BiPAP AVAPS BY AHMAD YOUNES PROFESSOR OF THORACIC MEDICINE Mansoura Faculty of Medicine

BiPAP AVAPS It's the only way of ensuring the delivery of targeted tidal volume for noninvasive ventilation patients. Short-hand for "Average Volume Assured Pressure Support," AVAPS sets the standard in noninvasive ventilation. The exclusive AVAPS algorithm automatically adjusts pressure support to meet changing patient needs while maintaining a target tidal volume.

BiPAP AVAPS

Warnings »You should read and understand this entire manual before using the device. »The device is not intended to provide your total ventilatory requirement. »The prescription must only be adjusted by a trained home care provider. »When using a breathing circuit that contains a mask with an integrated exhalation port or a circuit with a separate exhalation device, do not tape, seal, block the vent openings. »If oxygen is used with the device, the oxygen flow must be turned off when the device is not in use. »Oxygen should not be used while smoking or in the presence of an open flame.

Warnings »Do not use the device if the room temperature is above (35° C). If the device is used at room temperatures above (35° C), the temperature of the airflow may exceed (41° C), which could cause irritation to your airway. »Do not operate the device in direct sunlight or near a heating appliance because these conditions can increase the temperature of the air coming out of the device. »When the device is used with a humidifier, position the humidifier so that the water level in the humidifier is lower than you, and the humidifier is on the same level or lower than the device. »Do not attempt to wear your mask without the device turned on. Doing so could result in CO2 rebreathing. Rebreathing of exhaled air for longer than several minutes can, in some circumstances, lead to suffocation.

Warnings »If you notice any unexplained changes in the performance of the device, if it is making unusual or harsh sounds, if it and/or the power supply has been dropped or mishandled, if the enclosure is broken, or if water has entered the device, discontinue use and contact your home care provider. »Repairs and adjustments must be performed by Respironics authorized service personnel only. Unauthorized service could cause injury, invalidate the warranty, or result in costly damage. »Periodically inspect electrical cords, cables, and the power supply device for damage or signs of wear. »To avoid electrical shock, unplug the device before cleaning.

Cautions »The device may only be operated at temperatures between (5° C) and (35° C). »A properly installed, undamaged reusable foam inlet filter is required for proper operation. »Do not immerse the device or allow any liquid to enter the enclosure or the inlet filter. »Condensation may damage the device. Always allow the device to reach room temperature before use.

Intended Use The BiPAP AVAPS device is intended to provide noninvasive ventilation for pediatric patients 7 years or older > 18.2 kg and adult patients >30 kg with respiratory insufficiency or obstructive sleep apnea. This device may be used in the hospital or home. NOTE: The device is to be used only on the instruction of a trained health care professional.

Who potentially benefits from AVAPS™ technology? Restrictive patients benefit because AVAPS™ provides the comfort and leak compensation of a pressure mode and the safety of a guaranteed volume. Obese hypoventilation patients benefit because the algorithm compensates for changes in body position and maintains ventilation. COPD patients benefit because AVAPS™ achieves a combination of ventilation comfort and efficiency without compromise. The algorithm applies the right pressure at the right time.

Average Volume Assured Pressure Support in Obesity Hypoventilation: Randomized Cross-Over Trial This study conducted on 10 patients with obesity hypoventilation syndrome (OHS) showed that BiPAP® S/T substantially improves sleep quality and specific aspects of the quality of life; the addition of AVAPS further improves the decrease of PtcCO2.

Average Volume Assured Pressure Support (AVAPS) for Pressure-Controlled Ventilation (Bi-level Therapy with a BiPAP®AVAPS™ System) Three clinical cases of patients with chest deformities where the application of conventional ventilation methods (two patients using pressure-controlled ventilation and one using volume-controlled ventilation) did not produce satisfactory results. After switching to AVAPS, results included an increase in average SpO2, reduction of pCO2 and an improved acceptance of therapy compared to previously used ventilation methods. AVAPS technology makes it possible to combine the comfort and leak compensation of a pressure mode, and the safety and efficiency of an adaptable pressure support to fit current physiological conditions.

Short-Term Efficacy of Spontaneous AVAPS (Average Volume Assured Pressure Support) Mask Ventilation in Patients with Hypercapnic COPD The aim of this study was to evaluate the short-term clinical efficacy of spontaneous mask AVAPS versus PS ventilation in patients with hypercapnic chronic respiratory insufficiency. The primary end-point was to assess changes in blood gases whereas the secondary endpoint was to record the patient's comfort under these two different modalities. Results from 10 stable COPD patients: PaCo2 and patient comfort have been significantly improved Short-term AVAPS mask ventilation is feasible and effective in stable COPD patients with hypercapnia.

Contraindications 1-The device should not be used if you have severe respiratory failure without a spontaneous respiratory drive. 2-If any of the following conditions exist: Inability to maintain an open airway or adequately clear secretions At risk for aspiration of gastric contents Diagnosed with acute sinusitis or otitis media Allergy or hypersensitivity to the mask materials where the risk from allergic reaction outweighs the benefit of ventilatory assistance Epistaxis, causing pulmonary aspiration of blood Hypotension

Precautions »Immediately report any unusual chest discomfort, shortness of breath, or severe headache. »If skin irritation or breakdown develops from the use of the mask, refer to the mask instructions for appropriate action. »The following are potential side effects of noninvasive positive pressure therapy: »— Ear discomfort »— Conjunctivitis »— Skin abrasions due to noninvasive interfaces »— Gastric distention (aerophagia)

Rise time

S/T Mode

Mode summary

AVAPS averages Vt and changes PS value gradually. This occurs over several minutes. The rate of change is slow, so the patient is not aware of breath to breath change.

AVAPS features As the patient effort decrease,AVAPS automatically increase PS to maintain the target Vt. The IPAP level will not rise above IPAP Max. even if the target Vt is not reached. Conversely, as the patient effort increase, AVAPS will reduce PS, IPAP will not fall below IPAP Min. even if the target Vt is exceeded. If the IPAP Max. is reached and the targeted Vt is not achieved, the low tidal volume alarm is activated.

Bi-Flex comfort feature

Ramp

Respironics PR System One Once the device is powered, the home screen appears (it is a large box on the screen with four little boxes you choose from by turning the control wheel). Turn the wheel to toggle between the 4 options and highlight "setup". Once setup is highlighted press and hold both the control wheel and ramp button on the device for at least 5 seconds. You will hear a double beep and the provider mode screen will appear. Also, you should remove the smart card prior to making adjustments, otherwise it will revert to the previous settings.

Respironics PR System One Scroll down by turning the knob. Make a selection by pressing the knob down, which will activate the option. Change the setting by turning the knob again (for instance, from a 5 minute to 10 minute ramp time). Press knob to lock that choice in.

AVAPS suggested settings » 1. Set the target tidal volume to 8 ml/kg of ideal weight. »2. Set IPAP limits Max: 25 cm H20 depending on patient pathology Min: EPAP + 4 cm H20. »3. Set respiratory rate 2-3 BPM below resting respiratory rate.

Ideal body weight Estimated ideal body weight in (kg) Males: IBW = 50 kg kg for each inch over 5 feet. Females: IBW = 45.5 kg kg for each inch over 5 feet. Estimated adjusted body weight (kg) If the actual body weight is greater than 30% of the calculated IBW, calculate the adjusted body weight (ABW): ABW = IBW + 0.4(actual weight - IBW) The IBW and ABW are used to calculate medication dosages when the patient is obese. This formula only applies to persons 60 inches (152 cm) or taller.

»4. Set inspiratory time. » 5. Adjust rise time for patient comfort.

The recommended % IPAP time is usually between 30% and 40%. the default inspiratory time on nppv devices is commonly 1.2 seconds. (level a - consensus). A shorter inspiratory time (%IPAP time of approximately 30%) may be useful in patients with concurrent obstructive airways disease (especially at higher respiratory rates) to allow adequate time for exhalation. A longer inspiratory time (%IPAP time of approximately 40%) may be useful in patients with restrictive disease such as RTCD (decreased respiratory system compliance). (level a - consensus).

Suggested Protocol Set target tidal volume to 110% of displayed patient tidal volume in the S/T mode or 8 cc per kg of ideal body weight. IPAP Max = cm H20 IPAP Min = EPAP + 4 cm H2O *Respironics does not provide medical advice. This protocol is a suggested protocol only and is not intended to replace or modify your institution's established protocols.