1715 Case Discussion on CPAP Downloads (Collop …€¦ · 7.8% (< 10%) Large Leak = 22 min, 44 sec...
Transcript of 1715 Case Discussion on CPAP Downloads (Collop …€¦ · 7.8% (< 10%) Large Leak = 22 min, 44 sec...
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PAP Downloads
Nancy Collop, MD Emory University
Naricha Chirakalwasan, MD Chulalongkorn University
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Conflicts of Interest• Collop
– Royalties from UPTODATE as an author and editor– Received grant monies and was on advisory council for Jazz
Pharmaceuticals (2017-2018)• Chirakalwasan
– Symposium Honorarium from ResMed, Respironics, Fisher-Paykel – Research medical devices from ResMed, Respironics, Fisher-Paykel
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RESPIRONICS DOWNLOADS – Pg 1
RED Bars = < 4 hrsGreen Bars = > 4 hrs
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RESPIRONICS DOWNLOADS – Pg 2
RED Bars = < 4 hrsGreen Bars = > 4 hrs
Time of Usage
Numerator = hrs @ pressureDenominator = hours on
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RESPIRONICS DOWNLOADS – Pg 3
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RESPIRONICS DOWNLOADS – Pg 3
T90% - 90% of time pressure at or belowAvg CPAP level – 50% of time above/below
APAP Settings (Min/Max)
90th percentile – at or below pressure the device delivered for 90% of that night
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Events tallied by flow sensor embedded in circuit
CA = Clear Airway ApneaOA = Obstructive Apnea
RERA = respiratory effort related arousal !?!?
FL = Flow limitedVS = Vibratory Snoring
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RESPIRONICS DOWNLOADS – Pg 4Leak as a % of the night and total time in lg leak7.8% (< 10%)
Large Leak = 22 min, 44 secDouble the total leak (intentional + unintentional)
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RESPIRONICS DOWNLOADS – Pg 5
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RESPIRONICS DOWNLOADS – Last Page
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RESPIRONICS DOWNLOADS – Last Page
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RESPIRONICS DOWNLOADS – Last Page
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Resmed Download - Pg. 1
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Resmed Download - Pg 2
Leak:• absolute value• unintentional leak only• 95th percentile
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Resmed Download - Pg 2
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Case #1
• 43 yr old man • Snoring and apneas per wife• ESS 15• Has mild hypertension (untreated), hyperlipidemia
and NAFLD• BMI 28.9• Underwent HSAT
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WatchPAT studypAHI = 62.2pRDI = 61.7SpO2 nadir = 63%
Started on APAP
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PAP Download #2
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Patient started on autoPAP; No Large Leak noted
RESIDUAL AHI 6.7
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What would you do next?
A. Examine detailed CPAP download dataB. Put on fixed pressure of 14 cm H2O (mean)C. Put on fixed pressure of 17 (90% tile)D. Do formal CPAP titration studyE. Do ASV titration study
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What would you do next?
A. Examine detailed CPAP download dataB. Put on fixed pressure of 14 cm H2O (mean)C. Put on fixed pressure of 17 (90% tile)D. Do formal CPAP titration studyE. Do ASV titration study
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Another Example with Bilevel PAP
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PAP Download #2
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73 yr old man with hypertension, diabetes diagnosed with OSA (AHI 32) and put on autoPAP; first visit on PAP
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What intervention occurred at the time of the vertical line?
A. autoPAP pressure levels were manually changedB. Patient began sleeping longerC. Patient got a new CPAP maskD. Patient started drinking a glass of scotch each night
following that timeE. Patient increased the EPR setting on his machine
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What intervention occurred at the time of the vertical line?
A. autoPAP pressure levels were manually changedB. Patient began sleeping longerC. Patient got a new CPAP maskD. Patient started drinking a glass of scotch each night
following that timeE. Patient increased the EPR setting on his machine
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Case #3
• 65 yr old woman with diabetes, chronic kidney disease, hypertension
• Medications: insulin, lisinopril, potassium, furosemide, glyburide• Diagnosed with OSA (AHI 27) 3 years ago, here for annual CPAP
followup visit• Notes average sleep, some nights worse than others• Feels like CPAP is working ok• Download shows low AHI (2.3), no large leak, average use 8 hours,
11 minutes, uses 98% of nights
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PAP Download #3
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Night 1
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Night 2
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Why is night 1 so different than night 2?A. Drank a bottle of wine before bedtimeB. Mask leakage awakened patientC. NocturiaD. Took a pain medication before bed
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Why is night 1 so different than night 2?A. Drank a bottle of wine before bedtimeB. Mask leakage awakened patientC. NocturiaD. Took a pain medication before bed
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TOOK Furosemide PRIOR TO BEDTIME
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PAP Download #4
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What caused changes seen in CPAP usage?
A. Patient made changes to his CPAP machine
B. Patient travelled to US west coast from US east coast
C. Patient travelled from US east coast to Europe
D. Patient travelled from US east coast to Asia
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What caused changes seen in CPAP usage?
A. Patient made changes to his CPAP machine
B. Patient travelled to US west coast from US east coast
C. Patient travelled from US east coast to Europe
D. Patient travelled from US east coast to Asia
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PAP Download #5
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• 27 yo with neurofibromatosis s/p multiple spinal cord tumor resections
• Paralyzed hemidiaphragm on bPAP since age 14
• Hospitalized with PNA• DC’d and rehospitalized with
Hypercapnic RF• At DC, bPAP increased from
12/8 to 18/8
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What is likely cause of increase in AHIflow?
A. HypocapniaB. Inadequate pressure to maintain airwayC. Inadequate PAP sensingD.Patient started on opioid in the hospital
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What is likely cause of increase in AHIflow?
A. HypocapniaB. Inadequate pressure to maintain airwayC. Inadequate PAP sensingD.Patient started on opioid in the hospital
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PAP Download #6-8
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Mother of a 13 month oldBMI 45, AHI 12CPAP at 8; residual AHI 1.2
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Mother of a 13 month oldBMI 45, AHI 12CPAP at 8; residual AHI 1.2
Midnight
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Father of same 13 month oldBMI 47, AHI 41CPAP at 13; residual AHI 3.5
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Father of a 13 month oldBMI 47, AHI 41CPAP at 13; residual AHI 3.5
Noon
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Grandmother of same 13 month oldBMI 35, AHI 26CPAP at 11; residual AHI 2.7
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Grandmother of same 13 month oldBMI 35, AHI 26CPAP at 11; residual AHI 2.7
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A. Irregular sleep wake rhythm disorderB. Advanced sleep wake phase disorderC. Delayed sleep wake phase disorder D. Non-24 hour sleep wake rhythm disorder
When the 13 month old is 13 years old, what circadian rhythm disorder is she at risk for?
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A. Irregular sleep wake rhythm disorderB. Advanced sleep wake phase disorderC. Delayed sleep wake phase disorder D. Non-24 hour sleep wake rhythm disorder
When the 13 month old is 13 years old, what circadian rhythm disorder is she at risk for?
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PAP Download #9
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Humidifier Chamber Leak
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PAP Download #10
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• A 75 year old man diagnosed with severe OSA and on CPAP of 17
• His bedtime is midnight to 8.00. However; he frequently woke up in the morning without his CPAP mask
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What is the most likely cause of his problem?
A. Pressure intoleranceB. Excessive leakC. Occult periodic leg movement during sleepD.The use of alcohol before bedtime
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What is the most likely cause of his problem?
A. Pressure intoleranceB. Excessive leakC. Occult periodic leg movement during sleepD.The use of alcohol before bedtime
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What is the acceptable leak?
Total leak = intentional leak + unintentional leak
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Excessive leak• Increased side effects• Poor compliance• Risk factors of central apnea
Baltzan MA, et al. Respiratory care. 2011;56(5):591-5.Montesi SB, et al. JCSM. 2013;9(11):1187-91.
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Another case“Blow By”Did not like to wear it on her face, but like the air blowing over her face
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Case #11• 46 year old woman• Diagnosed with OSA 8 months ago (AHI 56); initially struggled with CPAP
(autoPAP) but now uses it• Has multiple social stressors (messy divorce, raising twins on her own, long
commute [150 miles], stressful job)• Tearful in the office
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PAP Download #11
Complaining about CPAP pressure!!
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What is atypical about this download?A. Excessive leakB. Elevated AHIC. Marked variability in pressure needsD. Insufficient usageE. Marked variable usage
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What is atypical about this download?A. Excessive leakB. Elevated AHIC. Marked variability in pressure needsD. Insufficient usageE. Marked variable usage
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15 hours
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Weekend non compliant user
SatSun
Sat
Sat
Sun
Sun
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PAP Download #12
Complaining about CPAP pressure!!
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What is cause of circled pressure changes?
A. APAP response to obstructive eventsB. APAP response to central eventsC. Machine malfunctionD.Patient ramping down device
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What is cause of circled pressure changes?
A. APAP response to obstructive eventsB. APAP response to central eventsC. Machine malfunctionD.Patient ramping down device
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• Pressure settings:– 5-20 cm
H2O• Awakening
from pressure elevations
• Would ramp down when it awakened him
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• Went on YOU-TUBE • Turned settings down to
5-8 cm H2O• Made AHI go up even
more
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PAP Download #13
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• 75 yr old with Type 2 DM, peripheral vascular disease, HTN, asthma, paroxysmal atrial fibrillation (DCCV 2009), CAD s/p CABG
• Complains of awakening with some SOB at night
• Feels like machine not working right any more and stopped using it about a month ago
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What is likely cause of worsening control of sleep disordered breathing noted?
A. worsening allergiesB. patient changed CPAP settingsC. flipped back into atrial fibrillationD.machine mis-sensing events
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What is likely cause of worsening control of sleep disordered breathing noted?
A. worsening allergiesB. patient changed CPAP settingsC. flipped back into atrial fibrillationD.machine mis-sensing events
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Atrial Fibrillation
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Case 14
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A 79 year old physician patient with underlying CHF EF 25% with AICD diagnosed with moderate OSA and CSA-CSBHe is currently using CPAP of 13 in which he has been sending you daily data via line
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• His last downloaded data as following
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What would you do next ?
A. Ask about the symptoms of dry throatB. Ask him to check his pulse oximeter at homeC. Ask him to lower the pressure by 1 cm of water and
observeD. Reassure
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What would you do next ?
A. Ask about the symptoms of dry throatB. Ask him to check his pulse oximeter at homeC. Ask him to lower the pressure by 1 cm of water and
observeD. Reassure
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Room air oxygen saturation of 88%
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CPAP downloaded data in conjunction with clinical information is useful as a tool for follow up patients with sleep disordered breathing
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