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AVAPS & AVAPS-AE Auto-titration Modes of Non-invasive Ventilation Preliminary Setting Guidelines. Nicholas Dawson, RRT and Bill Moller, RPSGT, RST. Philips Home Health. Educational Objectives What we will cover today:. What is AVAPS-AE? AVAPS mode; Why do we need it? - PowerPoint PPT Presentation
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Philips Home Health , NIcholas Dawson
Nicholas Dawson, RRT and Bill Moller, RPSGT, RST
AVAPS & AVAPS-AEAuto-titration Modes of Non-invasive Ventilation Preliminary Setting Guidelines
Philips Home Health
Philips Home Health , NIcholas Dawson 2
Educational ObjectivesWhat we will cover today:
• What is AVAPS-AE?
• AVAPS mode; Why do we need it?
• AVAPS & AVAPS-AE Modes; Settings and Range
• AVAPS-AE Suggested settings guidelines in OHS and COPD-OSA
• Summary/Questions
Philips Home Health , NIcholas Dawson 3
AVAPS-AE
AVAPS-AE is a auto-titration mode of noninvasive ventilation designed to treat respiratory insufficiency patients (OHS, COPD and NMD) in the hospital and homecare environments
• Proven performance of AVAPS – Maintains targeted Tidal volume
• Auto EPAP – Maintains patent upper airway at comfortable pressure
• Auto backup rate – Applies an auto backup rate near a patient’s resting rate
Philips Home Health , NIcholas Dawson 4
AVAPS; What is it?Average Volume Assured Pressure Support
• As name implies, it is simply volume targeted pressure support.• Auto titrating mode that responds in Inspiratory pressures to changes in
thoracic dynamics to ensure stable tidal volume delivery.• Considered a “Hybrid” mode since it is both Pressure and Volume
oriented mode of ventilation• Also used as an ‘adjunct’ or added to other modes of ventilation such as
“S” mode, “S/T” mode or even PC (Pressure Control) mode• Allows clinician to set operating pressure limits for safety or diagnostic
purposes• Available in R.A.D. platform, but more fully developed in Trilogy
Ventilator• Also recently developed in new Omni-Lab Advanced titration device.
Philips Home Health , NIcholas Dawson 5
AVAPS: proven effective
• Automatically titrates pressure support– Changes in body position– Sleep stage– Changes in respiratory mechanics
• Delivers average tidal volume– Throughout course of the night– Long-term progression = protects/defends resting lung volume.
• AVAPS produces results comparable to sleep lab titration of PS1 – CO2 reduction
– Health-related quality of life– Sleep quality
1Murphy, PBThorax thoraxjnl-2011-201081: Published Online First: 1 March 2012 doi:10.1136/thoraxjnl-2011-201081
Philips Home Health , NIcholas Dawson 6
AVAPS-AE: Who it treats
• AVAPS-AE is used for patients with complex breathing disorders with or without OSA component who suffer from Minute ventilation instability. Etiology can stem from Hypoventilation syndromes to airflow limitation related to obstructive pulmonary disease. Patients with dynamic I:E ratios and chronic parenchymal disease with limited reserve lung volumes can benefit from the auto rate feature alone.
• Many of these patients primarily have COPD and some Hx of Chronic Respiratory Failure who may be underserved by traditional sleep therapy modes & methods.
Philips Home Health , NIcholas Dawson 7
Who can benefit from AVAPS-AE?
• Neuromuscular disease
• Restrictive thoracic disorders
• COPD with Chronic respiratory failure
• OHS with chronic hypercapnea
• Pulmonary patients that fail to respond to traditional RAD device
therapy
Philips Home Health , NIcholas Dawson 8
AVAPS-AE: Adds Auto EPAP option
• Auto EPAP provides airway patency– Designed for NIV use only– Patient benefit: lower, more comfortable EPAP pressure
• AVAPS-AE and patient overlap
– ?? ~ 30% of COPD patients have OSA1
– 90% of OHS patients have OSA2
• AVAPS-AE: 1st NIV therapy with Auto EPAP designed for respiratory insufficiency and respiratory failure patients
1Jelic International Journal of COPD 2008:3(2)269-2752Mokhlesi. Chest 2007:131;1624-1626
Philips Home Health , NIcholas Dawson 9
AVAPS-AE: How to use it
• Start with tidal volume selection:– 8ml/kg IDEAL bw Suggest a range +/- 150mls
• Assess need for EPAP: select a range to monitor or manually titrate
• Choose Pressure support range: (2 methods) new user/existing user– New user: set Pressure support levels lower e.g. 5/15– Existing user: take existing Rx IPAP…+10 & -10
• Set back up rate if desired: set to auto for all COPD
• Set comfort settings: Ramp- Rise time- AVAPSrate
Philips Home Health , NIcholas Dawson 10
AVAPS-AE: Auto EPAP proactive analysis
Theory of Operation
Upper Airway Resistance
Device Pressure
P search
crit
Ptherapy
P searchopt
Illustration courtesy of Krames Medical Illustration.
Philips Home Health , NIcholas Dawson 11
AVAPS-AE: Auto EPAP proactive analysis
Popt – Optimal Pressure Search
(High Pressure Search)
EP
AP
P opt
P opt
P therapy
P therapy
Critical Pressure Searches
(Low Pressure Search)
P crit
P crit
P therapy
EP
AP
P crit
P therapy
Popt
Pcrit
Pther
Popt
Pre
ssur
e
Resistance
Pcrit
P opt
Philips Home Health , NIcholas Dawson 12
Comparison of Auto EPAP methodsCurrent PRI Auto EPAP/CPAP
FlatnessRoundnessPeakShape
AVAPS-AE
Flo
wP
res
su
re
Forced oscillation technique (FOT) at 5 Hz, 1 cm amplitude during EPAP
Philips Home Health , NIcholas Dawson 13
Benefits of FOT
• FOT may improve detection of obstructed airways at higher pressure support levels
– Not affected by high levels of pressure support– FOT measurements taken at end exhalation (10 breaR R R R
Increase in EPAP by 1 cm H2O s
Philips Home Health , NIcholas Dawson 14
FOT – Flow resulting from pressure
FOT signal
Resulting flow
Philips Home Health , NIcholas Dawson 15
FOT – Patent vs. obstructed airway
• . Patent/Normal airway
Resulting flow (higher resistance)
Resulting flow (low resistance)
Obstructed airway
Philips Home Health , NIcholas Dawson 16
AVAPS-AEMaintaining tidal volume and airway patency
EPAP
Target Vt
IPAP PS min
PS max
EPAP min
EPAP max
Resistance
Philips Home Health , NIcholas Dawson 17
Auto Back-up rate
• Auto backup rate is near resting rate
• Comfortable assistance when needed
• No manual adjustments (auto-default setting)
Auto Backup Rate
Auto backup rate combined with the tidal volume assurance of AVAPS provides a minimum level of ventilation
Philips Home Health , NIcholas Dawson 18
Auto Backup rateM
ovi
ng
bre
ath
rat
e
Minimum autobackup rate
Spontaneous breaths
Time 50 spontaneous breaths
10
Calculated spontaneous
rate
Target auto backup rate
Targeted auto backup rate is 2 bpm below avg. spontaneous rate
Bp
m
Philips Home Health , NIcholas Dawson 19
Auto backup rate
Spontaneous Breaths
Timed Breaths
Target auto backup rate
10 Auto backup rate buffer zone
The auto backup rate is buffered by spontaneous triggers to promote synchrony
with the device
• The buffer is reduced by timed triggers• The patient will be guided back to the
targeted backup rate
Bp
m
Mo
vin
g b
reat
h r
ate
Time (Night time session)
Philips Home Health , NIcholas Dawson 20
Auto Backup rate: Patient comfort features
• Comfort feature intent: Minimizes patient/device asynchrony
– Rate will not exceed patient’s initial resting
spontaneous rate
– Machine breath delayed if patient is still exhaling
– AVAPS-AE allows patient to terminate a machine delivered breath
Philips Home Health , NIcholas Dawson 21
AVAPS-AE suggested settings
OHS* COPD – OSA*Vt Target 8 -10 ml/Kg of ideal
bodyweight8 ml/Kg of ideal
bodyweight
Max P 35 cmH2O 30 cmH20
PS Max 19- 35 cmH2O 30 cmH2O
PS Min 14 -19 cmH2O 12 cmH2O
EPAP Max 14 cmH20 14 cm H2O
EPAP Min 4 cmH2O 4 cm H2O
Breath Rate Auto Auto
AVAPS Rate 2 N/A
* AVAPS-AE protocol Dr. N. Hart, Dr. P. Murphy, Lane Fox Respiratory unit, St. Thomas’ Hospital London UK* AVAPS-AE Multi Center Trial protocol l,Prof Jean François MUIR, France
Philips Home Health , NIcholas Dawson 22
AVAPS-AE: Comfort Settings
• Ramp- Sets pressure support back to minimum level setting. Use if patient sensitive to initial pressures at time of sleep. Can be turned “OFF” if not desired
• Rise time: setting 1-6 default is 3..lower toward 1 for flow starved patients, raise toward 6 for NMD
• AVAPS rate: sets speed of response for pressure support changes while chasing tidal volume
Philips Home Health , NIcholas Dawson 23
AVAPS-AE: What to monitor…
• AVAPS-AE will titrate pressure support based upon the tidal volume target set and the patients dynamic lung compliance or ability to generate volumes at the given inspiratory pressure support level.
• EPAP can be monitored during ventilation • Inspiratory flowrates can be monitored for patients who have disease
states that may require variability in inspiratory flow rates.• Respiratory rate can be set fixed BPM and monitored for flow
challenges with changing I:E ratios or can be set to “auto” and nocturnal respiratory rate can be monitored and compared to minute ventilation stability.
Philips Home Health , NIcholas Dawson 24
AVAPS-AE
• Proven performance of AVAPS– Confidence that tidal volume targets are being met
• Auto EPAP– Auto adjusting EPAP to meet changing patient needs – Maintains a patent airway
• Auto backup rate– Maintains a breath rate designed for patient comfort (easy to use)
Philips Home Health , NIcholas Dawson 25