The International Palestinian Congress in Sleep Medicine · §A mask that is too large or too small will be uncomfortable. §Nasal symptoms frequently respond to heated humidification

26and27October,2017NotreDameHotel,Jerusalem

TheInternationalPalestinianCongressinSleepMedicine

“TemporomandibularDisordersandSleepApnea”

MariettaBellamyBibbs,BA,RPSGT,CCSHManager,SleepDisordersandNeurodiagnostics

MortonPlantMease HealthCare- BayCareHealthSystemClearwater,FL

UsingPAPDownloadstoManageSleepApneaPatients

IAMSTILLSLEEPYBUTIAMUSINGMYPAPTHERAPY

StartingPAPTherapyTolerance

§ Everypatient’sexperiencewithtoleratingPAPtherapydependsonacombinationofsymptomsandconsequencesofthedisorder.

§ Eachpatient’sadjustmentprocessforstartingCPAPtherapyisunique.

AdjustingtoPAPTherapy

§WhenstartingPAPtherapy,patientsrequireaperiodofadjustment:§ thepresenceofthePAPmaskontheface§ thefeeloftheairpressuredeliveredbythePAPunit

§ Theadjustmenttimevariesandcantakefromafewdaystoafewweeks.

§ SomepatientsmaytakemonthstoadjusttoPAP.

NeverGiveUp!PersistencePaysOff

§ ThemostimportantrecommendationforanypatientstartingCPAPtherapyistonotgiveup.

§ Thesleepphysicianandthesleepcenterstaffcanhelppatientswhohavepersistentdifficultyadjustingtotherapy.

SideEffectsofPAPTherapy

§ ThemostcommonPAPside-effectsaremaskorpressurerelated:§ClaustrophobiatothePAPmask§Nasalcongestionrhinitisorarunnynose

§WhileCPAPside-effectsareanuisance,seriousside-effectsareveryuncommon.

§ Researchhasshownthattheside-effectsfromusingPAParerarelythereasonpatientsstopusingit.

SideEffectsofPAPTherapy

§Frequentnocturnalawakenings§Nasalirritation§Dryness§Puffing§Leaking§Claustrophobia§Snoring§Flatulence§Othersleepdisorders

FatigueandSleepiness

§ SymptomsareusuallyeliminatedassoonasPAPtherapyisstarted.

§ StudieshaveshownthatthemaximumeffectofPAPtherapyoccursinabout2weeks.

§ Forunclearreasons,somepatientshavepersistentsleepinessdespitegoodadherencetoPAP.

§ StimulantmedicationmaybeappropriateforsomeofthesepatientssincePAPwillnotmakeupforinsufficientsleep.

ManagePatient’sSymptoms§ IfmaskclaustrophobiaisinterferingwithPAPtolerance,sendthepatientfordesensitizationtraining.

§ GoalisgettingpatientaccustomedtothePAPmaskandpressuresothattheyforgetit’sontheirface.

§ StartwithshortperiodsoftimewhileawakeandengagedinadistractionlikewatchingTVorreading(10minutesandbuildfromthere).

§ GraduallyincreasethetimeusingPAPwhilesleepingfrom1-2hoursupto6-7hours.

ManagePatient’sSymptoms§Makesurethemaskiscomfortableandthehumidifierisworking.

§ Treatnasalcongestionwithheatedhumidificationornasalmedications.

§ Emphasizethepositivestopatientsaboutimprovementsinsleepandsleepapneasincethosepatientswhostrugglewiththerapyoftenlosetrackofsomeofthegoodthingstheyhavenoticedabouttherapy.

SimpleThingsCanHelpMinimizeSide-EffectsofPAP

§ ThePAPmaskmustbefittedappropriately:§ Amaskthatistoolargeortoosmallwillbeuncomfortable.

§NasalsymptomsfrequentlyrespondtoheatedhumidificationofthePAPair:§ PAPmachinesnowcomewithheatedhumidifiersbutmanypatientsdonotusethem.

§ Teachthepatientnottoovertightenthemask:§ Commonmistakecanleadtomaskdiscomfortandskinirritation.

§ Ifairleaksoccur,thePAPinterfaceshouldbechanged.

ExhalationRelief§ ExhalationreliefallowstheCPAPmachineorBPAPmachinetoreducetheinspiratorypressureduringexhalation,whichmakesiteasiertobreatheoutagainstthepressure.PAPmanufacturershavedifferentnamesforexhalationrelief,buttheymostlyworkthesameway.Pressurecanbeadjustedupto3cm forcomfort.

§ Respironics callstheirpressurereliefC-Flex,A-Flex,orC-Flex+.C-Flexlowersthepressureonexhaleandquicklyrampsbackuptotheprescribedpressure.A-FlexonAutoCPAPmachinesonly,lowersthepressureonexhalationandgraduallyincreasesthepressureduringinhalation.Thisallowsforamorefluidbreath.

§ ResMed usesEPR forpressurerelief.Pressuresaredecreasedupto3cmduringexhalion andquicklyincreasedbacktoprescribedpressurewheninhalationisdetected.

§ DeVilbiss - SmartFlex issimilartoRespironicsC-FlexandResMedEPR.

ManagingPatientswithPAPDownloadsWhatTheyTellUs?

SummaryReport

CPAP

SummaryReport

AutoCPAP

EncoreReportStructure:FullReport

DemographicsHoursofUsePressureTrend

PatternsofUse(Oneormorepages)

Long-TermTrends

18

Blackindicatesnobreathingdetected.IsthedeviceofforIstherealargeleak?

Patientisstrugglingwithcompliance.Noteallredbarswhichsignifythat4hoursofusageanightisnotbeingmet.Theblackbarssignifythatbreathingisnotbeingdetected.

BlowerOnandnobreathingdetected

BlowerOnandbreathingdetected

BlowerOff

Thefirstnumberrepresentstimeduration

oftotalcompliance.Thesecondnumber

representstotalblowerhours

PatternsofUse

20

Notethedifferencesintimes.Rightisblowertime,leftistherapytime.Theblackbarsindicatethatthedeviceisrunningbutbreathingisnotdetected.Itisadifferentviewofcomplianceissues.

LongTermTrend

AverageObstructiveindex

AverageFlowLimitationindex

AverageSnoreindex

Average%nightinlargeleak

AvetimeinLargeLeak

AverageHypopnea

AverageCentralApneaindex

Average%nightinPeriodicBreathing

AverageRERA

22

Isthistheappropriatetherapydevice?

Whatiscausinghighhypopneas?

WhatiscausinghighAHI?

Largeleakmaybeaproblemandlimittheautoalgorithm’sabilitytoreachtherapeuticrange

Thelongtermtrendpagecanprovidealotofinfo.Both%ofnightinPBandAverageCAindexcanhelpleaddecideifthepatientisontheappropriatedevice.

AhighAHIandmaskleakcanhelpwithdeterminingtheproblem.

ShawnHannah

FlowWaveformReport

1hourperpageupto8hoursofsleepsession

Thispageprovidesuptoeighthoursofdevicescoredtitration.Thebluelineshowspatientflowandtheredlineshowsdevicepressure.Ifthedeviceisinautomode,thereportwillshowchangingpressures,specificallywhenitchanges,howitchangesandwhyitchanges.

FixedCPAPReports:PatientDemograhpicsDatesforReports

Mode

C-Flexsetting

Humidifiersetting

Pressure

UsagePattern

AutoCPAPReports:PatientDemographics

90%pressure-

Mode

A-Flexsetting

Humidifiersetting

Maxpressuresetting

Min.pressuresetting

DeviceUsed

UsagePattern

DailyDetailsUpto7daysofDailyPressure,AHIandLeakReporting

PressureProfile

90%Pressure

AveragePressure

EventFlags:•Centralapnea•Obstructed•Hypopnea•Flowlimitation•Snore•RERA•AHI

Maxpressuresetting

Min.pressuresetting

%PeriodicBreathing

90%Pressure

MinutesatPressure

Timeinlargeleak

AveLeakinnight

DailyDetails

%timeinlargeleak

Bloweronbutnobreathingdetected

Breathingdetectedbuttoolargeforeventdetection

NormalMaskFit

TotalleakprofileinLPM

28

PeriodsofPBindicatethewrongtherapeuticdevice

Largeleakearlyandtoolowpressuretostart.Devicewillcorrectleakbydecreasingpressures.

ResMedAirView Report

ResMedAirView Report

StatisticsavailableintheResMedAirViewComplianceReport

ResMedAirviewTherapyReport

StatisticsAvailableintheResMed AirviewTherapyReport

LeakIdentification

IntentionalLeak Unintentional

Leak

TOTALFLOW

TOTALFLOW =Intentional+Unintentional

Leak(orFlow)isproportionaltoPressure

AVERAGEINTENTIONAL

LEAK

AcceptableMaskLeak

WhatisaLargeMaskLeak?

• LargeLeakLevelsoccur@>2timestheaveragemaskexhalationportleak

• Consideredtobein“Largeleak”ifthresholdexceededforgreaterthan1.5minutes.

• AlightgreenhashmarkonMaskLeakgraphindicatesalargeleakhasoccurred

WhatIsAcceptableMaskLeak?

WhathappenswithAutoandaLargeLeak?

LargeLeakLevelsoccur@>2timestheaveragemaskexhalationportleak

• “LargeLeak”clearedwhentheleaklevelfallsbelowthresholdformorethan1.5minutes.

• Dropspressure1cmeverytwominutes untillargeleakconditioniscleared.

AutoDeviceLeakTolerance

ShouldtheLeakBeTreated?

§ Isthepatientsymptomatic?

§ Doesthepatientorthespousecomplainthattheleakwakesthemupatnight?

§ Doesthepatientlimitthetimeofusesecondarytotheleak?

§ PAPdevicesdecreasepressurewhenlargeleaksaredetectedforover1.5minutes.

§ Donotincreasepressurestoaddresstheleak.

§ Largeleakisanindicationofmaskfitissuesrequiringcorrection.

IFeelBetterSinceIStartedPAPTherapy,ButMyHusbandTellsMeIAmStillSnoring

FixingMaskLeakMayHelpWithSnoring

AddingaChinStrapMayHelptoReduceSnoring

ChangetoaFullFaceMask

CheckMaskFit

NoAlgorithmResponse(CA)ClearAirwayApnea

PeriodicBreathing

Hypopnea

VibratorySnore

AdvancedEventDetectionIdentificationofcomplicatedandchangingconditionsthatmay

indicatealternativetherapy

(OA)ObstructedAirwayApnea

RERA

FlowLimitation

MaskFitIndicator

Flow

• Waxingandwaningbreathingpatternrepeatingitselfbetween30and100sec

• Thenadirischaracterizedbyatleasta40%reductioninairflowfrombaseline

• Thepatternmustbepresentforseveralminutes



PeriodicBreathingsuchasCheyne-StokesRespiration



Flow Flow

Pressure Pressure

ThisAirwayisObstructed ThisAirwayisClear


indicatealternativetherapyOA:ObstructedAirwayApnea

CA:ClearAirwayApnea

OA:ObstructedAirwayApnea

80%FlowReduction

80%FlowReduction

80%FlowReduction

Troubleshooting

§ Detaileddownloadnotavailable§ Reviewthepatient’shistory§ ReviewClinicalOutcomes(EpworthSleepinessScale,FOSQ,SnoreOutcomesSurvey,etc.)

§ ImproveUsage§ Workonimprovingcomfort§ ChangetypeofInterface

§ PAPAdjustmentPeriod§ Urgepatienttoreplacethemaskfollowingawakenings

§ Weardeviceduringnaps§ Placepatientonatrialsleepmedication

ReviewDetailedDownload

§AttentionTo:§Hoursofuse§AHI§Snoring§Leak

Doctor,I’mStillSleepy………….

StillSleepyonPAP?????

§ IncreasethePAPPressure§ ConsiderchangetoAutoPAP atsetrangetodeterminebestpressure§ ChoosemaximumIPAP§ ChooseminimumEPAP§ ChoosemaximumrangebetweenIPAPandEPAP

§ ConsiderchangingtoBPAP§ Setinspiratorypressure—resolvessnoringandhypopnea§ Setexpiratorypressure—resolvesapnea

EngagePatientinTheirTherapy

PhilipsSleepMapper

ResolveProblemswithPAPUsage

OnTopofTheWorld

Documents

The International Palestinian Congress in Sleep Medicine · §A mask that is too large or too small will be uncomfortable. §Nasal symptoms frequently respond to heated humidification