pap download interpretation and case-based discussion filepap download interpretation and case-based...

PAP Download Interpretation

and Case-Based DiscussionLoretta Colvin, APRN-BC

Nurse Practitioner

Clayton Sleep Institute

Objectives

• Review PAP adherence report elements

• Incorporate PAP report data into clinical

assessment

• Identify PAP machine technology

variations in reporting

Conflict of Interest

• I have no conflicts of interest to disclose

Adherence Assessment

Considerations

Data Assessment • Availability

– Software (Internet access, back-up options)

– Data transfer tools (Modem, card)

• Strengths

– Augments patient story

• Weaknesses

– Relies on manufacturer development,

communication and support

– wide variation in options

Patient Assessment

• Do subjective and objective reports agree?

• If not, which do you “believe” or how do

you assess further?

Recommendation

• ALWAYS view detailed data for issues

– Patient issues

• Not improving, Not tolerating,

– Report issues

• ↑ AHI, ↑ leak, ↑ pressure

• Data “issues”

• QUESTION technology when appropriate

Direct data from

machine display

screen

Data card

download in clinic

Modem

transmitted

DME creates

download and

sends to clinic

Pros: - Back-up when

no card (ex:

older machines)

- Back-up if no

computer

available

- You control the

data

- Can bring up

any report/time

range you chose

- Can access data

from anywhere

and at anytime

- Patient does not

have to bring

equipment

- DME does

the work for

you

Cons: - Limited data

available for

review

- Requires skilled

personnel to

download

- Relies on patient

to bring

machine/card

- DME must

“assign” the

modem to your

clinic

- Potential modem

glitches and

failures

- DME controls

what data

you get

- More

paperwork

and people

involved

Data Access

Software options

Web-Based PC Based

Fisher & Paykel Infosmart Web Infosmart

ResMed AirView(renamed from EasyCareOnline)

ResScan(Screens look very different)

Respironics EncoreAnywhere Encore Pro

Tip – update your PC Based programs to most current version

when any new machine is released (ex: AirSense)

• Data card

• USB or SD card

• Modem

• External

• Internal

• Viewing machine screens

• Typically basic usage available

Adherence Data

F&P

Icon

Respironics

System One

ResMed

S9 / AirSense

Data card USB SD SD

Office card download + + +

Home card download for clinician view

+ + -

Home download for patient viewing

- +SleepMapper

+MyAir (AS)

SleepSeeker (S9)

Modem download + + +

Data Downloads

F&P

Icon

Respirionics

System One

ResMed

S9 & AirSense

Upload schedule

•Fixed time(9 am CST)

•Pt initiated / set

•q 24 hours

•S9 Fixed time (1-4 pm PST)

•AirSense HALO

Patient transmission?

•Yes •Yes •No

Data transmission

•Cellular signal

•30 days stored

•External

•USB removed

•Cellular signal

•Blue tooth avail.

•External

•SD card stays

•Cellular signal

•S9 external

•AirSense internal

•SD card stays

Modems

Data “Pearls” for ResMed

• AirView (formerly Easy Care Online)– Cannot set range for historical detailed data

– Select BOTH compliance & summary for more data

– “Clock time” summary view not printable – hover mouse on screen

• AirSense– Modem: HALO (hour after last off) delay with AM appts

– Conveniently displays last night usage on machine screens

• S9– Detailed report – use card in ResScan, not modem

– SleepSeeker does not interface with clinician data view

• S8– Only stores 6 months, only downloads in ResScan

– Stores mini-card out of machine

Data “Pearls” for Respironics

• EncoreAnywhere

– DME must grant access for online script changes

– Custom “day” cut-points (helpful for shift work)

– SleepMapper requires DME to link office to patient

• System One

– Internal clock stays at noon cut-off for “day”, changes

can only be done in EncoreAnywhere report

• Respironics M-series and Legacy

– Lose card, lose data

Data “Pearls” for Fisher & Paykel

• InfoSmart web

– Change to settings screens to get custom date range

and click “generate” tab

– Reports may need to be “fit to window” for printing

• Icon

– USB easily inserts backwards in computer

– Home download allows office view w/o pt account set-up

– Screen display less user friendly

– Basic mode available for “low tech” patient screens

Report Components

F&P

Icon

Respironics

System One

ResMed

S9 / AirSense

Pressure Average &

90th percentile

Average &

90th percentile

Median &

95th percentile

Leak Total

>40-50 L/min high

Total

>40-50 L/min high

Unintentional

>24 L/min high

Custom date range

+Change screens

Detailed

+Initial screen

Summary & detailed report

+/-Count back days

Summary only,

not on detailed

Reports -Summary

+ Detailed

+ Summary

+ Detailed

+ Customized

+ Summary

+ Detailed

Key Components

F&P

Icon

Respironics

System One

ResMed

S9 / AirSense

Pressure relief

SensAwake Flex / Flex+ EPR

Humidifier

Chamber

0-7 0-5 S9 0-6

AS 0-8

Heated Tubing

Boost L-M-H 1-2-3 60 – 86 degrees

Comfort Features

Cases

Pressure Relief

ResMed EPR

• Baseline AHI 11

• Titration - 9 cm

recommended

• EPR 3 acts

similar to “mini-

Bilevel”

Fisher & Paykel SensAwake

• CPAP 9 orders

sent to DME

• DME left

SensAwake on

• AHI 2.9 on report

Another Example – SensAwake

Respironics SystemOne Cflex +PSG

AHI 120’s

Low sats 60’s

“AHI” 31

Leak

F&P Icon – Infosmart

• Is leak acceptable? (group)

> 50 is high

F&P Icon – Another Example

ResMed S9 – EasyCare Online

• Is this OK? (group)

Below 24 is

OK

for ResMed

(excessive

leak)

SystemOne - Encore Anywhere• What’s happening? (new patient returns for first CPAP f/u)

Respironics (cont)

What happened?

Another Case Example

Nasal

Interface

Full

Face

Mask

Case Example (cont)

Worsened Variable Leak

• Patient received replacement mask

seal for FFM, worsened variable leak

begins after seal received

• Inspect equipment

• Patient sent wrong seal, inserted it

over existing seal

AHI

Case #1

• Baseline AHI 12

• CPAP 10

recommended

• Patient

complains

machine turning

itself off

• What next?

Case #1

• “Auto off” was activated

• Machine turning itself off when not detecting airflow (leak)

• Ramping with each restart

• Events noted at low pressures

• Resolved with mask re-fit

Normal Leak

Maxed Pressure

Residual Events

Case #2

• Minimum

pressure

too low

• Events

reduce at

high

pressure

• Leak may

be

acceptable

(for high

pressure)

depending

on mask

Case #3• Baseline

– AHI 135

– SpO2 58%

• CPAP 14

– AHI 1.8

– SpO2 86%

– Supine/REM

“Summary Report” 2 week

“Trend Report”

• AHI 33.9

• VS Index

525.5

• 0.6%

large leak

Detailed View

• CPAP 14

• AHI 51

• OA 45

• Leak 40

(FFM 12 cm)

• 0.3% large

leak

Detailed Report Different Night

• AHI 1.2

• Leak 42

Home Oximetry

Case #3 Discussion

Case #4 Routine Appointment

Baseline

Day 1 and 2 (x 1 weeks)

2 weeks later

Case #4 Discussion

Case #5 “Compliance Report”

Case #5 “Therapy Report”

Case #6 “Detailed Report”

AHI 20 AHI 11 AHI 0.2

Case #7• 51 year old male

w/snoring, EDS, HTN

• BMI 29.9 m/kg2, weight

213 lbs, height 5’11”

• Home Sleep Test

performed

– RDI 13.7 events/hour

– Nadir oxygen 83%

• Auto PAP min 6 max 14

• Patient feels “horrible”– Foggy

– Headaches

– Worse than baseline

Case #7 Details

Case #7 Min Pressure Dropped

Machine and Patient

Discrepancy ?

Modem Case Example

• DOT driver with Respironics SystemOne

• Comes in for f/u

• No data for past 3 weeks on printed report

• What happened?

Respironics DOT modem • Assess last

machine usage

• May not transmit if no usage

• If concerned about modem, “test” by allowing to run for 1 min then transmit

• When in doubt, start self-monitoring

Patient Self-Monitoring

• Patient log

• Machine data monitoring

– On screens

– Online

Humidifier

Case Example

• Patient calls complaining of nasal and

mouth dryness on CPAP 12 using full face

mask.

• Reports humidifier set at 5

• What do you do? (Group)

– Change humidifier setting

– Do not change humidifier setting

– Ask more questions

Case Example – next steps

• Determine machine brand

• Verify no significant mask leak

• Use your cheat sheet for humidifier settings range

• Max varies based on machine (5-8) and tubing

• Patient vs. algorithm adjustment ?

• Can you walk a patient through changing it?

• Role for add-on equipment? (ex: heated tubing)

• Remember “quirk” for Respironics heated tubing

Using Technology

Always Pay Attention!

(especially after upgrades)

Customized Patient Report

Needs 2nd identifier

such as DOB for

medical record

Data Reporting

Pressure Reporting

• Pressure change

min 12 max 15 not

reflected in text data

Look for Details

Last settings

reported

aPAP settings

changed mid-

reporting period

Usage Data without AHI or Pressure

Insurance Communication

Questions

Thanks to Ann Cartwright, PA and Neil Freedman, MD

for providing cases.