Guidelines to CPAP

1
Guidelines to CPAP Bi-Level device pressure
titration in adults

• Belgian Society of Sleep Technologists

2
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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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.

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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.

5
Split Night procedure

• If documented gt 30 apneas with desats gt 4 from
  baseline after 3 hours after LOFF.
• ? Initiate CPAP !

6
Split Night procedure

• If related with OSAS appearance of
• Bradycardia lt 40 beats/min.
• PVC (Premature Ventricular Contraction) couplets
  or bigeminy.
• Sinus bradycardia gt 2.5 seconds.
• SAO2 lt 75 .
• ? Initiate CPAP !

7
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.

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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).

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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.

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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.

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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.

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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
  dont need higher pressure.

13
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.

14
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.

15
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.

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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 .

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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).

18
Bi-Level tiration

• Increase both IPAP EPAP till no more
  obstructive apneas.
• Then increase IPAP only, till no more hypopneas,
  snoring or RERAs.
• If these events still persists, increase EPAP by
  0.5 to 1 cm.
• In alveolar hypoventilation lower the EPAP to
  increase tidal volume.

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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).

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Oxygen therapy

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

21
Auto-/Smart (or stupid)-CPAP

• Subject excluded for auto-titration are
• Congestive heart failure.
• COPD and daytime hypoxemia.
• Hypoventilation syndrome.
• NO snorers (exUPPP) auto-CPAP Sound algorithm
  dont detect any abnormallity!

22
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).

23
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.

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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.

25
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 !!!

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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 ...

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This !

• No brain difference.
• Smaller mouth fatty dubbel shin.
• Smaller thorax.
• Huge abdomen.
• A lot of fat, rare muscles (dont run anymore!).
• Dont survive without CPAP device!!!

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Thank you for your attention.

• tiete.jo_at_chl.lu