"please keep me updated about oximeters "
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Rock Hinkle: Bi-level Titration
You are titrating a patient on bi-level. The patient has slept well and you've found what seems to be the IPAP and EPAP needed for this patient. The patient has COPD. Can you adjust for Rise Time, Ti Maximum and Ti Minimum, Exhalation, Trigger and Cycle Sensitivity to improve therapy any further? Or is IPAP and EPAP need the extent of your titration?
Betchya this one "ain't" on the exam!!!! *wicked grin*
Views: 209
Replies to This Discussion
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Permalink Reply by RockRpsgt on
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I have never been given special instruction regarding COPD pts. With the exception of adding o2 or attempting to Bpap. Even with those exceptions the rules did not change because of a Dx of COPD. I always refer to the P&P or the AASM guidelines.
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Permalink Reply by Mary Z on
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j n k, I wouldn't be embarassed by not knowing all the particular settings- I alway have to go to the menu to check mine. Having the access to the clinicians menu is a blessing and a curse. I can see what the settings are, but have no idea how to fix anything that feels wrong between doc appointments. LOL! I just set the ramp for long enough to get to sleep so I don't even know what it does for the rest of the night. My breathing style does not seem to fit anything they do, so that ramp is great. Settling on the other hand was just weird.
As an aside, when I first got with my partner she uses the TV as a way to relax and go to sleep. It's necessary for her and I had a hard time getting used to having the tv on when I was trying to go to sleep. Now I'm used to it and feel irritated if it's not on (I know it's not good sleep hygiene to have it on, but...) She will fall asleep surfing and I can wake up to the weirdest shows in the morning- difficult baby deliveries, preaching and especially infomercials on health food juicers and exercise machines like the Ab Circle Pro.
j n k said:Mary,
I don't know what my machine is on right now. Do you know how embarrassing it is for me to say that out loud?
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Permalink Reply by Judy on
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Yep, yep, jnk. I was doing just that until two weeks before the re-titration when I went back to the original bi-level titration settings and I did "just" a Statistics printout at each setting I tried. The sleep doc that was on rotation as that consult wasn't even interested in them or interested in discussing them. At this point I neither need nor want their "permission" to try a different pressure setting. I do it, I tell them. I give them the data. I ask for their recommendations based on the stats so far.
I've had TWO bi-level titrations prior to this recent one. I slept 5 hours or better at both so they had the time to get some good information. The first was IPAP 13, EPAP 8 w/2L of 02. The second was IPAP 10, EPAP 5 w/o any 02. The first was the better titration giving the best, most comfortable, results.
The problem is that I've changed masks and while that shouldn't make any difference - it has. I had a high leak rate w/the Simplicity simple nasal cushion which improved but not good enough w/the addition of a chin strap. I switched to the Zzz-Mask full face and my leak rate dropped to zilch or near zilch, 95th percentile never over 24 L/M, but my AHI shot outta sight. I like the Zzz-Mask, its comfortable and the Leak rate is great - so - finding the right IPAP and EPAP settings w/the Zzz-Mask is the current issue. Neither of the two titrations were done w/the Zzz-Mask. Both were done w/the Simplicity or the second half of the second titration w/an OptiLife nasal cradle cushion.
I have no idea what instructions the sleep docs gave the sleep techs.
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you do the same for me.
j n k said:Thanks, Rock. That's what can make my posts dangerous, though. I don't have any of the letters after my name that would give me the right to have the opinions I do, or to make them public. I often sound like I know more than I do, and that is not a good thing. So keep me careful, OK, pal?
jeff
Rock Hinkle said:Your post are very logical jnk.
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Permalink Reply by Randal on
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I have to say there were a number of times I lost you guys but for the most part I keeped up. This is a simple question to me but it is hard to get the history laid out to keep it logical. The question " is Auto BiPAP better for a person with COPD and would it maybe reduce the need for supplemental O2. Now for the history
1- went for a Caterack Operation in Oct 2009. During the prep they had a hard time getting blood O2 above 88. Told me I should talk to my primary care doctor
2- November 2009 - went to primary care doc for a check up. Talked about the O2, talked about being tired, wife talked about my snoring. Primary Care suggested a sleep test. I fiinally made the appointment ( after numeous follow up calls from sleep clinic ) for Jan 20th 2010.
3- Dec - Jan 2010 I was getting more and more tired. By the 1st week in January, I just had to sit down to fall asleep. Jan 7 2010 I fell asleep at moter-inl-laws funeral. And I loved her dearly. The follwing Tuesday my co-workers sent me hme from work. Sleeping at my desk. I could not stay awake and could no sleep for more then 4 hours in bed. Leaving work I went straight to the urgent care. they transport me by ambulance (20 miles) to the hospital. Long story short, they kept me for 5 days...Knee-moan-ya, acute respitory failure and COPD. They sent me home with a Auto BiPAP machine with a 2 lt O2 feed. This is the same O2 that I was using at home during the day. .
4 - Jan 20th Had first sleep test. They detirmined I need CPAP. A week later I went for tritation. Remember I have been using a BiPAP w/ff along at home. The Sleep Clinc refused to use a BiPAP till I failed with CPAP. They keep refering to insurance requirements. Two weeks later I meet with the Sleep Doctor. He is a Neurolist (Brain Guy). Passed CPAP, no Bipap needed, preassure set to 10 and still have O2.
Back to the question " is Auto BiPAP better for a person with COPD and would it maybe reduce the need for supplemental O2
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I too have often pondered on your PS of 5 Judy. I do not fully understand how they came up with this number. PS is something that, to my knowledge, can not be found in an incomplete titration. A successful titration is defined by the AASM as one that achieves supine REM for at least 15 minutes with an AHI<5. Whatever the PS was at this point should be the Rx settings. I understand the need for you to be on auto-Bilevel due to the lack of adequate sleep data in your last titration. But why limit the PS and cripple the auto-algorithm. Just my thoughts. what do I know though? A doctor I ain't.
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Sorry Randal, I meant to add your question to my last post. I got distracted.
I can not say if Bpap will reduce your need for o2. My studies backed with my lab experience tell me that a proper titration COULD lower those needs. This would be regardless of the type of unit you are on. We have quite a few pts that come in to the lab on o2. Following a succesful titration, and compliance with adequate therapy we have seen a great many of these pts come off of o2. Now you have to look at o2 needs on a case by case situation. If your spo2 baseline is not stabilized above 88% by PAP therapy, then your o2 needs will not change.
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WOW! What a dynamic doctor. Mary has spent too much time on the hospital floor.
j n k said:As long as you don't dream about surfing obstetricians preaching about juicers and exercise machines!
Mary Z said:. . . fall asleep surfing and I can wake up to the weirdest shows in the morning- difficult baby deliveries, preaching and especially infomercials on health food juicers and exercise machines like the Ab Circle Pro.
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Randal,
http://www.ncbi.nlm.nih.gov/pubmed/18585024
CONCLUSIONS: Sympathetic and parasympathetic neural control of heart rate is altered in COPD patients and that BiPAP acutely improves ventilation, enhances sympathetic response and decreases vagal tonus. The improvement of ventilation caused by BiPAP was associated with reduced cardiac vagal activity in stable moderate-to-severe COPD patients
Here is everything I found on COPD and Bpap.
http://www.ncbi.nlm.nih.gov/sites/entrez
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http://www.ncbi.nlm.nih.gov/sites/entrez
Overlap syndrome is a term which specifies the existence of both chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) in the same patient. The prevalence of OSA in COPD patients equals its prevalence in the general population. Overlap patients have a greater degree of hypoxemia and hypercapnea than COPD patients matched for stage. They also have a greater prevalence of pulmonary hypertension and right heart failure, and suffer higher morbidity. Due to these consequences of the overlap syndrome, it is recommended to actively search for its existence in COPD patients, and to treat it with continuous positive airway pressure (CPAP) concurrently with oxygen and optimal pharmacological treatment of COPD
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This one is pretty new.
http://www.ncbi.nlm.nih.gov/pubmed/19574323
Obstructive sleep apnoea syndrome (OSAS) often coexists in patients with chronic obstructive pulmonary disease (COPD). The present prospective cohort study tested the effect of OSAS treatment with continuous positive airway pressure (CPAP) on the survival of hypoxaemic COPD patients. It was hypothesised that CPAP treatment would be associated with higher survival in patients with moderate-to-severe OSAS and hypoxaemic COPD receiving long-term oxygen therapy (LTOT). Prospective study participants attended two outpatient advanced lung disease LTOT clinics in São Paulo, Brazil, between January 1996 and July 2006. Of 603 hypoxaemic COPD patients receiving LTOT, 95 were diagnosed with moderate-to-severe OSAS. Of this OSAS group, 61 (64%) patients accepted and were adherent to CPAP treatment, and 34 did not accept or were not adherent and were considered not treated. The 5-yr survival estimate was 71% (95% confidence interval 53-83%) and 26% (12-43%) in the CPAP-treated and nontreated groups, respectively (p<0.01). After adjusting for several confounders, patients treated with CPAP showed a significantly lower risk of death (hazard ratio of death versus nontreated 0.19 (0.08-0.48)). The present study found that CPAP treatment was associated with higher survival in patients with moderate-to-severe OSAS and hypoxaemic COPD receiving LTOT.
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