Download Noninvasive Positive Pressure Ventilation Homecare Training

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Noninvasive Positive Pressure Ventilation Homecare Training
ResMed Corp
I.
Objectives
A.
To provide the necessary tools for developing a complete NPPV program
B.
To describe nocturnal hypoventilation and central sleep apnea (CSA)
C. To demonstrate a growing need for noninvasive ventilation and a demand for product
D. To improve clinical outcomes for select patients with respiratory insufficiency
II.
Clinical Overview of SDB
A.
General term for any type of breathing disorder that occurs during sleep
B.
Characterized by recurrent arousals and associated sleep fragmentation
C. Changes induced during sleep can lead to worsening daytime function in patients who already have compromised
lung function
i. Breathing during NREM sleep
a. Withdrawal of the wakefulness stimulus to breathe
 Creates a fall in ventilation
 Affects the tone of the postural muscles
b. Increase in upper airway resistance
c. Increased rib cage contribution to tidal volume
d. Decreased responsiveness to hypercapnia and hypoxia
ii. Breathing during REM sleep
a. Additional reduction in alveolar ventilation
b. Atonia of postural and accessory muscles (inspiration becomes more reliant on diaphragm muscle
activity)
c. Patients with inefficient diaphragms or diaphragm weakness will have a reduction in inspiratory pressure
generation (may lead to hypoventilation or central apnea)
 Progression of Chronic Respiratory Failure (see Graph A.1)
 SDB in COPD (see Graph A.2)
D. Compliance
i.
Compliance
ii.
Key Drivers for Compliance
a. Mask Fit
b. Education
c. Nasal Irritation
d. Pressure Flow
E.
Noncompliance
i.
May be greater as Pressures increase.
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ii.
iii.
III.
Considered pressure greater than 13 to 15 cmH2O may contriute to noncompliance.
What to Expect with noncompliance
a. Patinet has difficulty exhaling against CPAP pressure
b. Increased arousals due to high pressure
c. Development of frequent Central Apneas at high pressures
F. Treating Noncompliant CPAP with Bilevel
i.
Bilevel offers an alternative to patients unable to exhale against high CPAP pressure
ii.
Average mask pressure is lower during Bilevel therapy
a. Decreases air leakage
b. Nasal congestion/rhinorrhea
c. Chest Discomfort
G. CPAP to Bilevel
i. Some suggest setting the inspiratory positive airway pressure (IPAP) at the level in which the CPAP pressure
eliminated most of the obstructive events
a. Nicholas Hill, Chief of Pulmonary and Critical Care, and Sleep Medicine, Tufts New England Medical
Center
ii. Independently adjust the IPAP and the expiratory positive airway pressure (EPAP)
iii. Use the rise time and IPAP MAX for comfort and mouth leaks
NPPV Overview
A.
What is NPPV Therapy?
i. NPPV is delivered by a Respiratory Assist Device (RAD)
ii. Provides two different pressure settings (IPAP and EPAP)
iii. Augments patient’s inspiratory efforts to improve ventilation during sleep
iv. Maintains stability of the upper airway
B.
How Does NPPV Work?
i. Prevents nocturnal hypoventilation
ii. Improves alveolar ventilation
a. Reduces nocturnal CO2 levels
b. Increases nocturnal O2 levels
c. Improves daytime blood gases
iii. Stabilizes upper airway
iv. Rests respiratory muscles
v. Decreases daytime sleepiness by correcting sleep architecture (reduces arousal due to SDB and associated
sleep fragmentation)
 Effects of NPPV (see Graph B.1)
C. Possible Explanations1
i. Resets central chemoreceptor’s sensitivity to CO2
ii. Increases lung compliance
iii. Improves respiratory muscle strength
D. Disease States that Benefit
i. Patients susceptible to significant deterioration in oxygenation and ventilation during sleep
ii. Problem related to:
a. Neuromuscular dysfunction
b. Chest wall abnormalities
1
Hill, NS. Noninvasive Ventilation: Does it Work, for Whom, and How? Am Rev Respir Dis 1993;147(4):1050-1055.
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c.
d.
e.
COPD
Diaphragmatic dysfunction and/or disorders of ventilatory control
CSA
E.
Disease Processes
i. Respiratory muscle dysfunctions
a. Previous poliomyelitis
b. Muscular dystrophies
c. Myopathies
ii. Neurological disorders
a. Neuropathies
b. Bilateral diaphragmatic paralysis
c. Spinal cord injury
d. Brainstem lesions
e. Primary alveolar hypoventilation
iii. Upper airway disorders (Severe OSA)
iv. Lung diseases
a. COPD
b. Cystic fibrosis
c. Bronchiectasis
v. CSA
a. Idiopathic central apnea
b. Neurological dysfunction
c. Obesity-hypoventilation
vi. Chest wall disorders (scoliosis)
F.
Symptoms of Nocturnal Hypoventilation
i. Fatigue
ii. Dyspnea
iii. Excessive daytime sleepiness (EDS)
iv. Morning headaches
v. Memory impairment/decrease in intellectual performance
vi. Use of accessory muscles to breathe
vii. Repeated hospital admissions for hypercapnic respiratory failure
G. Benefits of Ventilatory Assist
i. Decreases office visits, hospitalizations, and hospital lengths of stay1
ii. Increases activities of daily living (ADL)
iii. Improves quality of life/exercise tolerance
iv. Prevents cardiovascular consequences of nocturnal hypercapnia and hypoxia
H. Contraindications
i. Requires life support
ii. Allergy to mask material
iii. Claustrophobia
1
Jones SE, Packham S, Hebden M, Smith AP. Domiciliary Nocturnal Intermittent Positive Pressure Ventilation in Patients with Respiratory Failure Due to Severe
COPD: Long Term Follow Up and Effect on Survival. Thorax 1998;53:495-498.
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iv.
v.
vi.
vii.
viii.
ix.
IV.
Inability to clear sputum
Inability to communicate
Possibility of gastric aspiration
Susceptible to pneumothorax
Bullous emphysema
Emboli
NPPV Titration
A.
Principles of Titration
i. Independently adjust inspiratory pressures (IPAP) to augment patient’s inspiratory efforts
ii. Independently adjust expiratory pressures (EPAP, PEEP) to maintain control of the upper airway while gaining
the benefits of end expiratory pressure
iii. To achieve SpO2 > 90 %
B.
Factors Affecting the Level of Ventilatory Support
i. Difference between the IPAP and EPAP levels set (P)
ii. Inspiratory time
iii. Impedance of the patient’s chest wall/lungs
C. Primary Settings
i. Mode
a. Spontaneous (S): patient-triggered
b. Timed (T): machine-triggered
c. Spontaneous/Timed (S/T): patient- or machine-triggered
ii. IPAP
a. Pressure support delivered to the patient when the machine is triggered into the inspiratory phase
b. Increasing IPAP and IPAP-EPAP difference will increase tidal volumes
 To improve alveolar ventilation (hypoventilation)
 To decrease CO2 levels and/or increase O2 levels
 To reduce accessory muscle use
iii. EPAP
a. Amount of pressure remaining in the circuit during the patient’s expiratory phase
b. Increasing EPAP will:
 Eliminate obstructive apneas and hypopneas
 Increase FRC
 Improve oxygenation
 Counterbalance intrinsic PEEP (PEEPi, also known as auto-PEEP) in patients with lung disease
 Rate of lung emptying becomes impaired because of increased expiratory airflow limitation
 Airtrapping causes hyperinflation
 Higher lung pressure relative to mouth pressure present at end expiration (PEEP)
 Patient must overcome a positive pressure before inspiration can begin
 Increases patient’s work of breathing
 COPD Pathophysiology (see Graph B.2)
 Inspiration with PEEPi (see Graph C.1)
 Titration adjustments
 Adjust EPAP to counterbalance PEEPI
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

Improve EPAP-IPAP triggering
Decrease patient inspiratory efforts
Make breathing more comfortable
EPAP should remain below PEEPi
Ineffective inspiratory efforts (“missed breaths”) may occur if EPAP level is insufficient
(monitor patient’s ability to trigger inspiration)
 Effects of PEEPi on Inspiration (see Graph C.2)
iv. Back-up rate
a. In the Spontaneous/Timed mode, the rate is set as a back-up
 Patient has exhibited central apnea
 Slowing in the patient’s spontaneous respiratory rate
b. Suggested initial setting: 4-6 bpm below the patient’s resting respiratory rate (RR)
v.
IPAP Max
a. Maximum time the device will stay at inspiratory (IPAP) pressure
b. Created to resolve poor IPAP-EPAP cycling due to mouth leak
c. Improves effectiveness of therapy where mouth leaks are present
 Loss of Ventilation caused by Mouth Leak (see Graph D.1)
d. The problem with mouth leaks
 Decrease expiratory cycling which may result in:
 Patient-machine asynchrony
 Hyperinflation
 Discomfort
 Ineffective therapy
 Increase work of breathing and muscle fatigue
 Occur in the majority of patients on this mode of therapy2
 High Leak Flow: Nonadjustable 3 Second Ti (see Graph D.2)
e. Setting IPAP Max
 Set to profile the patient’s intrinsic inspiratory time
 Applies to spontaneous, or patient-triggered, breaths (unlike insp. % (or I:E ratio), which only works
with machine-triggered breaths
 Count patient’s resting RR
 Refer to the programming guide or use formula (60  patient’s RR  2 = IPAP Max setting)
 Based on the patient’s actual rate (not bpm)
 Establishes a 1:1 maximum (resting RR = 18 bpm; IPAP Max is set at 1.7 sec.; during sleep, RR falls
to 12 bpm; new I:E is 1:2)
 High Leak Flow: IPAP Max (Timax)Cycled (see Graph E.1)
 Advantages of IPAP Max (see Graph E.2)
vi. IPAP Min
a. Opposite of IPAP Max
b. Guarantees a minimum time at IPAP
c. Patient’s breath triggers the device to IPAP but is not sustained (results in premature cycle to EPAP and a
fall in minute ventilation)
d. Beneficial in neuromuscular and chest-wall deformity patients
 Advantages of IPAP Min (see Graph F.1)
 How IPAP Max and Min Work (see Graph F.2)
2
Meyer, et al. Sleep 1997
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vii. Rise Time
a. Time (ms) the device takes to go from EPAP to IPAP
b. Maintains set time during each breath
c. Influenced by:
 Pulmonary or circuit compliance
 Pulmonary or circuit resistance
 IPAP-EPAP difference (P)
 Inspiratory effort
 Leak
 What is Rise Time (see Graphs G.1-H.1)
d. Comfort feature
 Patients with a high respiratory drive require fastest transition from EPAP to IPAP (e.g. COPD)
 Patients that are startled by too much air may like a slower transition (e.g. neuromuscular disorders,
obesity-hypoventilation)
 Always adjust settings to patient comfort
V.
Key Aspects of Compliance
A.
Numerous factors can affect patient compliance
i. Mask interface
a. Refit mask
b. Try different mask
c. Re-educate
ii. Patient and family education
a. Consultations
b. Support groups
c. Literature
iii. Acclimation (allow the patient a chance to become familiar with the mask and flow generator)
iv. Patient/machine asynchrony
a. Adversely affects clinical outcome
 Increases work of breathing
 Prevents adequate respiratory muscle rest
 Limits improved gas exchange
 Leads to sleep disruption and fragmentation
b. Improving synchrony
 Make sure IPAP Max is set to correlate with the patient’s intrinsic Ti
 Set IPAP Min accordingly
 Adjust EPAP to counterbalance PEEPI
 Improving Synchrony with IPAP Max (see Graph H.2)
c. Solving mouth leak
 IPAP Max
 Full face masks
 Chin straps
 Heated humidification
B.
Overcoming Obstacles
i. Inability of the device to meet patient’s ventilatory demand
a. Adjust Rise Time
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b. Use a device capable of delivering set pressure at high flow rates (especially when leak present)
Ineffective ventilation
a. Pressure settings may not be optimal
b. Patient may need a different form of ventilation
 Volume-cycled
 Pressure-cycled
c. Patient may need full face mask (pressure lost through mouth)
iii. Upper airway obstruction leading to ineffective ventilation—set appropriate EPAP to address obstruction
iv. Inadequate CO2 washout when pressure support levels (especially EPAP) are low—use mask system/delivery
circuit which allows adequate CO2 washout
v. Gastric distention
a. Reassurance
b. Pressure reduction
c. Simethicone
vi. Nasal congestion
a. Heated humidification
b. Nasal steroids
ii.
VI.
Respiratory Assist Device (RAD) Guidelines
A.
Qualifying the Patient
i. For specific criteria, see Clinical Pathways
ii. COPD—E0470 (patients may qualify for a E0471 device after 61 days if criteria is met while using the E0470
device)
iii. Chest wall/neuromuscular disease—E0471
iii. Central sleep apnea—E0470 or E0471, based on the treating physician’s judgment
B.
Documentation Requirements for Continued Coverage (within 61-90 days of initiating therapy)
i. All patients must be re-evaluated to demonstrate:
a. Improvement of symptoms
b. Compliance with therapy (4hrs/24)
ii. Obtain Physician Compliance Statement
iii. Medicare Beneficiary Statement signed by the patient
C. Accessories
 A7034—Nasal application (mask frame), one per 3 months
 A7033—Nasal pillows/seals (replacement cushion), two per month
 A7035—Headgear, one per 6 months
 A7036—Chin strap, one per 6 months
 A7037—Tubing, one per month
 A7038—Filter (disposable), two per month
 A7039—Filter (non-disposable), one per 6 months
D. CPAP and Humidification
i. New code added for heated humidification (E0562)
VII.
Building an NPPV Program
A.
Identify potential referral sources
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i. Sleep labs
ii. Physicians
iii. Managed Care Organizations (MCOs)
iv. Neuromuscular and rehabilitation clinics
B. Describe therapeutic benefits of NPPV
C. Discuss ResMed’s superior product technology and ability to aid and maintain compliance
D. Gain credibility by offering clinical documentation and educational support
E.
Clinical forms
i. NPPV Patient Screening Criteria
ii. Physician Order
iii. Physician Communication Log
iv. NPPV Initial Patient Assessment
v. Medication Profile
vi. NPPV Follow-up Assessment
a. Use when optimal titration is achieved
b. Use to enforce positive outcomes for patient and physician
vii. Plan of Treatment (POT)
a. Obtain both physician and patient-specific goals
viii. NPPV Visit Record/Titration Log
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