Successfully Integrating PAP

Technology in the ClinicLoretta Colvin, APRN-BC

Nurse Practitioner

Clayton Sleep Institute

Objectives

• Review PAP technology options

• Identify PAP comfort technology

• Understand variations in technology

options available

Conflict of Interest

• I have no conflicts of interest to disclose

My Plans

• Discuss brands common in my practice

• Focus on newer model features

• Discuss adherence reports and

interpretation later today

Cheat Sheet

Be Prepared

Assess Equipment

When to Assess Equipment

• New set-ups

• Replacement equipment

• Yearly follow-up

• Any complaints

Look, listen and feel

Look at Equipment

• Machine

– Settings: do they match orders?

– Capabilities: brand, model, AHI & leak

• Disposables

– Mask: style, condition

– Tubing: style, condition

– Humidifier chamber: setting & condition

– Filters: condition, large/fine particle

• Data transfer (modem, card)

Listen to Equipment

• Machine noise

– Is it REALLY loud?

• Leak noise

– Machine, humidifier, tubing

– Connections and ports

– Look for holes!

“Feel” the Equipment

• Check pressure with manometer

– Verify against pressure setting

– BEWARE of

• Auto-ramp

• Pressure relief (ex: EPR)

• Bilevel or advanced modality

• Altitude (manual adjustment)

• Check heat plate

– Water level unchanged after use

– Is humidifier turned on? (zero=off)

Altitude Adjustment

• Auto-adjustment altitude– ResMed S8, S9, Airsense 10 (up to 8,000 ft)

– Respironics System One, M-series pro and auto (up to 10,000 ft)

– Fisher&Paykel Icon premo & auto, SleepStyle 608 (up to 9,000 ft)

• Manual adjustment altitude

– Respironics System One, M-series & Legacy plus

• 1:0-2500 ft, 2:2500-5000, 3:5000-7500

– F&P Icon novo and sleep style (other than 608)

• 1:0-3000, 2:3000-6000, 3:6000-9000

? ? X??

Case Examples

Assess Equipment!

Pressure Manometer

• ResMed S9 CPAP

• Ordered at 10 cm per titration study

• 4 cm on manometer

• Auto ramp @ 4 cm

• 7 cm on manometer

• EPR @ 3 = 3 cm reduction

Patient Reported High Pressure

• New patient,

old machine

• Tried CPAP

4 years ago

• Felt

pressure

was too high

• Manometer

reads 30 cm

New Machine at Correct Pressure

Patient Reported OSA Symptoms

• Patient moved to Denver from Texas

• Since move, feels OSA symptoms have returned despite

CPAP use

• Machine set at 9 cm

Re-Assessment

• Re-titration – 9 cm optimal (current setting)

• F/u after study – OSA symptoms persist

• What next?

• Manometer – blowing 6

• Has RemStar M-series PLUS machine

that does NOT auto-adjust altitude1 = 0 - 2500 ft, 3 = 5000 – 7500 ft (Denver 5280)

Report Indicates Leak

• Staff insist patient wearing

machine several hours nightly

• Patient was instructed to bring

ALL supplies and machine to

clinic

• CPAP placed on patient

• Machine REALLY loud

Patient Reports Loud Machine

• Limited hand mobility affects ability to

properly close humidifier lid

Extra Credit

• Patient returns for yearly f/u

• Started CPAP in 2008 – history of nightly usage

• What happened?

Answer

• 2008 recall on certain M-

series models-humidifier only

• Call Respironics customer

support with machine serial #

Comfort FeaturesHumidification & Pressure Relief

Humidification Audience Poll

• Does heated humidification increase

adherence to therapy?

Yes

No

Unsure

Humidification

• Across studies, results are inconsistent for: – Adherence, preference, side effects

– Subgroups w/oronasal symptoms may benefit

• AASM guidelines (2009)

– Standard recommendation

• Am College of Physicians (ACP - 2013)

– Insufficient evidence, inconsistent findings

• It is a comfort feature covered by Medicare

• Commonly ordered at onset of new therapy

Sawyer A et al 2011. Sleep Medi Review 15:343-356. Wickwire E et al, 2013. Chest 144(2):680-693.

Epstein L et al 2009. J Clin Sleep Med 5(3):263-276. Qaseem, A et al 2013. Ann Intern Med 159:471-483.

Extra Credit

• Humidification comes standard with PAP

therapy order?

Yes

No

Unsure

Humidifiers and Orders

• Humidifier is a separate HCPCS code,

technically requires separate order

• F&P and ResMed AirSense 10 use integrated

humidifier, cannot actually be “detached”.

• Medicare pays outright for humidifier, even if

patient returns machine for non-usage

• Some insurance may not actually cover

humidifier

Humidification Fine Tuning

• Heated Tubing

– Integrated circuit

• Beware – varied settings for tubing heat

vs. humidifier heat, brands vary

• Note – DME must provide tubing ($)

– Added circuit

• Insulated tubing

– “cozy”

Humidification OptionsMachine Chamber

Attachment

Chamber

Heater

Heated

Tubing

Patient

Controlled

Heated Tubing

System OneRespironics

Detachable 0-5regular tubing

“classic”/“system one”

1-3 heated tubing

Preheat option

0-5≥ 60 series

Note – if heated tubing

connected, the 0-5 dial

controls tubing, not heat

plate

+

If granted access

S9ResMed

Detachable 0-6Preheat option

60 - 86°controls tubing/chamber

+

AirsenseResMed

Integrated 0-8Preheat option

Auto controls tubing/chamber

Manual 60-86°separate chamber control

+

Icon Fisher & Paykel

Integrated 0-7No preheat option

Boost

L-M-H

+Advanced mode only,

push and hold chamber temp to

access thermometer icons

Note – heated tubing must be attached and “clicked in” to

activate heated tubing controls (when patient accessible)

Special Notes

Examples

Humidification Discussion

• Post-menopausal women

• Teenagers

• Dry climate

• Oro-nasal symptoms at baseline

• Anxious

• Elderly

• Long-haul truck drivers

Pressure Relief Audience Poll

• Pressure relief increases adherence to

PAP therapy

Yes

No

Unsure

Pressure Relief

• Across studies, findings are inconsistent – Benefit, no benefit, mixed results

– Published studies may not reflect all algorithms

– Sub-groups with poor adherence may find benefit

• AASM Guidelines (2009)

– Consensus recommendation

• Am College of Physicians (ACP 2013)

– Low quality evidence (discusses C-flex only)

Sawyer A et al 2011. Sleep Medi Review 15:343-356. Wickwire E et al, 2013. Chest 144(2):680-693.

Epstein L et al 2009. J Clin Sleep Med 5(3):263-276. Qaseem, A et al 2013. Ann Intern Med 159:471-483.

Pressure Relief (cont)

• Each manufacturer uses different proprietary

algorithm, goes through FDA approval

process

• Designed to selectively reduce pressure

• Use selectively in patients, not in all patients

• Know your machines and the varied

algorithms. Watch your detailed reports.

• Consider an “add on” if issues present later

Pressure Relief • F&P Sensawake

– Clinician sets low pressure

– Senses “wake” to drop pressure

• ResMed EPR– 1–3 cm pressure

– Easy-breathe bilevels only

• Respironics ‘flex”– Flex 1-3 refers to relative

drop

– Cflex+: 2 cm drop from baseline on exhalation (“mini-bilevel”)

ResMed – EPR

Respironics – cflex, cflex+ (and aflex, biflex)

Fisher & Paykel – Sensawake

Special Notes

Discussion

• Pressure relief requires a prescription

Yes

No

Unsure

• Patients should have uncontrolled access?

Discussion (cont)

It depends on your DME and your preference:

• Icon (sensawake)– Comes activated “out of the box”

– DME must turn OFF (!)

• SystemOne (flex/flex+) and S9/AirSense 10 (EPR)– Clinician must activate at set-up

• Patient access – Always (older machines)

– Clinician controlled

– Varies by device

Pressure Relief Discussion

• Lab-initiated feature

– Do you script for machine by brand?

• Provider scripted @ initiation

– When ?

• Add on feature

– When ?

• Replacement machines

Leak and AHI

Leak and AHI Data Reporting Manufacturer Device Leak

& AHI

Fisher & Paykel Icon Novo -

Icon Premo or Auto +

ResMed S9 Escape / Airsense 10 CPAP*some detailed data limitations in some software

-(auto has AHI)

S9 Elite or Auto +

Airsense 10 Elite / Auto +

Philips Respironics System one REMstar Plus -

System one REMstar Pro or Auto +

Note – The external appearance of the device may be quite similar,

but the internal software will vary.

Leak

Leak Audience Poll

• A leak > 24 L / min is considered a high

leak

Yes

No

Unsure

Leak

• Total leak (> 40 – 50 L/min generally concerning)– All the leak reported, including normal leak from mask

– Intentional (mask) + unintentional (seals)

– “abnormal” leak depends on mask and pressure

– Respironics • Black: Large Leak (LL) – approx 2X expected leak detected > 1.5

minutes

– Fisher & Paykel

• Excessive leak (>24 L/min generally high)– Leak above what is expected for mask selected on

machine

– Intentional leak only

– Must have right mask selected for calculation to work

– Resmed

Intentional

Leak

Unintentional

Leak

Leak References

• Each mask

manufacturer

can provide

you with mask

leak guides

• You may find

one in your

lab

AHI

AHI – Audience Poll

• An AHI > 10 on a detailed report indicates

in-lab titration must be performed

Yes

No

Unsure

Extra Credit

• AHI of zero indicates effective therapy

Yes

No

Unsure

•AHI and Leak = 0

•REMstar System One Plus in Encore Anywhere

•No AHI detection

•No leak report statistics

AHI and Leak Data

Leak and AHI Detection

• If leak not resolved, AHI detection can be unreliable

• Use particular caution when monitoring aPAPAHI (ie – no in-lab titration for reference)

• You will either get both measures, or you will get neither

• May add noise, detectable by some patients switching machines

• Leak above set

threshold for

intentional leak

(24)

• AHI not in

acceptable range

(< 10)

ResMed

Resmed (ResScan)

Normal

Leak

Excessive

Leak

Respiratory Events

Resmed AirView (Easy Care Online)

• Leak is horrible

• > 80 L/min (!)

• AHI wide

variation

• Undetectable AHI

is unusual

F&P Icon Leak and AHI

DOT Driver

Daily Details DOT Driver

DOT Driver

AHI Detection - Group Discussion

• Do you script for AHI detection?

– When

• Do you script by manufacturer?

– When

• Examples

– No REM or no supine observed at optimal

– Monitoring for centrals in certain scenarios• Idiopathic centrals on HST with limited in-lab

titration option due to insurance or deductible

Tips (and a little soapbox)

Equipment Assessment Tips

• Use a manometer

• Train scheduling staff to advise patient to

bring machine and ALL equipment

– Modem does not always mean data available

• Have a cheat sheet to help find settings

• Have power cords for all machines

• Keep spare cards for all machines in clinic

Download Tips

• Have backup PC based software for all

manufacturers

– Encore Pro, ResScan, InfoSmart

– Keep version updated, centralize data storage

• Have a cheat sheet to help “break into”

machines for pressure changes

Assessment Tips

• Double check the DME

– Check settings vs. orders

– Check for pressure relief

– Check the basics (humidifier)

– Set expectations (ex: AHI detection)

• Always “dig deeper”

– Use detailed reports when there’s a problem

“I’m Using My Machine”

• Assess technology– Was download done correctly? (ex: wrong dates)

– Was card inserted in machine?

– View machine screens to double check

• Assess patient– Clinical improvement?

– Describe the machine/mask? (ex: color)

– Would they over-estimate usage? (DOT, insurance)

• CPAP self-monitoring assessment– Log, patient data access (machine, online)

ResMed S9

• Card holds

only 6 mo

data

A Note on Mouth Breathing

• OSA patients do not remain mouth breathers….

• Patient preference for FFM initially– Coach patient to consider alternatives to FFM

• Clinician preference • Tech preference during titration

• DME preference for aPAP with higher max pressure

• Alternatives • Humidification helpful in many patients

• Chin strap an option, a good “trainer”

• Routine “practice” with PAP

A Note on Claustrophobia

Not all claustrophobics are the same

• Eye crowding, smothering, head straps, small spaces…

Mask style

• Some like smaller, away from eyes (pillows)

• Some want less “intense” pressure (nasal, FFM)

• Some want strapless (dental appliance – pillow combo)

• Unique: away from eyes, no pillows (whole face mask)

Pressure

• Air hunger – raise ramp or auto-PAP min

• Pressure intolerance – reduce pressure for comfort

• Teach them the ramp (don’t assume they know it!)

GIVE THEM TIME AT HOME http://ainsleyrae.blogspot.com/2014_06_01_archive.html

23:00 pm 2:30 am

3:00 am 6:30 pm

A Note About Oximetry

• Verify the patient using their PAP when

oximetry performed

Leak Trouble-shooting

• Look at download (when leak available)

– Constant

• Very poor mask fit, defect/hole, removal

• Turned on but not on patient(!)

– Fluctuating

• Patient: mouth opening, positional, removal

• Equipment:

– aPAP pressure changes without proper mask fitting

– mask change, old seals

– Examples (next slide)

Leak Examples

50 L/min

Insomnia – leaves machine running when OOB

Lost seal after first night

Not wearing (DOT)

Cost Containment

RESmart (3B Medical)

• Lost cost tubing

• Durability concerns

• Low cost machines

• Download

challenges

“I Want a Smaller Machine”

http://mytranscend.blogspot.com/2011/04/w

e-know-it-looks-strange-why-transcend.html

• Questions to discuss

– Will there be humidification?

– Do you require adherence monitoring?

• Insurance

• DOT

– Financial considerations with 2nd machine

Questions