is set relative to the back-up rate

When Ti is applied to all breaths, the patientWhen Ti is applied to all breaths, the patient’’s s spontaneous rate must be taken into account spontaneous rate must be taken into account during all stages of sleep under all during all stages of sleep under all circumstances circumstances

PAP Trigger and CyclePAP Trigger and Cycle

PAP Trigger = transition from EPAP to IPAPPAP Trigger = transition from EPAP to IPAP PAP Cycle = transition from IPAP to EPAPPAP Cycle = transition from IPAP to EPAP Medium trigger and cycle sensitivities work well Medium trigger and cycle sensitivities work well

in most casesin most cases Higher trigger sensitivity and lower cycle Higher trigger sensitivity and lower cycle

sensitivity may be useful in restrictive or sensitivity may be useful in restrictive or neuromuscular diseaseneuromuscular disease

Higher cycle sensitivity may be useful in Higher cycle sensitivity may be useful in obstructive lung diseaseobstructive lung disease

Rise TimeRise Time

Rise time = the amount of time (measured in Rise time = the amount of time (measured in milliseconds) set for the PAP device to reach milliseconds) set for the PAP device to reach IPAP when a breath is triggeredIPAP when a breath is triggered

Generally, shorter rise times are used for Generally, shorter rise times are used for obstructive lung conditions; longer rise times are obstructive lung conditions; longer rise times are used for restrictive lung conditionsused for restrictive lung conditions

Rise time should be set according to efficacy of Rise time should be set according to efficacy of treatment and patient comforttreatment and patient comfort

Mask SelectionMask Selection Mask TypeMask Type

Nasal maskNasal mask Nasal pillowsNasal pillows Oronasal (full-face) maskOronasal (full-face) mask

Mask type makes a difference!Mask type makes a difference! Changing between nasal and full-face Changing between nasal and full-face

mask may require additional PAP mask may require additional PAP adjustmentsadjustments

Mask and Tubing SettingsMask and Tubing Settings

All PAP machines need to be set correctly All PAP machines need to be set correctly for the type of mask and tubing usedfor the type of mask and tubing used

Bi-Level PAP S ModeBi-Level PAP S Mode

Sometimes used as a substitute for CPAPSometimes used as a substitute for CPAP Can be used for ventilatory support in Can be used for ventilatory support in

patients with COPD, neuromuscular patients with COPD, neuromuscular disease and obesity hypoventilationdisease and obesity hypoventilation

Not appropriate for patients with Cheyne-Not appropriate for patients with Cheyne-Stokes respiration or other forms of central Stokes respiration or other forms of central apneaapnea

Basic Bi-Level S SettingsBasic Bi-Level S Settings

EPAPEPAP IPAPIPAP Rise timeRise time

Timed inspiration (minimum-maximum Timed inspiration (minimum-maximum limits) are used on some equipment limits) are used on some equipment (ResMed)(ResMed)

Bi-Level S Mode TitrationBi-Level S Mode Titration

Starting pressures are typically 8/4 cwpStarting pressures are typically 8/4 cwp Rationale for adjusting EPAP and IPAPRationale for adjusting EPAP and IPAP

EPAP is increased for closed-airway apneas EPAP is increased for closed-airway apneas (keeping the same EPAP-IPAP span)(keeping the same EPAP-IPAP span)

IPAP is increased for residual hypopneas, IPAP is increased for residual hypopneas, RERAs and/or snoringRERAs and/or snoring

IPAP is further increased for added ventilatory IPAP is further increased for added ventilatory support (if indicated)support (if indicated)

Diagnosic study: severe hypoxemia during REM sleep

Improved O2 saturation levels and sleep architecture with bi-level PAPSettings: EPAP = 4 cwp, IPAP = 11 cwp (S mode)

Bi-Level S/T ModeBi-Level S/T Mode

S/T mode is used when a back-up rate is S/T mode is used when a back-up rate is requiredrequired

Sometimes used to treat select patients Sometimes used to treat select patients with opioid induced central apneawith opioid induced central apnea

S/T mode is generally not recommended S/T mode is generally not recommended for central apneas with Cheyne-Stokes for central apneas with Cheyne-Stokes respirationrespiration

Basic Bi-Level S/T Settings Basic Bi-Level S/T Settings EPAPEPAP IPAPIPAP Back-up rateBack-up rate Timed inspiration (Ti)Timed inspiration (Ti)

Fixed Ti is applied only to machine-delivered breaths Fixed Ti is applied only to machine-delivered breaths (Respironics)(Respironics)

Minimum-maximum Ti limits are applied to all breaths Minimum-maximum Ti limits are applied to all breaths (ResMed) (ResMed)

Rise timeRise time

aa

Opioid-induced Biot’s respiration

Fragmented sleep

Bi-Level S/T 12/4 cwp with back-up rate of 8 bpm

Sleep is partially improved

Bi-Level PC or PAC modeBi-Level PC or PAC mode

Fixed timed inspiration is applied to Fixed timed inspiration is applied to allall breaths breaths Ventilatory support is achieved by balancing the Ventilatory support is achieved by balancing the

EPAP-IPAP span with timed inspirationEPAP-IPAP span with timed inspiration Inspiratory time must be set to maintain Inspiratory time must be set to maintain

appropriate I:E ratio relative to the patientappropriate I:E ratio relative to the patient’’s s respiratory rate respiratory rate during all stages of sleep under during all stages of sleep under all circumstancesall circumstances

PC or PAC mode is sometimes prescribed for PC or PAC mode is sometimes prescribed for select patients with neuromuscular disease select patients with neuromuscular disease

Basic Bi-Level PC/PAC Basic Bi-Level PC/PAC Settings:Settings:

EPAPEPAP IPAPIPAP Back-up rateBack-up rate Timed inspiration (applied to all breaths)Timed inspiration (applied to all breaths) Rise timeRise time

Combined effect: NMD, opioid use and upper airway obstructive component

Bi-level S/T: 15/6 cwp with back-up rate 10 bpm

PC mode: 12/6 cwp; Ti 2 sec., back-up rate 10 bpm (IE ratio = 1:2)

Adaptive Servo-Ventilation Adaptive Servo-Ventilation (ASV)(ASV)

Intended for treating central sleep apneaIntended for treating central sleep apnea Not appropriate for hypoventilation syndromesNot appropriate for hypoventilation syndromes Variable EPAP maintains upper airway patencyVariable EPAP maintains upper airway patency Variable IPAP with back-up rate delivers Variable IPAP with back-up rate delivers

pressure supportpressure support Based on a recent study, ASV is contraindicated Based on a recent study, ASV is contraindicated

for heart failure patients with moderate-severe for heart failure patients with moderate-severe CSA and left ventricular ejection fraction <45%*CSA and left ventricular ejection fraction <45%*

* Serve-HF Clinical Trial* Serve-HF Clinical Trial

Considerations Regarding Central Apneas Considerations Regarding Central Apneas that are Unresponsive to CPAPthat are Unresponsive to CPAP

(Possible Causes)(Possible Causes)

Uncorrected obstructive apneas that appear Uncorrected obstructive apneas that appear ostensibly centralostensibly central

Central apneas caused by excessive PAP levelsCentral apneas caused by excessive PAP levels Central apneas temporarily appearing during Central apneas temporarily appearing during

adjustment to PAP therapyadjustment to PAP therapy Repetitive sleep-onset central apneasRepetitive sleep-onset central apneas Cheyne-Stokes respirationCheyne-Stokes respiration Opioid-induced BiotOpioid-induced Biot’’s respirations respiration

Cheyne-Stokes Respiration vs. Cheyne-Stokes Respiration vs. BiotBiot’’s Respirations Respiration

Cheyne-Stokes respiration is characterized by Cheyne-Stokes respiration is characterized by crescendo-decrescendo breathing with central crescendo-decrescendo breathing with central apnea or hypopnea, as often seen in patients apnea or hypopnea, as often seen in patients with congestive heart failurewith congestive heart failure

BiotBiot’’s respiration is characterized by brief s respiration is characterized by brief clusters of shallow breaths with central apnea or clusters of shallow breaths with central apnea or hypopnea, as typically seen in patients using hypopnea, as typically seen in patients using opioid medicationsopioid medications

Cheyne-Stokes respiration

Biot’s respiration

Biot’s / ataxic respiration

Basic ASV Settings:Basic ASV Settings: EPAP minEPAP min EPAP maxEPAP max PS minPS min PS maxPS max

Respironics also provides selection of auto Respironics also provides selection of auto vs. manual back-up rate, rise time and vs. manual back-up rate, rise time and maximum pressure limitmaximum pressure limit

Diagnostic study – central sleep apnea with obstructive component

NREM sleep with arousals

ASV titration (EPAP - 5; min PS - 0; max PS - 10; back-up rate - auto)

Transitional sleep

ASV titration continued (same settings)

Sleep is becoming more consolidated

ASV titration is complete (same settings)

Quiet NREM sleep

Volume-Assured Pressure Support Volume-Assured Pressure Support (AVAPS or iVAPS)(AVAPS or iVAPS)

Can be used for neuromuscular disease, Can be used for neuromuscular disease, obesity hypoventilation, restrictive or obesity hypoventilation, restrictive or obstructive lung disease, or for select obstructive lung disease, or for select patients with opioid-induced central apneapatients with opioid-induced central apnea

Uses a variable range of pressure support Uses a variable range of pressure support to maintain pre-set target tidal volumesto maintain pre-set target tidal volumes

Tidal VolumesTidal Volumes Tidal volume = volume of air moved in and out of Tidal volume = volume of air moved in and out of

the lungs with each breaththe lungs with each breath In healthy adults, normal tidal volumes are in the In healthy adults, normal tidal volumes are in the

range of approximately 500 milliliters per breath, range of approximately 500 milliliters per breath, or 7 milliliters per kilogram of body weightor 7 milliliters per kilogram of body weight

When using AVAPS or IVAPS, target tidal When using AVAPS or IVAPS, target tidal volumes are generally calculated based on ideal volumes are generally calculated based on ideal body weight relative to the patientbody weight relative to the patient’’s height s height (starting values of 6 - 8 ml/kg are usually (starting values of 6 - 8 ml/kg are usually applied, or as directed by the physician) applied, or as directed by the physician)

AVAPS Settings:AVAPS Settings: S, ST or PC modeS, ST or PC mode Target tidal volumeTarget tidal volume Back-up rate (ST and PC modes)Back-up rate (ST and PC modes) EPAPEPAP Minimum IPAPMinimum IPAP Maximum IPAPMaximum IPAP Timed inspirationTimed inspiration

Applied only to delivered breaths in ST modeApplied only to delivered breaths in ST mode Applied to Applied to alall breaths in PC model breaths in PC mode

Rise timeRise time

iVAPS SettingsiVAPS Settings Patient heightPatient height Target respiratory rateTarget respiratory rate Target alveolar ventilationTarget alveolar ventilation EPAPEPAP Minimum pressure supportMinimum pressure support Maximum pressure supportMaximum pressure support Minimum TiMinimum Ti Maximum TiMaximum Ti Trigger SensitivityTrigger Sensitivity Cycle SensitivityCycle Sensitivity Rise timeRise time

Evaluating the Respiratory DataEvaluating the Respiratory Data

The PAP flow and pressure channels should be The PAP flow and pressure channels should be checked for synchrony with the respiratory effort checked for synchrony with the respiratory effort channels channels

Asynchronous waveforms may be caused by Asynchronous waveforms may be caused by excessive mask leaks, mouth breathing, excessive mask leaks, mouth breathing, incorrect inspiratory time settings, or inadequate incorrect inspiratory time settings, or inadequate trigger and/or cycle sensitivity settings trigger and/or cycle sensitivity settings

PAP flow waveforms are synchronous with the chest and abdomen waveforms

PAP flow waveforms are asynchronous with the chest and abdomen waveforms

CPAP of 11 cwp with EPR of 3 – synchronous pressure and flow signals

Asynchronous pressure and flow signals – sporadic pressure support

Asynchronous pressure and flow signals with excessive PAP levels

Fine-Tuning the SettingsFine-Tuning the Settings Strategies for improving PAP flow synchrony:Strategies for improving PAP flow synchrony:

Check and correct mask leaksCheck and correct mask leaks Consider the possibility that the PAP levels might be Consider the possibility that the PAP levels might be

too hightoo high Check for appropriate inspiratory time values (if Check for appropriate inspiratory time values (if

applicable)applicable) Check for appropriate trigger and/or cycle sensitivity Check for appropriate trigger and/or cycle sensitivity

settings (if applicable)settings (if applicable) Try manipulating the rise time setting (extending the Try manipulating the rise time setting (extending the

rise time can sometimes help prevent mask leaks rise time can sometimes help prevent mask leaks during inspiration) during inspiration)

Evaluating the TitrationEvaluating the Titration Was the appropriate Was the appropriate PAP modalityPAP modality selected? selected? What type of What type of maskmask was used and why? was used and why? Was the machine Was the machine set correctly for type of mask set correctly for type of mask

and tubing usedand tubing used?? Was Was baseline EPAPbaseline EPAP increased and if so, why? increased and if so, why? If variable EPAP was used, were the settings If variable EPAP was used, were the settings

appropriate?appropriate? How much How much pressure supportpressure support was applied and was was applied and was

it appropriate?it appropriate? If variable pressure support was used, was the If variable pressure support was used, was the

range sufficient?range sufficient?

Evaluating the Titration (cont.)Evaluating the Titration (cont.) What was the patientWhat was the patient’’s s respiratory raterespiratory rate during during

wakefulness, during NREM sleep and during wakefulness, during NREM sleep and during REM sleep?REM sleep?

Was Was timed inspirationtimed inspiration applied and was it applied and was it appropriate relative to the patientappropriate relative to the patient’’s respiratory s respiratory rate?rate?

Was timed inspiration applied only to delivered Was timed inspiration applied only to delivered breaths or to all breaths?breaths or to all breaths?

If minimum-maximum inspiratory time limits were If minimum-maximum inspiratory time limits were applied, were the settings appropriate?applied, were the settings appropriate?

Evaluating the Titration (cont.)Evaluating the Titration (cont.) If If trigger and cycle sensitivitytrigger and cycle sensitivity settings were settings were

adjusted, were they appropriate and effective?adjusted, were they appropriate and effective? How was the How was the rise timerise time selected and was it selected and was it

appropriate and comfortable for the patient?appropriate and comfortable for the patient? Did the PAP flow Did the PAP flow waveforms appear waveforms appear

synchronoussynchronous with the respiratory effort with the respiratory effort waveforms?waveforms?

What were the What were the tidal volumestidal volumes readings during the readings during the study (NREM and REM sleep in all body study (NREM and REM sleep in all body positions)?positions)?

Evaluating the Titration (cont.)Evaluating the Titration (cont.) What were the What were the O2 saturationO2 saturation readings during the readings during the

study (NREM and REM sleep in all body study (NREM and REM sleep in all body positions)?positions)?

What were the recorded What were the recorded leak valuesleak values during the during the study (NREM and REM sleep in all body study (NREM and REM sleep in all body positions)?positions)?

Was the Was the head of the bedhead of the bed elevated during the elevated during the study and if so, did it replicate the patientstudy and if so, did it replicate the patient’’s home s home environment?environment?

Was Was supplemental oxygensupplemental oxygen used during the study used during the study and was it necessary?and was it necessary?

Evaluating the Titration (cont.)Evaluating the Titration (cont.) Was there any evidence of residual upper Was there any evidence of residual upper

airway obstruction or resistance (NREM and airway obstruction or resistance (NREM and REM sleep in all body positions)?REM sleep in all body positions)?

Were open-airway central apneas and Were open-airway central apneas and hypopneas adequately resolved with treatment?hypopneas adequately resolved with treatment?

Was the patient breathing quietly and effortlessly Was the patient breathing quietly and effortlessly (based on direct observation)?(based on direct observation)?

Was the patientWas the patient’’s sleep quality improved?s sleep quality improved? Did the patient tolerate the treatment well?Did the patient tolerate the treatment well? Did the patient feel better after treatment?Did the patient feel better after treatment?

SummarySummary EPAP and IPAP should be sufficient, but not EPAP and IPAP should be sufficient, but not

excessiveexcessive

All PAP settings (such as back-up rates, Ti, etc.) All PAP settings (such as back-up rates, Ti, etc.) must be verified as appropriate for the patientmust be verified as appropriate for the patient

Efficacy of treatment involves maintaining upper Efficacy of treatment involves maintaining upper airway patency, providing adequate ventilatory airway patency, providing adequate ventilatory support, and improving quality of sleep support, and improving quality of sleep