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Home NIV: Aims and Targets

Home NIV: Aims and Targets. Dan Adler, St.Gallen 2012. Aims of home NIV are:. To improve QoL and symptoms related to hypercapnia (questionnaires) To improve nocturnal SpO 2 and correct nocturnal hypoventilation (nocturnal SpO2/PtCO2)

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Home NIV: Aims and Targets

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  1. Home NIV: Aims and Targets Dan Adler, St.Gallen 2012

  2. Aims of home NIV are: • To improve QoL and symptoms related to hypercapnia (questionnaires) • To improve nocturnal SpO2 and correct nocturnal hypoventilation (nocturnal SpO2/PtCO2) • To ensurethatleaks are minimal, and estimated VE isadequate(What information canwegetfrombuilt-in softwares? Can we trust this information?) • To improvequality of sleep(Do wereallyneed PSG during NIV? Is there a surrogate marker for inspiratory effort and for cortical arousal?)

  3. Whyshouldwe monitor NIV duringsleep? • Patients on HMV admitted (yearly) to monitor NIV. • 41/53 patients presentedanyabnormality (leaks, desaturationdips or continuousdesaturation) • 20 OHS patients in stable condition admitted to monitor NIV • 55% with PVA • 40% withperiodicbreathingunder NIV • 48 patients admitted for a scheduled control in a phase of clinicalstability. • No IE during day NIV trial/ IE very frequent finding during sleep • 30 COPD patients in stable condition (no overlap syndrome), ~1/3 patients complained of severedyspneaimmediatelyafter interruption of NIV in the morning. • PVA found in all patients using PSG and subjective improvement of sleepqualityafter setting NIV with a predefinedapproach Rabec, ERJ 2009; Guo Chest 2007; FanfullaRespiratoryMedicine 2007; Adler Sleep and Breathing 2011

  4. Presentation outline: • Basic Monitoring • SRI Questionnaire+ “Geneva” Questionnaire • SpO2/PtCO2 monitoring • Built-in software • PG/PSG • Respiratory events classification • Setting NIV using PSG • When should you organize a PG/PSG under NIV? • New Tools: • PTT (pulse transit time) • PWA (pulse wave amplitude)

  5. SRI: The SevereRespiratoryInsufficiency Questionnaire • SRI questionnaire: Diseasespecificmeasure of health-relatedquality of life in patients receiving HMV. • Windisch W, J Clin Epidemiol 2003;56:752 • English Version • French Version: www.isplf.org • 8 domains: respiratory complaints, social functioning, sleep, anxiety, social relationships, well-being and physicalfunctioning+ SRI summaryscale Windisch, Breath 2011

  6. NIV has a major impact on HRQL • N= 137 patients: COPD, restrictive disease, OHS, NMD • SRI is more sensitive than SF36 to detect HRQL changes in thisspecific population SRI tot SF36 physical SF36 mental Windisch, ERJ 2008

  7. SRI too long for routine clinical practice? Windisch, ERJ 2008

  8. If NIV isintended to improvesleep, weshouldaimat maximal comfortduring the night 8 item VAS assessing sleep, comfort, perception of synchronisation, airflow, leaks, noise. Janssens, Respir Med, 2008; Adler Sleep and Breathing 2011

  9. Basic Monitoring: SpO2 monitoring is certainly not enough during NIV Desaturation drops Sustaineddesaturation > 10min Both patterns are non-specific for the underlyingmechanismleading to desaturation Janssens, Thorax 2010

  10. Poorcorrelationbetween diurnal PaCO2 and mean nocturnal PtCO2 Sn= 3/(3+18)= 14.3% Paiva, ICM 2009

  11. Normal values of nocturnal oximetry do not allow to exclude nocturnal hypoventilation Nocturnal SpO2 is not a surrogate marker of PCO2 CO2 60 CO2 35 2012 JIVD abstracts: Lamia and Muir, Niguyen-Baranoff and Rabec

  12. Transcutaneous CO2 monitoring can replace arterial PCO2 during NIV 3 modern PtCO2 monitor were compared After correction of the technical drift Storre, Respir Med, 2011

  13. Transcutaneous CO2 monitoring can replace arterial PCO2 during NIV • PtCO2 adequatelyreflects PaCO2 during NIV • Advantages: • Non-invasive • No sleep disruption • Continuous Gazométrie Gazométrie Gazométrie Gazométrie Storre, Respir Med, 2011

  14. Built-in Software: Whatcanwe trust? • Manyrecent home ventilators have built-in software whichallows monitoring of items such as: • Compliance • Leaks • Vt, MV, RR • % of triggered cycles • % of spontaneous expiration ( cycling) • AHI Pasquina, Respiration 2012

  15. Built-in Software +Monitoring system Leaks Normal Residual obstructive events? PB ? Hypoventilation? Rabec. ERJ 2009

  16. Built-in software: Validation of leaks and MV on a bench test R=0.959 P<0.0001 R=0.947 P<0.001 Bias: 0.7 L/min, not relevent! Rabec, ERJ 2009

  17. Built-in software: Leaks in a non hermetic system are intentional. What are we talking about? Total leak mesured Total leak mesured Leak above “intentional ones” Contal, Chest 2012

  18. Built-in software: Software estimation vsmesured leaks on a bench test. . “All ventilators are equal but some ventilators are more equal than others…” Only 3 ventilators had narrow limits of concordance! Contal, Chest 2012

  19. Built-in software: Vt software estimation vs mesuredVt • For mostventilators, Vtisunderestimated • Underestimationisworstwithhigher pressures • Vt estimation islittleaffected by leaks Contal, Chest 2012

  20. Built-in software: Is set pressure reliable? A= Effective PT product S= Surface of ideal PTP A/S ratio A Battisti, Chest 2005

  21. Widedifferencesbetweenpressurizationcapatilities in home ventilators Battisti, Chest 2005

  22. Low % of spontaneous inspirations in verysevere COPD Ineffective efforts? RR 14/ min Neural RR 24/min

  23. Correction of IE using PSG to set NIV Neural RR= Effective RR

  24. Adler, Sleep and breathing 2011

  25. Built-in Software: Summary

  26. The final touch…

  27. Janssens, Thorax 2010

  28. Leaks Gonzalez-Bermejo, Thorax 2010

  29. Upper airways closure “central” “Obstructive” Gonzalez-Bermejo, Thorax 2010

  30. PB under NIV Gonzalez-Bermejo, Thorax 2010

  31. Use PSG+SpO2/PtCO2 to adapt NIV settings Adler, Sleep and Breathing 2011

  32. New tools for NIV monitoring at home? PTT: Pulse Transit Time PWA: Pulse Wave Amplitude Basic knowledge: PTT changes with intrathoracic pressure swings Basic knowledge: PWA reduction is a surrogate marker of cortical arousal in healthy subjects and in OSA PTT: Smith ,Thorax, 1999 PWA: Delessert, Sleep 2010

  33. Obstructive or central event? Luo, Chest 2009

  34. PTT as a marker of inspiratory effort during NIV PTT mirror image of Poeso Contal , ERJ 2012

  35. PTT as effective as Peso for classification of respiratory events during NIV Contal, ERJ 2012

  36. Pulse Wave Amplitude Reduction: A surrogate marker of EEG-MA during NIV? A B EOG EEG Chin Pressure Flow Thx & Abd mvt SpO2 PWA Adler, submitted

  37. PWA Sn and PPV to detect EEG-MA related to respiratoryeventsduring NIV 2474 respiratoryeventsunder NIV wereanalysed in 10 patients. Sensitivity 89.1% and PPV 87% to detect EEG-arousal related to a respiratoryeventunder NIV Adler, submitted

  38. Home NIV: Aims and Targets • HRQOL. • SRI questionnaire • Nocturnal PtCO2 monitoring is mandatory. • Diurnal ABG is not a surrogate marker • Nocturnal SpO2 is not a good surrogate marker • Trust your built-in software only if it has been independently validated. • Use of PG/PSG only in special situations. In this case, take advantage of the sleep study to adapt the NIV settings while the patient is asleep. • New ambulatory tools may be available in a near future. • PWA is a surrogate marker of arousal related to respiratory events under NIV • PTT for classification between central and obstructive respiratory events under NIV

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