"The Ins and Outs of Home Noninvasive Ventilation" Amanda J Piper (12/01/2021)

December 09, 2021

ID7253

To CiteDCA Citation Guide

00:04So good afternoon everyone,
00:06and as usual I'll start with
00:08a few announcements before I
00:09introduce our speaker today.
00:11First, these sleep seminar lectures
00:12are available for credit when viewed
00:15in real time and to receive credit.
00:17Just text the ID for the lecture
00:19to Yale Cloud CME by 3:15 PM there
00:22will be information that shows up
00:23in the chat so you can see it.
00:25Then recordings of the lectures are
00:27available about two weeks after the lecture.
00:30There's no CME credit for recordings.
00:32If you have questions during the talk.
00:34Please use the chat.
00:35I will moderate the chat at the
00:36end so that way we can address all
00:38the questions and you'll have the
00:40opportunity to unmute yourself at
00:41the end as well and otherwise.
00:43Please keep your microphone muted,
00:45so now it's really my great pleasure
00:47to introduce today's sleep seminar
00:49speaker Doctor Amanda Piper.
00:50She joins us from Sydney where it is
00:53currently December 2nd and 6:00 AM,
00:54so that's amazing that she's here,
00:56and so we're thrilled for that.
00:58Doctor Piper is a team leader at
01:01Respiratory Support Service and
01:02home ventilation programs in the.
01:04Royal Prince Albert Alfred Hospital
01:06in Camperdown, Australia,
01:07and she's clinical associate
01:09professor at Central Clinical School,
01:11University of Sydney.
01:12Doctor Piper received her Bachelor
01:14of Applied Science and Physiotherapy
01:16at Cumberland College of Health
01:17Sciences at University of Sydney.
01:19her Master of Education at University of NSW,
01:22and her PhD in medicine at University
01:25of Sydney.
01:26Doctor Piper is considered one of the
01:28foremost clinicians in assessment and
01:30management of hypercapnic respiratory
01:32failure and non invasive ventilation use.
01:34She has an extensive publication record
01:36over 100 peer reviewed publications
01:38and book chapters on diverse topics
01:41related to respiratory muscle weakness,
01:43monitoring of sleep disordered
01:44breathing and the use of an Ivy
01:47in multiple clinical settings.
01:48She's been a keynote or guest
01:50speaker at multiple international
01:52and national meetings and she served
01:54on multiple clinical guideline.
01:56Writing groups,
01:57including most recently the ATS obesity
02:00hypoventilation guidelines and the ATS
02:02home in Ivy for stable CPT guidelines.
02:05She is an active educator.
02:06She's currently supervising 5 PhD
02:09students and two physiotherapy students.
02:12Her research centers on non invasive
02:14ventilation and other treatments in
02:16patients with chronic respiratory failure.
02:18She has been a primary or Co
02:20investigator in numerous clinical
02:22trials but just to name a few,
02:24the role of Don invasive
02:25ventilation in exercise.
02:26Training and rehab.
02:28Patients with chronic hypercapnic
02:29respiratory failure evaluation of different
02:31PAT modalities in the management of OHS.
02:34The effect of oxygen therapy
02:36on breathing in OHS,
02:37the use of NIV as an adjunct to
02:40secretion clearance in patients
02:41with Bronchiectasis and the use
02:42of an Ivy and oxygen in patients
02:45with motor neuron disease.
02:46In 2021,
02:47she received a very prestigious
02:49honorary member title to the
02:51European Respiratory Society,
02:52which is awarded to only
02:54two individuals per year.
02:55In recognition for both her
02:56pioneering work in the effective use
02:58of an Ivy and respiratory failure,
03:00and also in the wide dissemination
03:02of NID into clinical practice.
03:04So it's our distinct pleasure and
03:06honor to welcome Doctor Piper TL
03:08today to discuss in's and outs
03:10of home ventilation welcome.
03:13Oh, thank you so much Janet for the
03:15introduction and thank you everybody
03:17for for turning up and so good
03:19afternoon as you heard it is good
03:21morning for me just to begin with.
03:24I do have some financial disclosures.
03:26I have given talks for on behalf
03:29of Power Phillips in the last 12
03:31months and during the presentation
03:33you will see pictures of equipment
03:36from both Phillips and Res Med.
03:38They are the devices that
03:40we have most access to.
03:42Here in this country,
03:43and I think probably in the states as well.
03:46So as you heard,
03:48I'm from as Camperdown is a suburb of Sydney.
03:52This is a picture of the center
03:54of a Sydney and if you have a look
03:57that little red circle up in the
03:59left hand corner is our hospital
04:01Royal Prince Alfred Hospital.
04:03So this is another view of it.
04:05So here is our hospital in the
04:08middle top panel looking back.
04:10Seeing the city there and it's
04:12an interesting combination.
04:14A very old hospital built in the 1880s
04:18which is old for Australia and some very new,
04:22has a clinical services block and we are
04:25back on to the University of Sydney.
04:29So what I wanted to cover today
04:31is really just talk about what the
04:34goals of bilevel therapy are and
04:37really looking at it from sort of,
04:38you know,
04:39the in and out of how we should
04:41be managing or thinking about
04:44managing noninvasive ventilation.
04:45So I'm going to primarily concentrate
04:48on settings and that for patients with
04:52neuromuscular conditions and COPD,
04:54and you'll see why shortly and
04:55also talk a little bit about,
04:57you know automated.
04:59Therapy,
04:59but I think also a topic that's
05:02becoming more of interest around
05:04the world is where we should be
05:08locating the acclamation to therapy in
05:10individuals with sleep hypoventilation.
05:12So the inpatient versus the outpatient
05:16in lab with PSG in the home or in
05:20hospital situations and then talking
05:23about ongoing titration and monitoring.
05:26And I think some caveats before I start.
05:28First of all, uh, Australia is
05:31roughly the same size as the contiguous US,
05:34so we are a large country,
05:38a small, very small continent.
05:39Very large country,
05:41but we have very different populations
05:43are compared to the United States,
05:46so you know you have it roughly.
05:48You know 10 times our population at least,
05:51and that has a lot of implications for us,
05:55and you know,
05:56and the information that I gleaned from.
05:59The literature and what we do in terms of
06:01our population density and the travel times.
06:04A lot of our patients have in
06:06coming to see us and the barriers
06:09to therapy because of that very,
06:11very sparse population.
06:13So most of uh of Australians 50% live
06:18between what's Brisbane marked on this map,
06:21which is sort of the center of the right
06:24hand side of the continent down to Melbourne.
06:26So 50% of the Australian population.
06:30Living within that region and
06:32so a lot of the
06:34country is made up of individuals
06:36that you can see below,
06:38like this kangaroo and
06:40lots and lots of you know,
06:42open space what we call the red Center.
06:45The other obvious.
06:48Implication and how to interpret some
06:50of this stuff that I'm talking about
06:53is the huge difference in healthcare
06:55funding between our two areas.
06:57So in Australia we have the
07:00federal government collects taxes
07:02and then gives it to the state
07:03and territory governments who
07:05actually run the hospital systems.
07:07We do have our private health insurers,
07:10but they make up very much
07:12smaller proportion of the sort
07:14of healthcare that Australians
07:16receive and very much like Canada.
07:19We have a universal health health
07:21insurance scheme which is means although
07:24we pay for it through our taxes,
07:27we can turn up to you know,
07:28any public hospital for any
07:31condition and receive our free
07:33care at that particular point and
07:35that includes outpatient services.
07:37We also have subsidized medications,
07:40so when it comes to the provision
07:42of bilevel or ventilators in
07:44the state that I live in,
07:47it's funded through a specific.
07:49NSW government body called Enable
07:53where the criteria to get this
07:56equipment is largely evidence based
07:58with some clinical justification,
08:00so it's not particularly difficult
08:02to get equipment and patients
08:04don't have to pay for it.
08:07Apart from $100.
08:08I think that it is a year as a
08:11an administration fee which will
08:12be waivered if they just claim
08:15they can't afford that.
08:16Very different to the United States
08:18and I won't even try to get my
08:20head around how your reimbursement
08:22and funding system works,
08:25but I think there are two interesting
08:27papers which I haven't read all
08:29the way through because it's not
08:32pertinent to my situation but
08:33that big Mccleskey and Nikhil or
08:36written papers talking uh with
08:39some results from their technical
08:41expert panel report trying to look
08:44at how to improve the access to.
08:46Bilevel devices for patients
08:48with various types of sleep,
08:49hypoventilation in particular,
08:51getting easier access to the
08:53St modes of ventilation,
08:55because certainly there's increasing
08:58evidence that this can be quite useful,
09:00particularly in patients with
09:02with things like COPD.
09:06So when we think about
09:07non invasive ventilation,
09:08we have to think about what we're trying
09:10to achieve and obviously you know we.
09:13We think about improving gas exchange
09:15to not only when there is sleep,
09:17but hopefully they've already
09:18inhabit Catholic respiratory failure.
09:20Reversing that daytime respiratory
09:22failure primarily by preventing or
09:25minimizing abnormal breathing events,
09:27chilling sleep,
09:28and at the same time trying to
09:31facilitate uninterrupted sleep
09:33from a patient's point of view,
09:34they really want to have.
09:36Relief that their symptoms and
09:37improvement in their quality of life.
09:39And often this is around
09:42reducing hospitalizations,
09:43and if we are going to
09:45treat these individuals,
09:46we want to extend meaningful past survival.
09:51When it comes to therapy,
09:53there's a whole range of different
09:55machines that we can use from very simple
09:58bilevel devices to the more complex
10:01home high end machines.
10:02There's a whole range of
10:04masks that we have access to,
10:06as well as thinking about the
10:08primary settings on the machines
10:10and the different machines there,
10:12and silly settings that we should be
10:14using to try and match better what
10:16the machine is doing and what the
10:19patients ventilator demands are.
10:21So getting noninvasive ventilation
10:23right is very much about picking
10:27the right patient under the right
10:29circumstances at the right time
10:32and using the most appropriate
10:34and right equipment for them.
10:36And when we look at some of the stuff
10:38that is coming out from from Europe,
10:40for instance,
10:41you can see over the last two decades
10:44the increasing use of non invasive
10:47ventilation being prescribed for the home.
10:50So from the anti dear our database
10:53which is a very extensive database
10:55from the French you can see in the
10:59management of chronic respiratory
11:00failure over the last two decades at this
11:03marked reduction in treating these patients.
11:06With oxygen therapy alone fairly steady.
11:10Centage of patients still receiving CPAP,
11:13but the increasing number of patients
11:16receiving noninvasive ventilation either
11:18with without supplemental oxygen.
11:22And similarly a very recent
11:24study looking out of Switzerland
11:26looking around Lake Geneva area,
11:29just showing that over the last two
11:32decades the increasing number of
11:34patients with COPD which were being
11:37prescribed non invasive ventilation
11:39reducing numbers of patients with
11:43LHS receiving CPAP rather than non
11:46invasive ventilation and the numbers of
11:49patients with neuromuscular disease has been.
11:52Relatively steady.
11:53And this is before we've had the
11:56two guidelines regarding COPD
11:58and play chess come out out from
12:00the American Thoracic Society.
12:02And also some guidelines regarding
12:06COPD from the European Sports Society.
12:08So we would sort of expect particularly
12:12around COPD increasing members so
12:15I don't have to tell this group.
12:16You know the importance of the
12:19physiological changes that occur
12:21during sleep,
12:22which lead to increased upper airway.
12:24Resistance or reductions in the spiritual
12:27muscle turn and reduced chemo sensitivity,
12:30or reducing the potential for reduced
12:34minute ventilation and alveolar
12:37ventilation in patients with COPDV
12:40city hyperventilation and those
12:43with neuromuscular conditions.
12:44When we're applying on the basis
12:46of ventilation,
12:47we now have the opportunity to try
12:49and control that the upper airway,
12:52increase resistance or collapse.
12:55We have the inspiratory.
12:58Trisha support to try to improve
13:01title volumes.
13:02And we have the ability to add a backup
13:05rate all with the aim of increasing
13:07alveolar ventilation in these individuals.
13:10But we should never forget that there
13:13is a bidirectional relationship between
13:15sleep and non invasive ventilation
13:18in their non invasive ventilation
13:20can be disrupted for sleep but
13:22it can also improve sleep quality
13:25but likewise sleep have different
13:27impacts on invasive ventilation.
13:29Compared to the right from the
13:31state had when we have non invasive
13:33ventilation during sleep we can
13:35see things like glottic closure
13:37with central events created by
13:39noninvasive ventilation itself,
13:41which can have an impact on
13:43sleep and hints breathing,
13:44and we also have at any
13:47time during wakefulness or
13:48sleep. The potential to create patient
13:51ventilator asynchrony which can again
13:54impact the efficacy of ventilatory support.
13:58So if we start thinking about the inszoom
13:59outs of noninvasive ventillation,
14:01we have to start with inspiratory support.
14:04You know. And obviously,
14:05the higher that we set the iPad and
14:08epep difference, the more support
14:10the patient is going to receive.
14:12And in doing that,
14:14particularly if we have a a patient
14:17who is taking small breaths,
14:20we're going to add by increasing
14:22their title volumes.
14:24We often can steady there breathing down,
14:27reduce their respiratory.
14:29Right and making far more comfortable with.
14:32Surprisingly,
14:33sometimes with the higher pressures rather
14:35than the lower pressures the patient
14:37needs to feel as though they're being
14:39adequately supported with each breath,
14:41particularly patients with COPD.
14:44So when we're looking at setting
14:47that inspiratory pressure,
14:48we're looking at our ability to reduce
14:51the carbon dioxide because we've
14:53increasing our bill of ventilation.
14:55So generally we're trying to get
14:58that pressure support to a point
15:00where we can generate a title,
15:02volume,
15:03and the patients asleep somewhere
15:05between six and eight goals for
15:08per kilogram of ideal body weight.
15:11For patients with a neuromuscular
15:13condition and between 8.
15:15Teacher bad at mills for kilogram
15:17per patient with COPD.
15:19So here we are trying to reduce the CO2.
15:23Looking at nighttime.
15:24We want that nocturnal CO2 to be
15:28at least the same as the awake
15:31CO2 or in many patients,
15:32particularly those that
15:34have daytime hypercapnia.
15:35We want to make it lower than the they're
15:38awake CO2 levels and in patients with COPD.
15:42Certainly there is evidence
15:43coming out that way.
15:45Really, painting the goal is a
15:48reduction in CO2 of about 20%.
15:52The outs of course refer to the
15:55impact pressure and you know.
15:57Again,
15:57you know this group knows.
15:59You know we're using epact to prevent
16:02that airway closure or collapse,
16:04and particularly in patients
16:05with things like be sitting with
16:08related hypoventilation overlap
16:10syndrome and certain patients with
16:13neuromuscular conditions as well.
16:15And the problem is that that upper
16:18airway aperture can change depending
16:21on sleep stage and body position.
16:24We can also use the pack for
16:26offsetting intrinsic peak.
16:27In patients with COPD trying to
16:29reduce the effort of breathing,
16:31they haven't and work of breathing
16:34and trying to prevent our unrewarded
16:37efforts that often patients with
16:39COPD can present with during long
16:42invasive ventilation and they gain
16:44the ability to put these patients.
16:47At least from my experience.
16:49And I know some of the European
16:51experience having a backup rate
16:53high enough where we just don't see
16:55unrewarded efforts. Because we're.
16:57Hoping to ensure each breath is
17:01being is being received by the
17:03patient when they make an effort.
17:06That's a pet. It is a fine balance.
17:09We want enough to achieve the goals
17:12or preventing or offsetting intrinsic
17:14people or preventing upper airway collapse.
17:17But we also want to make sure
17:19we're not setting it too high,
17:21because it will be uncomfortable
17:23for the patient making it
17:24harder for them to breathe out.
17:26But also, as we increase the iPad,
17:28just creating unnecessary
17:30leak for the patient.
17:33I think we also have to think about.
17:36Groups where maybe a bit obstruction
17:40doesn't immediately come to mind,
17:42and certainly patients with
17:45a LS motor neurone disease.
17:48How can also often have a very
17:50tricky upper airway even though
17:52they've gotta love Chris Pucci,
17:54muscle weakness and George is this French
17:58group headed up by George is Dad 179.
18:02A list patients and thereby
18:04using very simple oxygen.
18:07Saturation monitoring and looking at
18:09the pattern of that as well as leak.
18:12They identify patients group that is
18:15either having adequate ventilation
18:17or being inadequately ventilated
18:19and this is a very experienced group
18:22of clinicians and researchers in
18:24this impatience with Payless and
18:26they found that when they set the
18:29patient up and they looked at them,
18:31you know within a month only.
18:3541% of them were inadequately ventilated
18:38and this was primarily due to upper
18:40airway obstruction and the important
18:42thing about you know this study and what
18:45it teaches us is that in this particular
18:48population if we fail to correctly
18:50obstruction it had quite a significant
18:53effect on these patients survival.
18:55So those patients that were
18:57inadequately ventilated because
18:58of upper airway obstruction.
19:01If they couldn't get that up
19:02in obstruction under control.
19:04Survival was very poor over the
19:07next 12 months and simply even
19:09those patients will help anyway,
19:11obstruction but really weren't
19:12desaturating look great deal also had
19:15very poor survival outcomes compared
19:17to those individuals who may have
19:20initially had up in late Struction,
19:22but they were able to correct it,
19:24which was in 58% of cases
19:27by adjusting ventilator.
19:29Their survival was far superior
19:31over that 12 month period.
19:34So when they're thinking
19:36about getting into patients,
19:37we really have to think about
19:39the masks that we're using and
19:41certainly looking at the literature,
19:43there has been news over the last.
19:46Two decades from nasal masks
19:49to oronasal masks,
19:50and certainly in our practice,
19:52we use a lot of oronasal masks,
19:54probably about 90% of our patients
19:57having our own nasal mask.
19:59The literature in general is talking
20:02about 75% leased the European literature,
20:06and we've got two very recent
20:08our cities showing that probably
20:10nasal oronasal masks are equally
20:13effective in patients with both
20:15neuromuscular conditions and.
20:17CRPD with respect to things
20:19like gas exchange and sleep,
20:21but it is very important.
20:22This can be quite considerable variation
20:25with some patients doing much better
20:27on the Mason mask and some doing much
20:29better with hate and orientation.
20:32Ask in this study out of Germany are
20:36pretty Young's group showing that in
20:40patients with non invasive ventilation there,
20:43particularly patients with
20:45neuromuscular conditions treatment.
20:47Associated with destruction occurred
20:49in about one in five individuals,
20:52but mainly in patients with neuromuscular
20:56conditions as opposed to other
20:59sleep hypoventilation conditions.
21:01And it wasn't there had a reasonable number
21:04of Payless patients in amongst this group,
21:07and the presence or absence of severe
21:10bulbar dysfunction didn't seem to
21:12influence whether or not patients
21:15would develop copyright substruction.
21:17Everything alright.
21:19Nasal mask.
21:20So we just have to remember if we are
21:23using these masks or removing someone
21:25from an Asian last oronasal that we
21:28can give up a distraction from that
21:30jewelry traction from that or a nasal mask,
21:33particularly in patients who have
21:35weakness of hypertonia of the
21:37tongues so we can see that it's in
21:39that quite a bit in patients with
21:42Princeton station muscular dystrophy,
21:43and in particular if they're
21:45in a supine position.
21:46And REM when the tongue is floppy and you
21:48can have high pressures during inspiration.
21:51Causing that blockage of the upper
21:54airway with that flop tongue
21:56said something to bear in mind.
21:58So let's think about then putting
22:01the in's and outs on more automatic.
22:04Where does auto titrating
22:07bilevel devices sit?
22:10Well when we think about
22:11volume tag or the pressure
22:13support it's a great idea in
22:15theory because hopefully these
22:17devices will adjust the pressure
22:19support so we're maintaining that.
22:21Target tidal volume irrespective of
22:23what the patient is doing in terms
22:25of sleep stage, sleep position,
22:28overtime as the patient gains,
22:30loses weight or disease progression
22:33and we have the power increasing
22:36numbers of people coming out showing
22:38it is effective in patients with COPD,
22:41obesity, hyperventilation,
22:43and neuromuscular conditions.
22:45But it is important to state
22:47that there's no evidence that
22:49these this device is actually.
22:51Giving us superior outcomes,
22:53but I think it's actually really
22:56useful option we starting to titrate
22:58or trying to optimize our patients and
23:01we do use it not on every patient.
23:04I do generally still use fixed pressure,
23:07but it's a really nice mode and an option
23:09to have or a number of individuals,
23:12and in particular we've found patients who
23:15require quite high pressures at night.
23:18Maybe for instance in can REM sleep.
23:21But they can't rate those
23:23pressures during wakefulness,
23:24and it can really help improve that
23:26comfort and acceptance of therapy.
23:28And also patients where we've
23:30got quite a bit done titration.
23:32And there's quite a lot of difference in
23:35pressure support between sleep stages.
23:37Then, I think,
23:38often only target pressure support
23:40is a low grade those individuals,
23:43but it isn't what these are not affected.
23:48Set and forget to type out black box.
23:50It's really important, Lee.
23:52How will they?
23:53This mode of therapy works depends
23:55on the targets that we've set.
23:58Understanding the limits of these
24:00devices and ensuring that we're
24:02monitoring these individuals to make
24:04sure the device is delivering what we
24:07think it supposed to vegetable drink,
24:09and the two major problems with these
24:12devices is first of all the auto titrating.
24:17Therapies is that the impact that
24:20unintentional leak can have on
24:23the effectiveness of ventilation?
24:25So you'll often see when you have these
24:28patients on non invasive ventilation.
24:30If there's a leak in the system
24:32the machine was with,
24:33a single line will start to
24:35read much higher tidal volumes.
24:37So if you've got a volume target
24:39pressure support and there's
24:40a large leak in the system,
24:42the machine will often think that the
24:44patient is getting too large and breath.
24:47It will see that high tide environment
24:49and start to reduce the pressure support.
24:52So affectively will begin to under
24:55ventilate the individual and Nugent
24:58and has done and so Joe had done a
25:00number of studies looking at that
25:03particular moment in patients using
25:05volume target pressure support
25:07modes of ventilation.
25:09The other thing we have to be really
25:11careful of is the prisons of airway
25:13obstruction that's not being properly
25:15treated because this will lead to.
25:17Ineffective ventilation as you can
25:20see in this picture here you can see
25:23the variation in the pressure the
25:26patient has upper airway obstruction,
25:28the machine and as a result of that
25:31there's a drop in tidal volume.
25:33Machine tries to ramp the pressure
25:35up the patient because
25:36at the end of the extraction then
25:39arouses takes a few deep breaths.
25:41They now over ventilated so boring
25:43machine takes the pressure support down.
25:46The patient goes back off to sleep.
25:48The obstruction occurs again and then
25:50we can get the entire period time
25:52with this repetitive obstruction.
25:54Variations and tidal volume and minute
25:57ventilation and potentially quite
26:00high tidal volumes with not lead
26:04into effective dentistry support.
26:06And so we know that persisting at
26:09the airway obstruction can impact
26:11both ventilation, gas exchange,
26:13sleep quality,
26:14and in some patients even survival.
26:17But for many of these individuals,
26:19that high pets not required continuously,
26:22so the availability of the auto
26:25epac modes can be quite useful.
26:28You know this may present in some
26:31machines as auto AE or auto epap,
26:34or it could be automated airway.
26:36Management in other devices and the
26:39idea of this has been under set that
26:42minimum and maximum impact pressure.
26:45So the machine now has the capability
26:47of not only increasing and hopefully
26:50very impressed support in response
26:52to hypoxia or low tidal volume
26:55associated with non obstructive
26:57had partners but also increasing
26:59EPAC to manage that hypoxemia or
27:03obstruction caused by airway closure.
27:07But of course,
27:08we're not relying on these devices
27:10and the algorithms within them to
27:12be good enough to recognize mental
27:14power increase pressures at quarter,
27:16and went increasingly pack in response
27:18to that drop and tidal volume,
27:21whether it's related to obstruction
27:23or non obstruction.
27:25And we have two papers,
27:27one out of five WA with Nigel regardless
27:31group and also here in the states.
27:34Looking at the use of auto ipat
27:39during PSG guided titrations.
27:41And both of these studies used
27:43patients who were already used
27:46to non invasive ventilation,
27:48so these were not naive to to therapy
27:50and what both of these studies showed.
27:53Whether you're looking at a hi.
27:56Looking at ody that the use of these
27:59auto ipet modes of people that support
28:02we're not in power inferior to PS
28:06she carded using fixed pressure,
28:08but particularly look at the Mikado paper.
28:11You can see there's quite variable
28:14individual response to whether another
28:17patient responds better to the auto E
28:21pack or two A2 affixed to a fixed pressure,
28:24and unfortunately in their paper they wasn't.
28:27Large enough numbers under different
28:29diagnostic groups to work out
28:31any pattern of which patients
28:33might respond better to the fixed
28:35versus an auto titrating a pet.
28:37And we also don't have longer
28:40term information about how these
28:43this mode of setting a PAP.
28:47Works in the longer term.
28:49Some of those additional
28:51settings things like rise time.
28:52It can be incredibly important in
28:54terms of patient comfort and given
28:56the air into patients so that you
28:59know the rise times how fast that
29:01E Peppers going Oakley pressure
29:03support is going for epub to iPad.
29:05And depending on the device
29:07within numerical time scale,
29:09so generally speaking,
29:11patients with COPD prefer that faster
29:13pressurisation in particular compared to.
29:16If you look at a patient with
29:18a new mushkilat conditions.
29:19So what we're trying to do with that
29:21rise time is matched the patient
29:23speaking spirit reflow so his COPD
29:26patients generally prefer that the
29:29higher the faster pressurization life.
29:32It is too fast.
29:33It can be quite uncomfortable for
29:35the patient and create these very
29:38high and unnecessary peak flows and a
29:40neuromuscular patient for neuromuscular
29:42condition is likely to complain about.
29:45You know the pressure being too
29:47high even if the pressure is
29:48actually set relatively low.
29:50It's a flow rate at them is just
29:52too hot and it is too high.
29:54You often get this little peek
29:56on the on the pressure,
29:58just indicating that they're being
29:59hit in the face a little bit too hard.
30:02On the other hand,
30:03if he said it too slow and the patient,
30:05particularly those with COPD,
30:07will fill up their suffocating,
30:09they just were not matching their
30:12inspiratory peak inspiratory demands
30:14and can be quite uncomfortable for.
30:18So it's not just about comfort,
30:21it can also impact on tidal volume.
30:23Pan in this illustration.
30:25Here it is a an exaggeration,
30:28but you can see that the green
30:32arrow in the top panel with the
30:34rise time with 100 mills.
30:36If you look at that, sorry 100 milliseconds.
30:38You can see the tidal volume here.
30:41It's close to about 500 mills,
30:43keeping all the settings exactly the
30:46same could change the rise time to 7.
30:49190 seconds you get,
30:51you know,
30:51just over 100 mil drop in tidal volume
30:55because there's less area under that
30:57that curve to to give us that title volume.
31:00So thinking about as we change particularly
31:03make large changes in the right time,
31:06help may impact on cattle.
31:10Inspiratory times settings can be very
31:14important to make sure that we're
31:16matching what the machine is doing
31:18to what the patient is is required.
31:20So generally speaking in machine
31:22deluded Brits, we need to to set up a
31:26machine at A TI inspiratory tonight,
31:29but there are now a number of
31:32devices where we can also set
31:34a T and wind and less feature,
31:37and this is clearly really useful
31:39where we're trying to match.
31:41Machine is doing to the patients neural
31:44time and so when we think about the
31:47T I'm in there trying to make sure
31:50that the when the patient triggers the
31:53breath that inspiration is going to
31:55occur for at least a minimum period of
31:58time to get that chest wall expansion,
32:02which is very useful in patients with pay
32:06with restrictive lung languages for pology.
32:09On the other hand, the T IMAX.
32:11Is it's really a limit or security to make
32:15sure that the machine will not continue
32:18on inspiration beyond what is reasonable,
32:20sensible for that particular patient.
32:22If, for whatever reason particularly
32:24are either long mechanics or lick
32:27that presets are conflict criteria,
32:29is not met by the machine having the T IMAX,
32:33is that surety to make sure that we
32:36haven't gotten inspiratory enough so in
32:39patients with chest wall lungs restriction?
32:42They just generally have a tendency.
32:44Because of that apology to cycle off early,
32:48and so we've got the TIF machine.
32:50It is often much shorter than what
32:52the patients new runtime they'd
32:54love to take a longer break in a
32:56bigger and better tidal volume,
32:58but there longer canix just won't let them.
33:00And if the machines following their
33:03respiratory inspiratory flow,
33:04we're going to get that very
33:06short inspiratory time,
33:07which can be uncomfortable.
33:08And we're going to get title volumes
33:11that are less than desirable.
33:13So we can increase the T I'm in.
33:17In those in that particular case,
33:19or maybe set a the cycle of less
33:21sensitive to allow the machine to
33:23go out and terminate that cycle
33:25at a slightly longer period.
33:27So this is an illustration here of the
33:30patient that we had in the sleep laboratory,
33:32and this is a patient who had a
33:36restrictive chest wall disorder.
33:37Very short that I TE ratio is just
33:40too short by pushing out the T.
33:42I'm in getting much better.
33:46Inspiratory times and much more.
33:48Comfortable for the patient.
33:49On the other hand,
33:51we also don't want to push
33:53the minimum inspiratory time
33:54out too far for a patient in.
33:56You really wants to already breathe that,
33:59and you can see here the patient
34:01they flow is has is decreasing,
34:04but the machine is still maintaining that
34:08inspiratory flow that dealt with the iPad,
34:11and that can be again very
34:13uncomfortable for the patient.
34:14So you might see something like that.
34:15In the pic you set that ER minimum
34:18too long in obstructive lung disease,
34:21they often have the opposite problem.
34:23They have a tendency because of their long
34:25mechanics to have a delay in their cycling,
34:27so they have a prolonged TI compared to
34:32with the machine compared to Murali.
34:34What they would ideally like to do so
34:36again it can be very uncomfortable
34:38and we've got this patient who
34:41is prone to hyperinflation.
34:44Having difficulty trying to exhale
34:46out and they because they've got
34:48less time for breathing out.
34:50As you can see here in the illustration
34:52at the bottom of the page where the
34:55patient is trying to breathe out.
34:57If you look at the flow,
34:58but the machine is getting hung
35:00up on inspiration,
35:01and that's actually then impacting
35:03and you can see ineffective efforts
35:06occurring along with problems
35:08of that inspiratory hang up.
35:11So this is an illustration of where we.
35:14Limit the TR Max on that individual
35:17to what their normal neural
35:19neural inspiratory time is.
35:21We're going to get much better
35:23patient ventilator synchronization,
35:27so let's think about inpatient versus
35:30outpatient initiation of therapy,
35:33and certainly I think it was
35:34only a decade ago.
35:35Is that the best clinical practices
35:39for sleep hypoventilation and
35:42the titration was published?
35:45And in that, in those guidelines,
35:48PSG was the recommended approach to
35:52titrating long base ventilation with
35:54the authors of that publication,
35:57saying that you attended titration
35:59with the PSG and there's definitive
36:02identification of an adequate
36:04level of ventilatory support,
36:06so that was only a decade ago,
36:08but certainly technology has really moved
36:11on in that period of time in a study.
36:15Looking at PSG versus outpatient
36:18setup with Molly basic ventilation,
36:22this group Australian group down
36:25from Victoria Leader for being
36:28Hannon looked at 60 in Ivy naive.
36:31Mark enabling made patients
36:34most of those had.
36:36Turn off master that problem and what
36:40they did was all the patients came
36:43in and had a daytime titration and
36:45and then we send home to acclimatize
36:48to therapy and then came back at
36:50roughly two or three weeks later
36:52when they at least starting to
36:54use the machine and they underwent
36:56either a sham PSG where they had
36:58all the leads could on.
36:59But when they're in there
37:01nobody touched the settings.
37:02The settings overnight where exactly the
37:04same that had been set up during the daytime.
37:07All the patients underwent some titration
37:10of settings during that particular study,
37:13and then the patients were
37:15again reviewed with the PSG
37:17somewhere between six and eight weeks later,
37:20and what this study showed that while the
37:24individuals that underwent the sham PSG,
37:27when they were reviewed at roughly about
37:3110 weeks of therapy use, they had much
37:36higher patient ventilator asynchrony.
37:38Index there was no difference between
37:41the groups in terms of their arousal
37:43index during the SLEEP study.
37:45Any other aspects of the SLEEP study
37:48and there is also no difference
37:50in their compliance with therapy,
37:52their level of daytime,
37:55CO2 sleepiness, sleep quality,
37:58or nocturnal gas exchange.
38:00And but the interesting thing that
38:02came out this paper was that those
38:05individuals are in the sham PSG group.
38:08We just had the daytime titration only
38:12who were very poor users of therapy.
38:15So less than four hours a night.
38:18When they were reviewed at 10 weeks,
38:21they hadn't hadn't improved
38:23their compliance whatsoever.
38:25In contrast,
38:26those individuals that had the PSG
38:29titration who had been for users increase
38:32their usage among basic ventilation
38:35by by almost an hour and a half.
38:37So he really suggesting that
38:39PSG is one of those things,
38:41and and certainly something that we
38:43do is using it for patients who are
38:46not responding well to our date.
38:49That's where we would use the PSG
38:52to try and titrate and understand
38:55better what is about ventilatory
38:58support that the patient is just not
39:02comfortable and not using it so patient
39:05comfort on therapy can sometimes be
39:07a good trigger to think about PSG.
39:10There is a lot of work now looking
39:13at bamboo tree models of care FCB
39:16for all sorts of reasons during the.
39:19The COVID pandemic.
39:20We've had our sleep lab closed with
39:23only just started opening things up.
39:25Probably about two months ago,
39:27so we've had not a great deal of access
39:30to to sleep laboratory PSG titration.
39:33So we've been using a lot
39:35of ambulatory care models,
39:37again from the Victorian group are
39:40showing that using a daycare on
39:43ambulatory model of IVS set up.
39:45Not only was able to reduce how
39:48quickly they can get patients.
39:50Wanted therapy and this was a group
39:52of patients with palets,
39:54so it would significantly reduced
39:55how quickly patients to be treated
39:58by just bringing them in during the
40:00daytime rather than their usual
40:02practice which was bringing them
40:04into hospital pad for a couple of
40:06days and then doing a PSG and.
40:08The important thing about this study
40:11was that those patients that were.
40:16Set up in this manner with the day
40:19set up actually had better survival
40:21at 12 months and there's a number
40:24of studies showing exactly the same
40:27thing that that the daytime setup
40:30isn't inferior to the inpatient
40:32acclimation in terms of changes in
40:35quality of life changes in CO2,
40:37and it is can be much more cost effective.
40:42How we would have, you know,
40:43approached set up with this ambled
40:45remodel how we use transfer case carbon
40:47dioxide monitoring quite a bit so we
40:49would set the patient up with that
40:51we would mask fit them with whatever
40:54mask was most comfortable and then
40:56if the patient has a diagnosis of
40:59COPD we would start with M&ST mode.
41:03Will be back up rate somewhere
41:05between 14 and 15 by perhaps starting
41:0812 to 15 centimeters in the pack.
41:11Alright, and then sitting out Eli minimum
41:14and maximum on these individuals of the
41:17web using a certain devices and arise,
41:20time will be the one to two or 100 to
41:22200 milliseconds and adding the same
41:24amount of oxygen is that what they
41:27would normally have in during the day.
41:29We would then,
41:31if it was a neuromuscular patient,
41:33very similar,
41:33except that usually will start with a
41:35lower back up rate just to begin with.
41:37How to make sure that they they
41:39feel like they have some control
41:41and see how good they are at
41:42actually triggering the device?
41:44Setting them up more iPads
41:46for roughly the same E pets.
41:48And again,
41:49if the device had minimum and
41:51maximum inspiratory times,
41:52setting that and rise time,
41:55usually at a much slower slope
41:58at 200 to 300 milliseconds.
42:01For two to three independent events,
42:04we would then during that that period
42:08we passed during the day up titrate
42:11the IPAP and changed the settings,
42:13trying to increase the iPad to whatever
42:15they could maximally tolerated while
42:17looking at the title volume spiritually,
42:20rate leak,
42:20and the impact they're having on CO2.
42:23How and often makes individuals will
42:25fall off to sleep so we can actually
42:28capture what's going on during sleep.
42:31We would then,
42:32if they did pull up to sleep,
42:33we can then adjust the epac part
42:36as necessary and then we would
42:38send them home and do remote
42:40monitoring with ongoing titration
42:42of settings it's needed and with
42:45looking at Target title bonds,
42:47which we may not have achieved
42:49on that very first day.
42:51But looking at the target volumes,
42:53about 6 to 8 mil for the NEUROMUSCULAR'S
42:56and the eight to 10 patients with
42:59COPD and looking at using that.
43:02You might wanna try to adjust the epep.
43:04Often these individuals have integrated.
43:08Oximeters that we can.
43:10Into the machine or a an external one,
43:13and we will actually monitor what
43:16their situation is doing as well,
43:18and and by remote monitoring looking at
43:20things like that leak or paddle boarding,
43:22respiratory rate and usage
43:24and making changes on that.
43:26If the patient isn't doing well
43:28we will bring them back to PSG,
43:31but otherwise I clinical reviews
43:33looking at in particular the
43:35information that we can get from
43:38either the cloud or from the data.
43:41And certainly there are now
43:43studies showing that patients set
43:45up in hospital compared to those
43:48set up include home initiation,
43:51which is sort of this study
43:53out of the Netherlands,
43:54which is quite small country.
43:56But they by setting patients up in home,
43:59found that the long term an invasive
44:02ventilation over six months wasn't
44:04inferior to in hospital with
44:06similar improvements in CO2 and
44:08health related quality of life.
44:10And very significantly
44:12improvements in savings.
44:14But the important thing though,
44:15is remembering that in this
44:17particular study they used remote
44:19monitoring and they did use CO2.
44:21Transmitting is CO2 in the home,
44:24which is not available to all centers
44:27that are doing this type of therapy.
44:30So what about inpatient and
44:32outpatient in Ivy in COPD?
44:35And I think you know up front.
44:36We have to be very careful which
44:39patients with COPD that we put on
44:41long invasive installation because
44:42not all patients will respond and
44:44hence we've got a lot of literature
44:46with quite variable or not and and
44:49conflicting results regarding women based
44:52ventilation and stable public XCOPD.
44:55However,
44:55you know one of the recent
44:58guidelines from the ATS looking at.
45:01We use it in,
45:02I think in this particular population,
45:03some of the questions that
45:05we we looked at was firstly,
45:07should it be used versus usual tier and
45:11the suggestion the recommendation was
45:13to to use it with moderate certainty
45:17based on the evidence that is out there.
45:20Then another question that we tackled was,
45:25should it be used and initiated in
45:29patients hospitalized just immediately
45:31after acute exasperation with acute
45:34and chronic respiratory failure,
45:36and our recommendation was conditionally
45:40not to be and instead waiting a
45:43couple a couple of weeks to make sure
45:47that the patient was still hypercapnic.
45:49But again,
45:50that recommendation came.
45:51It's no certainty.
45:53Before softly,
45:53the limited evidence that was out there,
45:56and finally should be beat should
45:59long term non invasive ventilation
46:01be determined using overnight PSG
46:04in this particular population and
46:06again the recommended conditional
46:08recommendation was not to use it
46:11not to use PSG overnight titration,
46:14though that was associated with
46:16low very low certainty around the
46:19data quickly available to us.
46:22The power that recommendation
46:23came from the fact that we use
46:25is high in this population.
46:26High intensity or high pressure in
46:28Ivy seems to be the way in which we
46:31should be treating these patients.
46:33So this is a specific approach to
46:36ventilating these individuals where
46:38you going to use higher settings
46:41and you might normally think about.
46:44But the idea is not to get the maximum,
46:47but rather you try.
46:48You're looking very carefully at
46:50the CO2 and trying to achieve normal
46:52cap near or at the lowest CO2
46:55abuse and possible so around about.
46:58You know 20% or CO2 list then have
47:0248 millimeters of mercury and that's
47:04achieved in a stepwise titration by Pat.
47:07And again this measure analysis by
47:10all and colleagues recently published
47:12showing that those individuals.
47:14Which CRPG where a targeted approach
47:18to NI V trans, normally CO2.
47:21You've got much better daytime CO2
47:24reductions compared to not targeting
47:27the CO2 which fits in also with
47:30the recommendations from European
47:33spiritually as society and this high
47:36intensity approach can't be achieved
47:38in single night, particularly,
47:39people are doing a diagnostic
47:42diagnostic half titration study.
47:44In Europe they used to admit patients
47:48for four to seven days in our country
47:51as someone who's otherwise well,
47:53our patients don't wanna come into
47:55hospital for that period of time,
47:56nor do we often have bed capacity to do that.
48:00So this is where remote monitoring
48:02titration becomes incredibly important.
48:04And again, the group out of the
48:06Netherlands have looked at even
48:08setting the patients with COPD at
48:10home compared to being in hospital.
48:13And while it may have taken
48:15longer for the patients.
48:16To get to those higher pressures when
48:18they were being treated and set up
48:21at home and over the next six months,
48:24there was no difference in the the CO2
48:27between those that were set up in hospital
48:29and those that were set up at home.
48:31And similarly the health related
48:33quality of life improved to a similar
48:36degree with those patients that were
48:38set up within might be at home having
48:42significantly reduced costs of care.
48:45Remote monitoring is becoming very,
48:47very important how your devices
48:50have really excellent information
48:52around calligraphy and we can
48:54get information about flow,
48:56tidal boarding,
48:57the spiritual rate in some devices.
48:59It's even breath by breath so and
49:02we use that quite a lot.
49:04This information we can upload it
49:06to the cloud had it providing that
49:09ability to identify patients early,
49:11but I think one of the things before
49:13we get too far down the track.
49:15We need a lot more information about
49:18how accurate and how liable all of
49:21these parameters that are coming to us,
49:24and really how we should be using
49:26this data in interpreting how
49:28which we're going to be changing.
49:30You know,
49:31settings and clinical management of
49:33these individuals because depending
49:35on the manufacturer of these devices,
49:37they can often define leaks or
49:40define how admin had partners
49:43are are expressed with these.
49:45Machine so we need to know a lot
49:47more about their algorithms and
49:49how reliable they actually are.
49:51So I just want to finish up and
49:53showing him this is a lady that we
49:55had a number of years ago with severe
49:58COPD constantly coming into hospital
50:01with with an exacerbation moderate
50:04cognitive impairment when we saw her,
50:08we had put her on acute non invasive
50:10ventilation was award happy Kapnick
50:12discharged her husband who was
50:14at that stage 90.
50:16Said I would like to try this at home.
50:18We weren't sure they were going to
50:20manage but we gave them a trial
50:22three months and three weeks later we
50:24brought her back to our outpatients.
50:26She was actually using it really well,
50:28but a CO2 was still high at at 54
50:31when we downloaded from the card.
50:34The information you can see she
50:36had really quite high.
50:37Hi,
50:38the title bombings here were
50:40under 400 mills hand,
50:42but leak was not a problem
50:45and when we looked at the breath by.
50:46Risk we could see that she was actually
50:49still having quite a lot of obstruction.
50:51She was on a full face mask and she wasn't
50:53going to use anything else, so we come.
50:56Decided that we needed fire pressures.
51:00We talked them into being able to remote
51:03remote monitor them and change the
51:05settings and you can see over the next
51:07little while we gradually increased the
51:10pressures and we got to the point where we
51:12had enough increasingly PAP and support.
51:14You can see this dramatic drop in the
51:18AHI the improvement in title volumes and
51:21now the patient with the backup rate was
51:25being much much more passively ventilated.
51:27Which is what we were trying to achieve
51:30when we looked at the breath by breath data.
51:33Much better we had actually control
51:35that upper airway obstruction remotely.
51:38We brought it back for a blood gas
51:40and you can see that she now had a
51:42normal CO2 and three years down the
51:44track she's still going,
51:45so we're certainly seeing increased
51:47use of client information for
51:49chronic respiratory failure.
51:51Lots more devices with broadening
51:53our range of modes available to
51:56us to help us try and match.
51:58That the spiritual needs of the
52:00patient to the ventilator output.
52:01Thinking about all those
52:04alternatives appear sketchy,
52:05which we've been using quite a
52:08lot through these pandemic times,
52:09and in many cases the evidence
52:12shows they're not inferior to PSG
52:14and can be more cost effective
52:16and convenient for the patient.
52:18But we have to still have a PSG
52:21for patients not responding auto
52:23titrating modes again and not inferior,
52:26but really important.
52:28Mass edema, tations,
52:29and I think the importance.
52:32However,
52:32we approach these patients that
52:34ongoing monitoring and that remote
52:36monitoring is really giving us
52:38opening up part convenience for
52:40both past center patients.
52:42So I will stop there for any questions.
52:49Thank you so much Doctor.
52:50Pepper that was outstanding.
52:52Really. A wonderful wonderful talk.
52:53I think I I just learned so much.
52:56Every time you speak.
52:57So thank you. I I I'm struck by
53:01several things that you said I,
53:02I think people can get overwhelmed
53:04sometimes with all the settings.
53:05And I love how you started out with saying,
53:07you know these are the goals that
53:08we're trying to achieve and I think
53:10that's important thing that we always
53:11try to bring home to our fellows too.
53:13It's like we want to improve oxygenation.
53:15We kind of want to improve ventilation.
53:16We want to improve hospitalizations,
53:18outcomes,
53:18outcomes that are important to the patient,
53:21and we're using these techniques
53:23in order to do that.
53:25So, so thank you for a really,
53:27really terrific talk.
53:29Just a question.
53:30You know.
53:31I had the same observation that with COVID,
53:32we've really gone outside the box.
53:34We used to do a lot more PSGS.
53:36We're doing less now in the US.
53:38We don't really get to bring them in,
53:40even for a day,
53:40so we use we relying on the
53:42durable medical equipment companies
53:43to get our patients set up.
53:45And then we're doing a lot
53:46of the back and forth.
53:47Monitoring as well,
53:48but I think your point of the title
53:51volume is is really important
53:52when we're looking at the numbers.
53:55I think sometimes people get focused
53:56on the number is the title volume OK?
53:58And at the end of the day that may
53:59not even be accurate if there's
54:01high leak and and that's a really
54:03important point that you brought up.
54:04I do want to open it up to questions
54:07I'm I'm just want to take a look here.
54:09There's one question so far from
54:11the audience and one is.
54:13Thank you for a wonderful talk.
54:16It's an example of a seal PD patient
54:18using their respironics breath by
54:19breath data to your knowledge is
54:21breath by breath data available
54:22from Res Med devices,
54:24especially on the cloud or airview.
54:27So unfortunately the answer is no.
54:29So the advantage of the Phillips is you
54:31can get some limited breath by breath,
54:33but with the simple devices and.
54:36You can't do that with the res Med,
54:39but we just get the patience
54:40or post in the card.
54:41And in fact the the information on the cards,
54:44the last five or six days is
54:46actually superior to what you
54:48get on the on care orchestrator,
54:51because you can actually blow it up.
54:54You know you can look at it
54:56one one minute 32nd, 5 minute,
54:58so there's a lot more flexibility
55:01and and a lot more data.
55:03Much more richer data with
55:05the reasoning device, but.
55:06It is on the card only,
55:08whereas with the Phillips device,
55:10once you get on the card and what you
55:13get on the cloud is about the same so.
55:15It's a lot more limited,
55:16but it's there a lot more frequently,
55:19so convenience versus depth of information.
55:24City, thank you. Thank you.
55:26Other questions. People can feel
55:27free to either type into the chat.
55:30I'll be happy to read or if you want to
55:31unmute yourself you should have that
55:33capability to unmute yourself. Now.
55:34If you have a question that you want to ask.
55:41Maybe what people are doing that I think that
55:43you know when we're sitting these settings,
55:45different people can approach the setting
55:47of these patients in slightly different
55:49ways and still get the same end result.
55:52But you know what are the goals,
55:53not just what we're trying to achieve?
55:55We're always trying to achieve that drop
55:57in carbon dioxide patients may have
55:59slightly different goals to our clinic.
56:01What we clinically,
56:03objectively want to have,
56:05and I think there's a good paper
56:07by Patel in thorax looking at.
56:10Difference in settings between a large
56:12French group and a large English group
56:15and basically the patient survival.
56:18There wasn't any difference in a whole lot
56:20of parameters even though they approached.
56:21I think the French group had slightly
56:24lower pressures than the English group
56:26and slightly higher respiratory rates,
56:29but the the final outcomes exactly the same.
56:32So two different clinicians may
56:34do things slightly differently,
56:35but with that monitoring it comes
56:37down our two with how we're doing it.
56:40Is it effective for the patient?
56:44What percent of your patients do you think
56:46you're currently doing Poly sonography on?
56:49You know who these difficult patients?
56:50And would you? And do you think
56:52there's a difference between the
56:53neuromuscular group and the COPD group?
56:55OK, so we've probably had we still
56:58get because of our and then again
57:00because of the tyranny of distance
57:03some of the patients are who we,
57:05if they were living in Sydney we would
57:07see them just coming in as our patients.
57:10They have just traveled five
57:12hours so we're going to be doing
57:14them in the sleep laboratory.
57:16I would say that probably the Group
57:19of neuromuscular patients we bring
57:21into the into the lab most frequently
57:24would be our many of our MMD pay a LS
57:27patience with the tricky upper Airways
57:29that no matter what we're doing,
57:32they still got up.
57:33It why obstruction and trying to make
57:35sure it's not us or something about
57:37the machine that you know for some
57:39of them it is just hyper reflexive
57:41they had in the upper airway.
57:42No matter what you do,
57:43they're still going to have
57:44upper airway obstruction.
57:45But to give them the best
57:46possible outcome we will bring
57:48them into the sleep laboratory.
57:49But I would say probably only
57:51about 20 banknotes hard because
57:53of the last couple of years.
57:55We haven't had the sleep laboratory
57:57there closed down one at a time,
57:59but probably about.
58:0220% of our patients are coming in or
58:0430% a lot of them are being set up.
58:07But back home or just coming
58:10into house that day.
58:12And metric here models of in Ivy City.
58:15Great, thank you.
58:16Let's see another question,
58:17another excellent talk.
58:18Thank you so much with the
58:21auto adjusting ipat modes.
58:22Can we use it in patients
58:25with hypoventilation?
58:25Given concern of variable title volume
58:29and the answer is yes
58:30and that's why I always.
58:31I tend to start in a fixed pressure
58:34and then by a remotely I can see if
58:37they're not leaking then I'm very happy.
58:39And because remotely logging machines you
58:41can actually change from fixed to to,
58:44you know like the the.
58:46IE mode or something like that.
58:48Oh so the IE mode so you're just you're
58:50not talking about the volume target,
58:52you're just talking about the
58:54at the epac itself.
58:55Auto epub itself, yes,
58:57and we will often if a patient is
58:59leaking a lot rather than using volume
59:02targeted pressure support with AE
59:04will use fixed pressure support and
59:06then use the the the the auto E Pebble
59:11am with them making a little bit
59:14hard at the moment because of other.
59:16Things that are happening with FDA
59:17with one of the devices that does that,
59:19but the device that did do that,
59:21we would often use fixed pressure
59:25support with a variable.
59:28The the problem with the Rays Med
59:30devices that patients leaking
59:32a lot and you want the AE.
59:33You also have to use the the IBEX
59:35mode as well and then you've got to
59:38think about what they're leaking alot.
59:40What will I that's you know what
59:41will be I that's due in terms of the
59:43tidal volume so it becomes a little
59:45bit trickier when would stuck now
59:46with only one one device that we
59:49have access to that can do that can
59:52do 5X and the AE or a vexing the AE.
59:56Terrific thank you. How often?
59:58You know it's you know it's
60:00obviously in, you know,
01:00:01using the the inspiratory time well,
01:00:03you know with Bilevel St you
01:00:05know can really help you know.
01:00:07Improve title volume with
01:00:08these neuromuscular patients,
01:00:09how often do you wind up switching these
01:00:11patients over to pressure control?
01:00:14We we probably would have about maybe
01:00:1915% of our patients in pressure
01:00:21control and they generally are
01:00:23patients with neuromuscular problems
01:00:25and who got leak. For instance,
01:00:27you know where leak is a problem,
01:00:29so that seems to work better
01:00:30and you're a muscular patients.
01:00:32And once you get the settings right,
01:00:34they'll go along with anything.
01:00:35So they're very,
01:00:36very comfortable in pressure control mode.
01:00:39Sometimes the way we set it up the the
01:00:41settings for the iPad mini and iPad Max.
01:00:44Are so close together they may as
01:00:46well be in pressure control mode,
01:00:48but we give them a little bit of
01:00:50wiggle room if they just like to
01:00:52have a slightly they're feeling
01:00:53like machines imposing something
01:00:55on them during wakefulness.
01:00:56But a lot of neuromuscular
01:00:58patients where we use it a lot.
01:01:00They tend to go along with it and
01:01:02they find it actually quite quite
01:01:04comfortable and they like that idea of
01:01:06being being pushed out and expand it.
01:01:08They'll say, oh,
01:01:09I can actually feel the air
01:01:10getting down there.
01:01:11Gonna be careful they might actually
01:01:12be sore for the first couple
01:01:14of days because they're moving.
01:01:15Maybe some ribs and some joints
01:01:17they haven't moved for a long time,
01:01:19but it can often be very,
01:01:21very effective and very comfortable for them.
01:01:23And again by remote monitoring like we
01:01:25could go home and gradually increase that.
01:01:28And to a point where they
01:01:29no longer saw in there.
01:01:30You might be getting a decent size spread.
01:01:33Terrific, well thank you.
01:01:34Well, we're at time so otherwise we
01:01:36would keep asking you questions I think,
01:01:38but it's really been such a pleasure
01:01:39is really a pleasure to have you here.
01:01:41Thank you so much for joining us.
01:01:43Well it was delightful.
01:01:44Thank you so much for asking
01:01:46me and it's a pity I can't
01:01:47actually see you in in real life.
01:01:49But hopefully ATS might be on.
01:01:53Barring Omicron,
01:01:54so we'll see what happens.
01:01:57OK, really?
01:01:58So thank you. Thank you so much.
01:01:59Enjoy your day. Bye bye bye everyone bye
01:02:02bye.
01:02:05Please.