Non Invasive Positive Pressure Ventilation Titration

1. Non Invasive Positive Pressure Ventilation Titration BYAHMAD YOUNES PROFESSOR OF THORACIC MEDICINE Mansoura faculty of medicine

2. Customizing NIV settings to the patient’s unique physiology of respiratory failure. • NMD patients are often started on BPAP at low pressures (IPAP = 8, EPAP = 4) ,If patients tolerate nocturnal NPPV with low pressures, the settings are increased over weeks to months based on symptoms and/or daytime arterial PCO2 measurement (or end-tidal PCO2). • In patients with rapidly progressive NMD, the main goal of treatment is often palliation of symptoms and improvement in quality of life rather than normalization of nocturnal arterial PCO2.

3. Non Invasive Positive Airway Pressure Therapy • Uni-level positive airway pressure Provides a constant pressure throughout the respiratory cycle. Fixed uni-level eg. Fixed CPAP , Auto-unilevel Auto- CPAP . • Bi-level positive airway pressure (spontaneous mode): Provides a higher level during inspiration and a lower pressure during expiration eg. Fixed bilevel as Rrisma 25,Auto-bilevel as Auto BiPAP, Prisma 25. • Bi-level positive airway pressure (spontaneous/timed mode):provides two pressure levels at a set rate to assist ventilation. Fixed bi-level eg. BiPAP -ST,VPAP –ST, Fixed bi-level with auto-EPAP eg. Prisma –ST 25. • Dual Auto-bi-level positive airway pressure (spontaneous / timed mode plus target tidal volume) + auto EPAP eg. BiPAP A40 , prisma ST30.Prismavent 40,ASV,AutoSV advanced, AcSv.

5. Auto-bilevel positive airway pressure with a minimum (EPAP) of 6 cm H2O and a maximum (IPAP) of 25 cm H2O.

6. ASV is a variant of BPAP that was developed to treat Cheyne-Stokes central apnea. Both ASV and BPAP devices with a backup rate are approved for use with patients with central apnea and complex sleep apnea

7. Non Invasive Positive Airway Pressure Titration Modalities • Manual Titration (gold standard method) . • Auto-titrationDevices(Autobilevelspontaneos mode) . • Advanced Auto-titration Devices : 1- Inter-breath dual mode ventilation • Fixed EPAP (AVAPS ,iVAPS, BiPAP A 40 , Ventimotion 2,Ventilogic LS , Steller 150 . • Auto EPAP ( Prisma ST 30 ,Prisma vent 40 . 2- Intra-breath dual mode ventilation ( VPAP ASV ,BiPAP SV . PrismaAcSV . • Pathologic Default. • Empirical NIPPV Titration

8. GOALS OF NIPPV TITRATION • The goal of PAP titration is to identify the optimal pressure that eliminates : 1-SRBD events (apneas, hypopneas, RERAs and snoring) 2- Oxygen desaturation and Preventing nocturnal hypoventilation (or worsening of hypoventilation during sleep if daytime hypoventilation is present). 3- Providing respiratory muscle rest. • The optimal pressure from PAP that accomplishes all this should beadequate during all stages of sleep and in all sleep positions (particularly supine position),

9. PREPARATION FOR PAP TITRATION • The AASM practice parameters recommend that all eligible patients receive: 1- Adequate PAP education, 2- Hands-on demonstration, 3-Careful mask fitting, and 4- Acclimatization to the PAP device before titration. • PAP education before titration could be in the form ofa video describing sleep apnea, consequences of untreated sleep apnea, rationale for the use of PAP, the process involved during the diagnostic and PAP titration polysomnogram , the device parts and side effects related to the PAP and mask interfaces.

14. Auto-bi-level positive airway pressure Spontaneous

15. Auto-bi-level positive airway pressure Spontaneous • Auto-bilevel Spontaneous is effective in treating OSAS unable to tolerate CPAP.eg. Auto-biPAP, Prisma 25. • Auto-adjusting bilevel ventilator system with different algorithms able to detect and treat obstructive events such as apnea,hypopnea and snoring. • Adjustable parameters are: minEPAP (from 4 to [maxIPAP-3]), maxIPAP (from [minEPAP +3] to 25 cm H2O), and maxPS (from 3 to 8). • If 2 consecutive obstructive apneas are detected in a period of 3 minutes, the algorithm increases the EPAP value 1 cm H2O, maintaining a minimum difference of 3 cm H2O from the IPAP. If hypopnea or a flow limitation is detected, the algorithm will raise IPAP to eliminate the event until the maximum adjusted level is reached. • A further increase of IPAP will lead to a same increase of EPAP to maintain the adjusted maxPS constant.

16. Auto-bi-level positive airway pressure Spontaneous • AutoS mode combines the pressure support of a BILevel S therapy with automatic adjustment of the expiratory pressure against obstructions as in APAP. • Adjustable parameters in autoS mode,PDIFF 0 hPa to 21 hPa, EPAPmax 4 hPa to 23 hPa, EPAPmin 4 hPa to 23 hPa, TRILevel ,On,Off, minimum IPAP is automatically adjusted accordingly if you change the values for PDIFF or EPAPmin (BILevel) and EEPAPmin (TRILevel), maximum IPAP is automatically adjusted accordingly if you change the values for PDIFF or EPAPmax.

17. Dual Auto-bi-level positive airway pressure ST with inter-breath targeted tidal volume + Fixed EPAP

18. Advanced methods of Autotitration • Newer generation devices can can increase the IPAP alone in order to ameliorate obstructive events (Auto Bi-level PAP),correct hypoventilation (averaged volume assured pressure support [AVAPS], Intelligent Volume Assured Pressure Support (iVAPS ) or combat central apneas in patients with complex sleep apnea (Servo-Ventilation). • Devices may also introduce a back-up rate to prevent central apneas and although in general they are not referred to as APAP devices, they function using similar principles and can be judged as the latest generation of APAP devices .

19. BiPAP AVAPS, Ventimotion 2 ,Venilogic LS

20. BiPAP AVAPS, Ventimotion 2 ,Venilogic LS

21. Ideal body weight • Estimated ideal body weight in (kg)Males: IBW = 50 + 2.3 for each inch over 5 feet.Females: IBW = 45.5 + 2.3 for each inch over 5 feet. • Estimated adjusted body weight (kg)If the actual body weight is greater than 30% of the calculated IBW, calculate the adjusted body weight (ABW): ABW = IBW + 0.4(actual weight - IBW) • The IBW and ABW are used to calculate medication dosages when the patient is obese. • This formula only applies to persons 60 inches (152 cm) or taller.

22. VPAP™ ST with iVAPS and Stellar 150

23. Anatomical Dead space • Inspired/expired air remaining in conducting airways • Not involved in gas exchange • Correlation between patient’s height and dead space (Vd) • Height is used to calculate anatomical dead space (Vd) for each breath of air (Tidal Volume) • Example dead space volume (Vd) : 120 ml for height 175 cm or 70 inches

24. Anatomical dead space in relation to height of the patient

25. As alveolar ventilation drops , iVAPS rapidly increase pressure support until target Va is reached, and as alveolar ventilation increase , iVAPS rapidly decrease pressure support .

26. Intelligent back up rate (iBR) stays out of the way at 2/3 spontaneous rate whenever the patient spontaneously triggers above 2/3 of the target . once the patient rate reach minimum back up rate (2/3 of the target ) iBR increase towards patient spontaneous rate to maintain alveolar ventilation .Once spontaneous trigering returns, iBR drops back to 2/3 of the target / spontaneous rate.

27. Dual Bi-level positive airway pressure ST with inter-breath targeted tidal volume + Auto EPAP

28. PRISMA ST 30 • PRISMA ST 30 provide Volume compensation with auto-EPAP. • When the target volume is activated, you can also set the following parameters: EPAPmin(bilevel) EEPAP(trilevel) 4 hPa to 25 hPa,IPAPmax(bilevel) IPAP(trilevel) 4 hPa to 25 hPa ,PDIFF 0 hPa to 26 hPa, Pressure adjustment (speed of pressure adjustment at levels 1: Slow, 2: Medium, 3: Fast)autoF,On,Off ,Ti/Tset: 25% to 67%

29. BiPAP A40 Ventilator • BiPAP A40 comes with well-known and clinically proven Philips Respironics technology such as Auto-Trak, AVAPS and a Dry Box humidifier design. • The device is capable of non invasive and invasive pressure ventilation, up to 40 cmH2O, providing treatment for your chronic respiratory insufficiency patients. • The device featuresAVAPS-AE, the first fully automatic ventilation mode, designed to help clinicians during titration process, while maintaining comfort and therapy optimization at the lowest pressures.

30. Prismavent 40 • The device is capable of non invasive and invasive pressure ventilation, up to 40 cmH2O, providing treatment for your chronic respiratory insufficiency patients. • Volume compensation with auto-EPAP • Obstructive respiratory disorders such as COPD ,Restrictive ventilation disorders, such as scolioses and deformities of the thorax ,Neurological, muscular and neuromuscular ventilation disorders, such as pareses of the diaphragm, Central respiratory regulation disorders as OHS

31. Dual Bi-level positive airway pressure ST with intra-breath targeted tidal volume + Auto EPAP

32. Advanced methods of titration • Servo-ventilation made by different manufacturers can successfully detect and treat central apneas . • During servo-ventilation, the expiratory positive airway pressure is set at a level to treat obstructive apneas and obstructive hypopneas. • Combining APAP and servo-ventilation, with APAP determining the EPAP level automatically, whereas the servo-ventilation controlling periodic breathing and central apneas has been recently reported to be effective in ameliorating SRBD .

33. Prisma AcSVRespironics autoSVResMed VPAP Adapt SV

35. ASV is BiPAP with a twist. The IPAP and EPAP can vary, depending on the patient's needs. In some ASV-type machines the EPAP is fixed and only the IPAP changes; in others both can change. Basically, in ASV one or both pressures is continuously adjusted, so that the ventilation delivered to the patient 'adapts' to the situation.

36. ASV is a variant of BPAP that was developed to treat Cheyne-Stokes central apnea. Both ASV and BPAP devices with a backup rate are approved for use with patients with central apnea and complex sleep apnea

37. Dual Bi-level positive airway pressure with targeted pathologic default

38. Pathologic defaultsoffer a choice of disease-specific preset setting values to facilitate a quick and sensible starting point to therapy.

39. Severe OSAS with high pressure requirment

40. Presets SCOPE COPD-OSA OVERLAP

41. Obstructive sleep apnea and additional central apneas or pressure support requirements (e.g., intermittant hypoventilation, slight OHS).

42. Stellar pathologic defaults

43. Empirical NIPPV Titration • In many centres when NIV is implemented, ventilatory parameters are chosen empirically taking into account the underlying disease, patient tolerance while awake, and changes induced in diurnal arterial blood gas. • NPPV can be started on an outpatient basis at low pressure (BPAP 8/4) and increased as tolerated based on patient symptoms and oximetry, daytime PETCO2 measurements, or daytime arterial blood gas measurements. • In circumstances in which NPPV treatment is initiated and adjusted empirically in the outpatient setting based on clinical judgment, aPSG should be utilized if possible to confirm that the final NPPV settings are effective or to make adjustments as necessary.

45. Empirical NIPPV Titration • Close follow-up after initiation of NPPV by appropriately trained health care providersis indicated to establish effective utilization patterns, remediate side effects, and assess measures of ventilation and oxygenation to determine if adjustment to NPPV is indicated.