pap interface and titration guide - the atlanta school

PAP Interface and Titration Guide

Essentials of Sleep Technology

• OSA overview• Review role of CPAP in OSA• Discuss successful

approaches to: • PAP acclimation• Interface sizing, fitting, &

selection• Humidification requirements• CPAP• Bi‐level• NPPV• ASV

• Interactive titration exercise• Interactive mask fitting –

PAP acclimation

PAP Interface and Titration Guide


Mechanical Failure: Muscle Relaxation – occurs with sleep,

REM = muscle atonia

Negative Inspiratory Force = airway instability

Body position – gravity increase airway instability

Narrowed airway

Narrow airway + relaxed muscle + negative inspiratory force = tissue collapse

Obstructive Sleep Apnea


PAP Therapy = Mechanical Correction

• Therapeutic PAP provides a pneumatic splint, opening the upper airway.

• CPAP Titration = adjusting the level needed to keep the airway patent.

Positive Pressure Therapy


PAP Components

Essentials of Sleep TechnologyEssentials of Sleep Technology

Interface/Mask

Blower /Pap Unit Tubing

CPAP Compliance

Compliance

• Usage + outcomes or response

• Should be an objective measurement

• Depends greatly on lab experience


Factors Influencing Compliance


Patient Education

Interface Selection & Fit

Appropriate Pressure Setting

Humidification requirements & nasal issues

Appropriate Therapy Mode

Bi‐level

Product‐specific pressure adjustment mode

Patient follow‐up, problem‐solving

Titration Study Process

Acclimation Period PAP Titration

1 2




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• Patient Interview

& Education

Interface selection & fitting

PAP pre‐studyacclimation


Acclimation Period

• Patient education & interview

• Education regarding OSA

• Establish impact of OSA on QOL & health consequences of untreated OSA

• Education regarding PAP therapy in role in treatment of OSA – Gauge patient understanding & acceptance

• Interview patient for special interface requirements

• Anxiety / claustrophobic response, self‐image

• Interview patient for nasal route complications:• Nasal obstruction (deviated septum)

• Nasal congestion (seasonal allergies, sinusitis, mild/mod/severe time of study)


Interface Categories

• Nasal Masks

• Oral/Nasal or Full Face Masks

• Specialty or Minimal Contact Masks


a. Sides of nostrils

b. Bridge of nose zone

c. Below the nose tip,above the lip

Landmarks in Mask Fitting


Interface Selection & Fitting

Selection depends in part on the interview process• Example: mod/severe nasal conges on → full face mask• Claustrophobic response → minimal contact mask• Persistent mouth breathing → oral breathing protocol

Common interface complications

• Mask pressure → poor fit• Skin abrasion • Poor patient tolerance

• Mask air leak →poor fit• Conjunctivitis

• Fragmented sleep & SDB � poor fit

• Skin dermatitis – mask material

Lee‐chiong, t.L., Sleep medicine, 397‐411, 2000




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Appropriate Therapy

Optimal Pressure

Address: nasal route issues


Physiologic treatment goal review

• Eliminate apneas

• Eliminate partial airway obstructions (hypopnea)

• Eliminate snoring and airway resistance‐related arousals

• Using the lowest possible pressure…

PAP Titration Goals


• Document reasons for pressure changes‐ Apneas

‐ Partial Airway Obstructions

‐ Hypopneas

‐ Desaturations

‐ Snoring

‐ Respiratory effort‐related arousals (RERAs)

• Establish a pressure threshold for conversion to bi‐level therapy (Robinson,et al., Sleep Disorders Medicine 2nd edition 1999, 345.)

Titration Zone


NAME __________ Date ________ MD _________

Time Epoch Stage Event CPAP Comments

N2 OA 5

N3 OA 6

N3 OA 7

R H 8

Flow Sheet


• Intentional Leak is the expected leak at the exhalation port.

• All masks have an intentional leak.

• Unintentional Leak occurs around the interface • Total Leak = Intentional Leak + Unintentional Leak

System Leak


• Leaks that need to be fixed include leaks:• Into the eyes

• That bother the patient

• Effect pressure stability

• Most equipment compensates

For leaks between 60‐100 lpm

Unintentional Leak


1) All potential PAP titration candidates should receive adequate PAP education, hands‐on demonstration, careful mask fitting and acclimatization prior to titration

2) CPAP (IPAP and/or EPAP if BPAP) should be increased until the following are eliminated or the maximum recommended pressure is reached.

‐ Apneas, hypopneas, RERAs and snoring

3) Recommended minimum starting pressures

‐ CPAP: 4 cm H20

‐ BPAP: IPAP: 8 cm H20 and 4 cm H20

4) Recommended maximum pressures

‐ Age < 12 yr

‐ CPAP: 15 cm H20

‐ IPAP: 20 cm H20

‐ Age > 11 yr

‐ CPAP: 20 cm H20

‐ IPAP: 30 cm H20

AASM Clinical Guideline Update: JCSM, Vol. 4, No. 2, 2008; www.aasmnet.org


AASM Clinical Guideline

5) recommended minimum IPAP‐EPAP differential: 4 cm H20

Recommended maximum IPAP‐EPAP differential: 10 cm H20

6) cpap (ipap and/or epap, depending on type of event)

Should be increased by at least 1 cm H20 with an interval of no less than 5 minutes

7‐10) indications for increase in pressure

>11 yr old:

CPAP (IPAP and EPAP, if BPAP) should be increased from any CPAP (or IPAP) level if:

‐ At least 2 obstructive apneas

‐ At least 3 hypopneas

‐ At least 5 reras

‐ May be increased if at least 3 minutes of loud or unambiguous snoring



11) titration algorithm for split‐night or full night titrations should be identical

12) switching from CPAP to BPAP may be done if:

‐ The patient is uncomfortable or intolerant of high pressures

‐ There are continued obstr. Events at 15 cm H2O

13) pressure of CPAP or BPAP prescribed should reflect reduction in RDI to low levels (preferably < 5), minimum spo2 above 90% at the pressure and a leak within acceptable parameters.

14) an optimal titration

‐ reduces rdi < 5 for at least a 15 min. Period

‐ Includes supine REM at the selected pressure that is not continually interrupted by spontaneous arousals or awakenings.

15) a good titration

‐ Reduces RDI < 10 or by 50% if the baseline RDI <15

‐ Includes supine REM, as above



16) An adequate titration:

‐ Does not reduce the RDI <10, but reduces the RDI by 75% from baseline (esp. In severe OSA patients),

or

‐With optimal or good titration that does not include supine REM at selected pressure

17) An unacceptable titration does not meet any of the above criteria

18) A repeat titration should be considered if the initial titration does not achieve a grade of optimal or good and, if a split‐study, fails to meet AASM criteria (i.e., titration duration should be > 3 hr.



7‐10) Indications for increase in pressure

<12 yr old:

‐ At least 1 obstructive apnea

‐ At least 1 hypopnea

‐ At least 3 RERAs

‐May be increased if at least 1 minute of loud or unambiguous snoring


PAP tolerance & response

Bi‐level is an effective salvage therapy for approximately 50% of patients who do not

tolerate and/or respond to CPAP

Szumstein, et al., ATS/ALA Abstract , 1999

Bi‐level Therapy


Critical Point of Airway Collapse EPAP – set for the obstructive apnea threshold, provides the initial pneumatic splint IPAP – set to eliminate all other forms of sleep disordered breathing, provides further

stabilization during the inspiratory cycle when the critical point of airway collapse increases. EPAP – for obstructive apneas IPAP – for everything else (Hypopneas, RERAs, snoring, desaturations) Pressure differential better matches normal mechanics of ventilation = comfort

Bi‐level Therapy


Reasons for initiating Bi‐level

• Not able to fall asleep on CPAP therapy

• Non‐tolerant of CPAP therapy

• Reach pre‐determined pressure threshold ex: 13 cm H20 to 15 cmH20

Bi‐level Titration Initiation



NAME __________ Date ________ MD _________

Time Epoch Stage Event CPAP Comments

N2 OA 9

N3 OA 10

N3 OA 11

N2 H 12

R OA 13

N3 H 13/9 Change mode to BiPAP

N2 OA ?

Flow Sheet

Non Invasive Positive Pressure Ventilation

• Bilevel pressure may also be used to augment patient’s own tidal volume / minute ventilation• S Spontaneous (Used when treating OSA)

• S/T Spontaneous Timed (Central apnea)

• T Timed (Not recommended)

• P/C Pressure Control (pressure targeted ventilation)

• ASV Auto (Adaptive) Servo Ventilation (Central or complex sleep Apnea)

• AVAPS (Central apnea, hypoventilation)




Summary

• Proper mask selection essential for CPAP success

• Titration algorithms are effective in eliminating sleep related breathing disorders

• Positive pressure ventilation may be effective in providing non invasive ventilation


pap interface and titration guide - the atlanta school

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