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Guidelines to CPAP & Bi-Level device pressure titration in adults. Belgian Society of Sleep Technologists. Normal procedure. Conducted over 2 polysomnographic nights: The first night is to establish a reliable baseline diagnostic for OSAS. The second night to initiate & titrate nasal CPAP.

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guidelines to cpap bi level device pressure titration in adults

Guidelines to CPAP & Bi-Level device pressure titration in adults

Belgian Society of Sleep Technologists

Jo Tiete - CHL

normal procedure
Normal procedure

Conducted over 2 polysomnographic nights:

  • The first night is to establish a reliable baseline diagnostic for OSAS.
  • The second night to initiate & titrate nasal CPAP.

Jo Tiete - CHL

night 1
Night 1
  • Document sleep apnea at least while sleeping in supine position.
  • In all stages, but most significantly in REM sleep (REM atonia).
  • Sleeping on the side can lead to a false negative diagnostic result.

Jo Tiete - CHL

night 2
Night 2
  • CPAP titration procedure to specify the lowest pressure, wich abolishes apneas, hypopneas, snoring & arrousals (RERA).
  • Also in all stages, specially REM & at least in supine position.
  • Note: REM is almost always more prominent in last third part of the night.

Jo Tiete - CHL

split night procedure
Split Night procedure
  • If documented > 30 apneas with desats >= 4% from baseline after 3 hours after LOFF.

 Initiate CPAP !

Jo Tiete - CHL

split night procedure6
Split Night procedure
  • If related with OSAS appearance of:
    • Bradycardia < 40 beats/min.
    • PVC (Premature Ventricular Contraction) couplets or bigeminy.
    • Sinus bradycardia > 2.5 seconds.
    • SAO2 < 75 %.

 Initiate CPAP !

Jo Tiete - CHL

split night procedure7
Split Night procedure
  • At least 3 hours of CPAP titration & treatment is needed.
  • Research indicate that up to 49 % is inadequatly titrated in split studies because of lack in time!
  • If fail to titrate adequatly: new full PSG titration.

Jo Tiete - CHL

ncpap titration
nCPAP titration
  • Explain procedure to patient! Fit the mask.
  • Start with 3 to 4 cm H2O till sleep onset.
  • Increase with 1 or 2 cm every 5 to 15 min. till 10 cm H2O.
  • If necessary, increase with 0.5 to 1 cm above 10 cm H2O every 15 to 30 min.
  • 15 to 18 cm H2O is max, except very rare cases! ( tear off mask during sleep).

Jo Tiete - CHL

ncpap titration9
nCPAP titration
  • If « sensation of not getting enough air » start with more than 4 cm H2O:
    • Common with nasal congestion.
    • Severe obesitas.
    • Prior chronic CPAP treatment.
  • Richards et all: up to 40 % nasal congestion, dry nose & sore throat with CPAP device.

Jo Tiete - CHL

ncpap titration10
nCPAP titration
  • If claustrophobia or anxiety:
  • You will need even more time to explain, prepare & calm down subject.
  • In this case increase pressure very sloooooooowly!
  • Sleeptech workload:
    • explaining, preparing & educating of patient.

Jo Tiete - CHL

ncpap titration11
nCPAP titration
  • To control therapeutic pressure is correct:
    • Reduce slightly pCPAP & watch for respiratory events or arrousals to re-appear.
  • If pressure is set too high:
    • Discomfort.
    • Awakenings.
    • Hypnogram fragmentation.
    • Oral leak & noise (gasping).
    • Appearance of central apneas.

Jo Tiete - CHL

ncpap titration12
nCPAP titration
  • If obst. or mixt. apneas are converted to central apneas of the Cheyne-Stokes type (periodic breathing):
    • Test with upward pressure.
    • If no luck: leave at pressure to stop obstructive events.
  • Central apneas in REM without desats or arrousals don’t need higher pressure.

Jo Tiete - CHL

ncpap titration13
nCPAP titration
  • If central apneas (not Cheyne-Stokes type) with arrousals:
    • Investigate for preceding snorings/airflow limitation or UARS:
      • Then try with higher pressure.
    • Investigate for arrousal because of too high pressure and/or mouthleak:
      • Then try with lower pressure.

Jo Tiete - CHL

ncpap titration14
nCPAP titration
  • If high pressure is necessary to maintain airway patency, but not tolerated:
    • Do a temporary pressure reduction with slow increase.
    • If several attempts to do so are not succesfull, change to Bi-Level.
  • If CPAP not supported because of nasal congestion: use heated humidifier or topical vasoconstrictor spray.

Jo Tiete - CHL

ncpap titration15
nCPAP titration
  • If high mouth leaks:
    • Try with heated humidifier.
    • And/or Shin strap.
  • If still no succes:
    • Switch to Bi-Level.
    • Or use a full face mask.

Jo Tiete - CHL

ncpap titration16
nCPAP titration
  • Not uncommon: first a succesfull titration, but after position change, respiratory events reappearing.
  • Even when CPAP is succesfully titrated, many causes can lead to the inability to tolerate CPAP.
  • Therapeutic failure to CPAP is estimated to be 20 to 30 %.

Jo Tiete - CHL

bi level tiration
Bi-Level tiration
  • From start only:
    • if severe pulmonary reasons & asked by physician.
  • Indications:
    • CPAP not tolerated.
    • COPD(Chronic Obstructif Pulmonary Disease).
    • Hypoventilation.
    • High mouth leak with humidifier & shin strap.
    • Other pneumological diseases (ex: scoliosis).

Jo Tiete - CHL

bi level tiration18
Bi-Level tiration
  • Increase both IPAP & EPAP till no more obstructive apneas.
  • Then increase IPAP only, till no more hypopneas, snoring or RERA’s.
  • If these events still persists, increase EPAP by 0.5 to 1 cm.
  • In alveolar hypoventilation: lower the EPAP to increase tidal volume.

Jo Tiete - CHL

alter subject position
Alter subject position
  • If CPAP or bi-level pressure not tolerated:
    • The bed will be elevated by 30 degrees.
    • Use lateral sleep position (tennis ball, pillow).

Jo Tiete - CHL

oxygen therapy
Oxygen therapy
  • If despite of good titration, SAO2 < 90% then:
    • Start with 1 liter O2 inline CPAP.
    • Maximum 4 to 5 liters O2 (ask your doctor!).
    • If > 3 liters O2 use of humidifier recommended.
    • Slooowly increase O2 till SAO2 > 90%.
  • Danger: fire, CO2 retention, mucosa irritation & epistaxis (nose bleeding).
    • pCPAP + Oxyconcentrator !!!

Jo Tiete - CHL

auto smart or stupid cpap
Auto-/Smart (or stupid)-CPAP
  • Subject excluded for auto-titration are:
    • Congestive heart failure.
    • COPD and daytime hypoxemia.
    • Hypoventilation syndrome.
    • NO snorers (ex:UPPP)… auto-CPAPSound algorithm don’t detect any abnormallity!

Jo Tiete - CHL

auto smart cpap
Auto-/Smart-CPAP
  • Auto-CPAP is not indicated in Split night procedure, but sometimes used for an attended polysomnography.
  • Some auto-CPAP devices have proven their utility for the Cheyne-Stokes type apneas (Resmed CS).

Jo Tiete - CHL

adherence follow up
Adherence & follow-up
  • Education, education, education…
  • Review subject after CPAP initiation within 3 months.
  • Follow-up, control & adjustment on yearly basis.
  • Change deteriorated consumables (mask,…).
  • At least 4.5 hours PAP use/night.

Jo Tiete - CHL

sleeptech experience
Sleeptech experience
  • Important:
    • A trained staff for CPAP use & titration.
    • Good understanding: in respiratory physiology, anatomy and sleep & respiratory disorders.
  • Higher compliance succes rates with well trained sleeptechs.

Jo Tiete - CHL

my cpap evolution theory homo erectus
My CPAP Evolution Theory: Homo Erectus
  • Rather small brain.
  • Big mouth, good flux.
  • Big thorax volume.
  • Small abdomen.
  • No fat, but muscles! (…had to run for the dinausaur!).
  • No need for CPAP !!!

Jo Tiete - CHL

nasa send this picture in space
NASA: send this picture in space
  • Clean & ideal drawing of Homo Sapiens.
  • But if extra-terrestrial life should visit the earth one day, they will find ...

Jo Tiete - CHL

slide27
This !
  • No brain difference.
  • Smaller mouth & fatty dubbel shin.
  • Smaller thorax.
  • Huge abdomen.
  • A lot of fat, rare muscles (don’t run anymore!).
  • Don’t survive without CPAP device!!!

Jo Tiete - CHL