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

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

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

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7. 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. 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. 9 Physiologic Changes in Respiratory Control with Sleep Major Influence on breathing Pattern of breathing Central Apneas/Hypopneas 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. InactiveActiveTransitiona l Sleep* Stage 2Slow Wave Sleep REM Sleep Metabolic Regular Absent Present Phasic Behavior Irregular Absent Decreased Phasic Metabolic** Periodic Often Variable Phasic Metabolic Regular Rare Mild Decrease Phasic Metabolic Regular Absent Mild Decrease Phasic Non- metabolic Irregular Frequent Mod. Decrease Paradoxical

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

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

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

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

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

15. 15 < 1 cmH 2 O / min increase AVAPs Algorithm Desired VolumeVolume IPAP SettingPressure 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 Obstructive Events Try to breathe but can’t get enough in 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? Impaired Gas Exchange Oxygen drops/Carbon Dioxide rises Impaired Gas Exchange Oxygen drops/Carbon Dioxide rises CSA Central Events Don’t breathe at all or pattern is mixed up Central Events Don’t breathe at all or pattern is mixed up Hypoventilation 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? What would this look like on a PSG? HST? Therapy download? 16

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

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

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

20. BiPAP autoSV Advanced Theory of Operation Servo Ventilation Algorithm 20 Algorithms to match the pathologies

21. 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 21 cmH 2 0 Auto CPAP cmH 2 0 CPAP

22. 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. 22 cmH 2 0 Bi-Level cmH 2 0 Auto SV Flow pattern could look different depending on position and spontaneous vs machine breath. Why? How would this graphic look for AVAPS?

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

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

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

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

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

28. 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. 29 IF: Peak flow is at target THENASV delivers CPAP pressure only Servo Ventilation Algorithm – Normal Breathing I wonder what hypoventilation would look like?

30. 30 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 Servo Ventilation Algorithm – Normal Breathing Hypoventilation would look like THIS!

31. 31 IF: Peak flow falls below target THEN: autoSV Advanced increases pressure support Servo Ventilation Algorithm – Decreased Flow

32. 32 < 1 cmH 2 O / min increase Assured Volume Algorithm Desired VolumeVolume IPAP SettingPressure 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 SS OA S H Pearl SV algorithm works ‘on top’ of Auto EPAP The higher the EPAP, the less “space” the ASV algorithm has to work - Life is all about compromise! Max pressure EPAPmax EPAPmin S = Snore H = Hypopnea OA = Obstructive apnea Auto EPAP 25 15 5

34. The Complex Sleep Apnea Bucket List PathologiesPreferred Treatment OSACPAP, APAP Periodic BreathingaSV or AVAPS Cheyne Stokes type Periodic Breathing aSV Central Sleep ApneaaSV or AVAPS Central HypopneaaSV or AVAPS HypoventilationAVAPS CPAP emergent “Central Sleep Apnea” Depends. Check baseline PSG. May change with treatment. 34 Complicated X

35. 35 What do you see?

36. 36 AM060606 What do you see?

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

38. 38 AM060606 What do you see?

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

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

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

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

44. Terms you need to understand 44 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. 45 EPAPmin EPAPmax Max pressure PSmax 15 cm H 2 O PSmin 3 cm H 2 O Let’s take a look at these terms graphically We will discuss this more when we talk about titration PSmin Auto EPAP - Looks like Auto CPAP! Auto EPAP PSmax 25 15 5

46. 46 EPAPmin EPAPmax Max pressure PSmax 10 cm H 2 O PSmin 0cm H 2 O Let’s take a look at these terms graphically We will discuss this more when we talk about titration PSmin Auto EPAP - Looks like Auto CPAP! Auto EPAP PSmax 25 15 5

47. Understanding what “success” looks like 47

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

49. Titration goals 1.Keep the upper airway open (airway management). 2.Stabilize breathing patterns by monitoring the patient’s response to therapy. 3.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 49 Pearl Exquisitely designed algorithms in partnership with your clinical experience, knowledge and observations AND a clear definition of “success” results in SUCCESSFUL THERAPY

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

51. Titration Protocol References This protocol is consistent with device validation studies and the following AASM clinical guidelines : 1.Clinical Guidelines for the Manual Titration of Positive Airway Pressure in Patients with Obstructive Sleep Apnea; J. Clin. Sleep Med 2008, 4(2)157-171 2.Clinical Guideline for the Evaluation, Management and Long-term Care of Obstructive Sleep Apnea in Adults; J. Clin. Sleep Med 2009, 5(3)263-276 3.Best Clinical Practices for the Sleep Center Adjustment of Noninvasive Positive Pressure Ventilation (NPPV) in Stable Chronic Alveolar Hypoventilation Syndromes, Accepted for publication J.Clin.Sleep Med Aug. 19, 2010 51

52. Complex sleep apnea patients may challenge even the most experienced, skilled sleep technologist! Complex sleep apnea patients have multiple pathologies each requiring the attention of the technologist Helpful hints for complex sleep apnea titrations –Obstructive apneas, obstructive hypopneas, central apneas, hypopneas, RERAs and periodic breathing may all be present intermittently throughout the sleep period –Making the patients 100% normal may not be a realistic goal –Optimizing therapy within a range the patients tolerate, will be compliant with and are much better than they were is an achievable goal –Patience is key to successful titrations –If a change is needed, Watch, Wait, Observe and Think before making any other adjustments. If the change isn’t effective, put it back to the original setting and wait before you try something else. 52

53. 53 Patient Follow-up

54. Titration is just the beginning of successful therapy Continuing clinical assessment is essential for: –Compliance and efficacy –Achieving long term benefits, lower morbidity/mortality Complex sleep apnea patient may be the most challenging to follow up because they have multiple, changing pathologies requiring therapy –Achieving optimal therapy and meeting patient comfort needs can be a challenge that requires ongoing assessment of therapy device downloads and interviews with the patient 54

55. 55 SV algorithm works ‘on top’ of Auto EPAP AUTO EPAP Advanced technology and YOU The perfect combination! How do you think the patient’s physiology will change during the first weeks of ASV use?

56. Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain, Robert J. Farney, M.D; J Clin Sleep Med. 2008 August 15; 4(4): 311–319. –Retrospective study Conclusions:“Due to residual respiratory events and hypoxemia, ASV was considered insufficient therapy in these patients Persistence of obstructive events could be due to suboptimal pressure settings (end expiratory and/or maximal inspiratory). Residual central events could be related to fundamental differences in the pathophysiology of CSR compared to opioid induced breathing disturbances.” 56

57. Pearls 57 Complex physiology and pathology makes many patients difficult to treat. They are a moving target. Many times, making them BETTER THAN THEY WERE on the titration night IS a success! In contrast to uncomplicated OSA patients titrated on CPAP, the complex patient’s titration doesn’t END on the titration night. It is just the beginning! Know and understand SMART technology. It needs your understanding and guidance to succeed

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