Sleep 2023.05.10 Owens

Name: Sleep 2023.05.10 Owens
Uploaded: 2023-05-26T21:50:50.2333333Z
Duration: 1 h 8 min 22 s

May 26, 2023

Information

ID: 9974
To Cite: DCA Citation Guide

Download Transcript

00:00Thank you so much.
00:01And thank you so much, Bob, for being here.
00:03Doctor Owens, we're very fortunate
00:05to have him as a speaker today.
00:07He's a professor of medicine in the division
00:10of pulmonary and critical care at UCSD.
00:12He's the medical director of
00:15their Medical Oncology, ICU.
00:18He's also heavily involved in
00:19Sleep Medicine and he's associate
00:21editor of JCSM and on the editorial
00:24board of the Blue Journal.
00:26He's San Diego Top Dr.
00:28among many other awards.
00:30He's AOA and he did his sleep
00:33fellowship at at Harvard as well.
00:35And he was here prior to
00:37going to UCSD and we're very,
00:39very excited to have him
00:41speaking today on OSA and COPD.
00:45So without further ado.
00:48Well, thank you very much.
00:48And I, you know,
00:50I did spend a lot of time in Boston.
00:52I was there 10 years and I love hearing
00:54the hospital names and everything.
00:56I do have to correct you that I did.
00:58I feel a little bit of shame,
00:59but I never completed a formal
01:01sleep fellowship and so
01:04I would have been none the wiser,
01:06especially given your robust
01:07research career and and yeah,
01:09but but other than that I don't want the,
01:12you know, CV police to come and get me.
01:14So let me see if I can share my slides here.
01:18So you did Home Critical Care fellowship at
01:23MGH and then
01:26yeah, so I I did my residency at
01:29MGH and then did Home Critical
01:31Care and then working with the tool
01:32Malhotra and sort of David White,
01:34Andrew Wellman did the practice pathway
01:37And so that that existed at that time.
01:40And now you know,
01:41I don't know where that is right now.
01:42I count that as fellowship as a
01:44sleep fellowship, but. Maybe.
01:47Maybe. I'm not official. So
01:50can I can you? Are my slides projecting?
01:53Yes. All right, Perfect. Cool. Well,
01:56thank you very much for the introduction.
01:58Again, This is in some ways,
02:00you know, coming home.
02:01I'm like the only person in San Diego
02:04who misses the weather of Boston.
02:06And, you know,
02:07people look at me funny when I say,
02:08yeah, I might go back sometime.
02:10But anyway, today I'm going to talk about.
02:12Sleep apnea and COPD,
02:14as you heard my background
02:16is in pulmonary medicine.
02:18I I'm very interested in
02:20sleep apneopathogenesis,
02:21some of the stuff that Andre and
02:23Clar do in terms of endotypes
02:25and phenotypes for sleep apnea.
02:26But I I felt that would be hard
02:29to to top some of the local talent
02:31that you have so wanted to talk
02:33about this area of sleep and COPD.
02:36Which I've been interested in
02:37and have done some advocacy work
02:39and I wanted to talk about some
02:40of the guidelines and advocacy
02:42work that we're doing with that.
02:44I don't know if I need to show
02:45this slide for very long,
02:47but I have no disclosures.
02:49And if you want to get CME,
02:51you can see the number to text there.
02:53Let me see if there's anything in the chat.
02:56OK.
02:56Looks like you can do that
02:58from the chat as well.
02:59So I think the main question,
03:01you know,
03:01why would I talk about COPD and sleep and.
03:05You know,
03:06very briefly,
03:07both COPD or chronic obstructive
03:09pulmonary disease and obstructive
03:10sleep apnea are incredibly common.
03:12And that means that whether you're
03:14coming from a pulmonary background
03:16or you know you're in sleep clinic,
03:18many of your patients will have
03:20COPDI Think understanding a little
03:22bit the Physiology that happens with
03:24sleep helps you direct the treatment
03:26or address the underlying problem
03:28in why sleep is bad with COPD.
03:30We also have very few interventions
03:33that improve COPD outcomes.
03:35So I'll talk about briefly.
03:36Yes, we can give oxygen.
03:38We can tell people not to smoke.
03:39But COPD is a global problem and
03:44very morbid and high mortality.
03:47And there's some data that using
03:49noninvasive ventilation at night,
03:50which is really the focus of my talk,
03:52can reduce mortality.
03:53And the last thing is I'd like to try
03:56to break down silos between disciplines.
03:58So when I was in Boston.
04:00Maybe some of you worked at sleep health,
04:02but you know we were really out almost
04:04in the community and if I had a patient,
04:06I wanted to get a blood gas check APA,
04:10CO2 level couldn't really do that.
04:12And right now even in our current division,
04:15you know,
04:16kind of the sleep docs address
04:17things that go bump in the nights
04:19and the pulmonologist kind of don't
04:20ask about sleep because they don't,
04:22you know,
04:22it may not be good and they're
04:24not sure what to do.
04:24So would like to try to bridge
04:26that gap a little bit.
04:29If you're interested in this topic,
04:31I just, I've written a a little bit
04:33about it and so this was a review
04:36article that Melissa Canowert had
04:38asked Bernie Sunwoh and I to write.
04:40And so you can see this came out
04:42last year in clinics of Chest
04:44Med that she was the editor on.
04:45So we talked about sleep apnea,
04:46sleep deficiency and chronic lung
04:48disease and then more recently slightly
04:51different focus but wrote this review
04:53article in European Respiratory Review.
04:55And if anybody ever asks you to write
04:58a review article with two people
05:00you've never met in other countries,
05:03I would say do it.
05:04So working with Eric Durham in the
05:07Netherlands and Nicolini and Rossini
05:09in Italy was was a really cool,
05:11interesting experience.
05:12And then the last thing and the
05:15last article I mentioned for
05:17now and what I'll talk about for
05:18kind of the bulk of the time.
05:20Is that I was lucky enough to chair a
05:23clinical practice guideline for the
05:25American Thoracic Society looking
05:26at non invasive ventilation for
05:29chronic stable hypercapnic COPD.
05:31And again this is this was the 2nd
05:33clinical practice guideline I had joined.
05:36But you learned a lot when you see
05:37how these things are put together
05:39and you review all the evidence
05:40and I would make a plug both for
05:42the American Thoracic Society,
05:44specifically the sleep assembly
05:47but also just being part of.
05:49You know,
05:50the bigger picture of how these
05:52guidelines are put together.
05:53So with that kind of introduction,
05:56you know,
05:56my outline for today is I'm
05:58going to have one slide on COPD.
05:59So if you're expecting an indepth
06:02COPD talk that is not going to happen.
06:04I want to just review for maybe 5
06:06minutes kind of what happens with
06:09normal Physiology of breathing,
06:10why that's a problem particularly for
06:13patients with COPD when you go to sleep.
06:16A little bit of a detour for maybe
06:1810 minutes or so talking about
06:20patients who have both COPD&amp;OSA
06:22and kind of why you should care.
06:24And then I'll finish by talking about
06:26COPD and noninvasive ventilation.
06:30And I'm assuming that people, you know,
06:33we can have questions at the end,
06:34but if there's something that I, you know,
06:36really screw up or really burning question,
06:38feel free to interrupt.
06:39So this is my one slide on COPD,
06:43so chronic obstructive pulmonary disease.
06:45I just want to emphasize that
06:46this is again a common disease.
06:47So reckon that about 6%
06:49of US adults have COPD,
06:51it has overtaken I think
06:54it think it was stroke,
06:56but now it's the third leading
06:57cause of death in the United States.
06:59And those of you who work in Ava population,
07:01you know that prevalence of 6%.
07:03I mean that that may be true
07:04in sort of the community,
07:06but you know locally in your institution
07:08you may take care of a lot of people with
07:11COPD and this is not just a Western European.
07:14You know, United States problem,
07:16it's a worldwide problem and
07:17it's not just cigarette smoking,
07:18but cook fires and other environmental
07:21pollutants that lead to COPDI.
07:23Want to make the point here
07:25and I'll come back to this,
07:26that COPD is very heterogeneous.
07:29We don't really use these terms of pink
07:31puffer or blue bloater much anymore.
07:33These are the Frank Netter drawings.
07:35I hope people still use the netter
07:37drawings in anatomy classes,
07:39but you know this patient here.
07:41The, the classic pink puffer is kitectic,
07:43is using all of their sort of energy
07:46and and metabolism in order to breathe.
07:49And so this person, you know maybe
07:51need some assisted ventilation.
07:53The blue bloater who's got sort of
07:55core pulmonale peripheral edema,
07:57maybe you're worried about
07:58rostful fluid shifts.
08:00You know,
08:00maybe this patient has more of an upper
08:02airway problem than a lower airway problem.
08:04And as I mentioned COPD we don't
08:06we you know be great if we have
08:08therapy to regrow the lung but
08:09but we don't really have that.
08:11Right now.
08:11So again,
08:12I just want you to take away
08:14that COPD is incredibly common
08:15and in your sleep clinics,
08:17you're going to see people with COPD
08:19and sometimes pulmonologists are
08:20sending them to you because they don't
08:22know what to do with them at night.
08:26So let's just talk for 5 minutes about
08:28kind of Physiology of sleep and breathing
08:30and then how that is particularly
08:32stressful for people with COPD.
08:34So hopefully this is review for everybody,
08:37but we all know that.
08:40People breathe less when they go to sleep.
08:42So you know these are pretty old data,
08:44but if you look at the sleep stages
08:46here on the X axis you can see minute
08:49ventilation drops when people go from
08:51awake to the different stages of sleep.
08:54Again dating this slide a little bit,
08:55we have stage 3 and stage 4 sleep and then
08:59the lowest ventilation during REM sleep
09:01and this is mostly by a drop in tidal
09:04volume and respiratory rate stays about
09:06the same and primarily this is driven by.
09:09The sensitivity of of
09:12your system for you know,
09:14your negative feedback loop
09:15to control your PA CO2,
09:17so how your body responds to carbon dioxide,
09:20that slope changes when we go through
09:22the different stages of sleep.
09:24And one thing that we don't know
09:25a lot about and I worry you know,
09:27I'm in ICU doc as well and you know,
09:30you see people come in with these
09:32crazy high Co twos and I don't think
09:34we appreciate how abnormal that is.
09:36But we don't really know how people
09:38transition from sort of normal
09:40CO2 response to abnormal response.
09:42Is that something that happens at night
09:44and then bleeds over into the day?
09:45You know, it's not very well described,
09:49but I've, you know,
09:50been saying for a while that I think
09:53of sleep as kind of a stress test,
09:55especially for those with lung disease.
09:57So when you're sleeping,
09:58we have less minute ventilation,
09:59CO2 is going to go higher.
10:01I won't go into it very much, but.
10:03There's some lung volume and other
10:05effects that lead to worse VQ matching,
10:07which is always the answer in
10:09pulmonary medicine.
10:09And so there's lower oxygen saturation
10:12and then the upper airway narrows.
10:13Even if you don't have obstructive sleep
10:16apnea, and particularly during REM sleep,
10:18you have fewer muscles to help
10:20with breathing.
10:20And so, you know, that's for everybody.
10:23And if you have somebody who's
10:25really dependent on accessory
10:26muscle used to help them breathe,
10:27whether it's COPD,
10:30other lung problems,
10:31you really run into problems.
10:34And so classically with chronic
10:37obstructive pulmonary disease,
10:39you know we worry about something
10:41called nocturnal oxygen desaturation.
10:43So people start out maybe kind of
10:45on the steep part of the oxygen
10:47hemoglobin desaturation curve.
10:49And so just a small shift in the
10:53PA O2 can lead to a drop in the
10:56oxygen saturation and that can
10:58and so again the the effect of.
11:01All of the things that I just showed you
11:03means that classically people with COPD,
11:05that the classic finding on overnight
11:08oximetry or polysomnography is that people
11:10would have nocturnal oxygen desaturation.
11:13So what I'm showing you here is a hypnogram.
11:16You can see the different stages of
11:18sleep and in the bold or stage one
11:21sleep on this hypnogram is REM and
11:23then you can see the oximetry here.
11:25And the pulse oximetry is pretty
11:27poor in this patient,
11:28so starts out at about 80%
11:30when the patient is awake.
11:32But you can see drops precipitously
11:35during REM sleep, OK.
11:36So I think most people,
11:39when you think about COPD,
11:41the classic literature has been,
11:43you know, watch out,
11:44particularly during REM,
11:46they're going to desaturate and a
11:47lot of it is going to be due to
11:50hypoventilation you need to think about.
11:53Kind of extreme oxygen desaturation even
11:56with maybe only modest daytime hypoxemia.
11:59So these are data from actually
12:01patients with cystic fibrosis.
12:03This study hasn't been that
12:04well done in COPD patients,
12:06but you can see on the X axis is the
12:09awake resting oxygen saturation,
12:11on the Y axis is the O2 nadir
12:13during the night,
12:14and people that are in the 9293
12:17range when they're awake can
12:19desaturate down into the 70s.
12:21This is without.
12:22Sleep apnea,
12:23things like that.
12:24And it the amount or degree of oxygen
12:26desaturation at night is often worse
12:28than what you see with exercise, for example.
12:31So we're pretty good.
12:32We walk people during the day,
12:33we see if they need oxygen,
12:35but we don't always check what
12:37happens at night, so who cares?
12:40You know what?
12:41So people desaturate,
12:42you know,
12:43we really care about that.
12:45This is a a more invasive
12:47study looking at sleep,
12:49oxygen saturation and then PA pressures.
12:52And systemic artery pressures and
12:54I guess what I would have you take
12:56away from this slide is that during
12:58REM when you see drops in oxygen,
13:00you see the PA pressures go through
13:01the roof and you can see that
13:04people are quite hypertensive.
13:06And at least in,
13:07you know one night in the lab
13:09if you give people oxygen back
13:11and you correct that hypoxemia,
13:13then you can prevent the O2 drop
13:15and you can prevent the rise in PA
13:18pressures and systemic pressures.
13:22OK. So that's kind of in the lab.
13:26Do we have other consequences that
13:27we think are due to sleep and COPD?
13:30And so this is a really interesting
13:33article that was Walter McNicholas who's
13:35published in this area quite a bit.
13:38He asked the question when do patients
13:41with COPD or as it was called bronchitis
13:44and emphysema, when do they die.
13:45So these are people admitted to the hospital,
13:48his control groups were.
13:50People who had non respiratory cancers or
13:53stroke and so people without you know COPD
13:57basically died evenly throughout the day,
14:00but people with emphysema died preferentially
14:02at night and it was really the type 2
14:04respiratory failure with hyper captia.
14:06So I just it's just you
14:08know thought provoking.
14:08I think we also know that people with COPD
14:12even in the relatively modern era, so 2011.
14:18When you look at big COPD trials,
14:20most patients report difficulty with sleep.
14:23So if you look at COPD symptoms,
14:25you have dyspnea cough,
14:27but then you get into
14:28fatigue and sleep problems,
14:29so they're very common.
14:31Many people take sleeping pills,
14:33which may not be the most healthy
14:35thing to do.
14:36Luke Donovan has some data that that
14:39may be associated with worse outcomes.
14:42And what's really interesting is
14:43just asking people, hey,
14:44is your sleep good or bad?
14:47Tells you something about whether or not
14:49they're going to have an exacerbation or
14:50how soon they will have an exacerbation.
14:52So those with better sleep,
14:55longer time before an exacerbation.
14:58So all of this is to just give you
15:00background that I think sleep is
15:02a tough time for those with COPD.
15:06And So what do we do about it?
15:09And here's what we know.
15:10So this is a pretty classic study,
15:12the longterm oxygen.
15:13Sorry,
15:14the nocturnal oxygen therapy trial group.
15:16So this is an old study looking at people
15:19who need who needed oxygen all the time.
15:21And if you do that,
15:22if you give people oxygen
15:25who are hypoxic all the time,
15:27you can see that they do
15:29better outcomes are improved.
15:30So X axis here is duration of treatment
15:33in months and Y axis is a survival curve.
15:36And so this study looked at people
15:38who are hypoxic all the time
15:39throughout the day and the night.
15:41If you just give them oxygen at night,
15:43or you give them oxygen all the time,
15:45they do better with more oxygen.
15:48But what we didn't know until
15:50relatively recently is what about the
15:52people who just desaturated night?
15:54And those people turn out to be hard to find,
15:58actually.
15:58So it took a long time to do this study.
16:01This is the Inox trial group.
16:03It was published, you know,
16:05a few months after COVID.
16:07So it's in the New England Journal,
16:09but I'm not sure.
16:10Kind of how much attention it
16:11got at the time.
16:12But this study specifically was designed
16:15to address whether or not people
16:17who only desaturate at night what
16:19happens if you give them oxygen at night.
16:22They wanted to follow people for
16:24three or four years and it it's a
16:27little bit disappointing but there
16:28was no difference between the two
16:31groups in terms of those who got
16:33oxygen or those who got just air and.
16:35One thing I'll point out,
16:37although I don't think it
16:38would have changed the results,
16:39but this study was very hard to recruit for.
16:41So the they all ended up with about 250
16:44patients that that was only a fraction
16:46of the sample size they were going for
16:48before running into issues with COVID.
16:51But it's just hard to recruit.
16:53So the question for all of us is,
16:56you know, we know people who are,
16:58you know, profoundly hypoxic, you know,
17:00Sats in the 80s all the time.
17:01Oxygen is good.
17:02I showed you some data that
17:04people desaturate a lot at night.
17:07There are physiological consequences of that.
17:09Why doesn't oxygen at night help?
17:12And I think the the kind of
17:13elephant in the room here,
17:15which we don't measure very much,
17:17is going to be carbon dioxide.
17:19So I think that you have oxygen saturation,
17:22which we measure all the time.
17:24We tend not to measure
17:26transcutaneous CO2 like in our lab.
17:28We have about 7 beds,
17:29only two of them measure CO2.
17:31In our research lab we we
17:33do measure CO2 as well,
17:34but you can have kind of stable
17:37oxygen saturation but you may not
17:39see changes in carbon dioxide.
17:41So I think with COPD, yes,
17:44oxygenation is a problem,
17:45but it's often due to ventilation
17:47which is rarely really measured.
17:49So again,
17:49what I want you to take away from kind
17:51of this background is just that sleep
17:53and breathing is tough with those
17:54with COPD due to oxygen desaturation,
17:58but really due to hypoventilation.
18:00So I'm going to come back to
18:01that issue of ventilation.
18:02I'm going to just take a, you know,
18:05quick detour talking about COPD&amp;OSA,
18:08something called the overlap syndrome.
18:10And partly this kind of reflects just
18:13the the order of the field over time.
18:17So the,
18:17the first guy that came up with
18:20this term of overlap syndrome
18:22is a guy named David Flenley.
18:23He was a respirologist in Edinburgh.
18:26And he said, look, you know,
18:28we have all these people walking
18:29around with chronic lung disease
18:30and they might have sleep apnea.
18:32And so this is his sort of figure about
18:34what he meant by overlap, You know,
18:35sort of this Venn diagram here.
18:37And you know,
18:38he said you could have people
18:39with pulmonary fibrosis,
18:40CF, whatever.
18:41But he was worried most about people who
18:44had chronic obstructive lung disease
18:46that were the blue bloater phenotype.
18:48He thought those would have the
18:50greatest amount of oxygen desaturation
18:55and so. He wanted to study these folks.
18:58He called them the overlap syndrome,
19:00sort of gave them preference.
19:02And I'm not sure how useful this term is.
19:04So I mentioned that there's a lot
19:06of heterogeneity in terms of COPD.
19:09And just as a thought experiment,
19:11you know, you could have somebody who's
19:12got horrific COPD with an FU V1 of 15%
19:15but very mild obstructive sleep apnea.
19:18They get labeled as overlap
19:20and then you have.
19:22People who maybe have relatively preserved
19:24lung function but have severe OSA.
19:26And so I'm not sure how useful this term is.
19:29And I would encourage anybody who is,
19:32you know, using the term overlap
19:34to to kind of put some weighting,
19:36you know is this 90% OSA and
19:3810% COPD or vice versa,
19:39because I do think that will direct
19:42your focus a little bit the other.
19:45Problem with sort of this definition,
19:46not that it's just kind
19:48of a loose definition,
19:48but you know our definition of hypotonia
19:51is often relies on oxygen desaturation.
19:54So if you have people that are kind of more
19:57on the precipice of oxygen desaturation,
19:59maybe you overcall hypotonia.
20:01So you know in the literature if you
20:03look you know I PF is associated with
20:06very high rates of OSA but that's
20:08driven almost all by hypotonia.
20:11So.
20:11So I think the definition has some issues.
20:14And then if you look at the epidemiology,
20:17you get really variable estimates of
20:19how many people have both COPD&amp;OSA
20:21depending on what population you look at.
20:23So if you go out into the community,
20:25maybe about 1% of people have both disorders.
20:29But as you move into you know older
20:31population like the VA, so older men,
20:34more smokers or exsmokers,
20:36lot of people are going to have
20:38both things Chavi solare in.
20:40At UCSD had a pulmonary rehab
20:44population where you know,
20:46most of the patients had obstructive
20:48sleep apnea and it's kind of
20:51interesting to think about why
20:52these diseases might go together.
20:54This is a a figure,
20:56you can tell we had a really
20:57high art budget for this.
20:59This is a figure from a review article
21:01with Madalina McCrea and Mihaela TER de
21:03Rescue from University of Wisconsin Madison.
21:06But you know,
21:06there are people that say,
21:07well, obstructive sleep apnea,
21:09you have repetitive collapse
21:10of the upper airway,
21:11maybe that promotes lower
21:13airway inflammation.
21:14There's some data supporting that.
21:16With COPD,
21:16we give people Prednisone,
21:18we give them also inhaled steroids.
21:20Does that lead to a weakening or
21:22increased collapsibility,
21:23the upper airway?
21:24So it's interesting to think about
21:26how these diseases might go together,
21:28but even by chance alone you're
21:30going to have people with COPD
21:32and obstructive sleep apnea.
21:33And I'm telling you this for two reasons.
21:35The 1st is that people with
21:38COPD&amp;OSA might look different
21:39and you should be aware of that.
21:40And then there are some data that if
21:42you treat the obstructive sleep apnea
21:44in patients with COPD that they'll
21:46do better. And so here's what I
21:49mean by your patients with both
21:52OSA&amp;COPD might look different.
21:54These are data from Resta and
21:56colleagues and they looked at a
21:58group of patients who had only COPD.
22:01And their FEV 1% predicted,
22:03their lung function was about
22:0545% of predicted and they had
22:07no hypercapnia during the day.
22:09So even with reduced lung function,
22:12PA CO2 was normal.
22:13And that's in contrast to patients
22:15who have both COPD&amp;OSA where the lung
22:18function is relatively preserved.
22:19Their FEV 165% of predicted and yet you
22:23start to see the PA CO2 going up to 45.
22:27So I almost wonder if these
22:28folks are a little bit like.
22:30Obesity, hypoventilation syndrome,
22:31people, you know,
22:32trouble breathing during the day
22:34and at night gets you to a higher
22:37CO2 than you might otherwise.
22:39So if you see a patient with
22:40COPD who's hyper capmic and you
22:42just don't think they should be
22:44based on their lung function,
22:45you need to think about
22:48obstructive sleep apnea.
22:49So as I said,
22:50the second reason I'm going over
22:52this is that there's some data that
22:54having both OSA&amp;COPD is bad for you.
22:56And this study by Jose Marin and
22:58colleagues in the Blue Journal.
23:00Followed people over 12 years and
23:01you can see the difference between
23:03COPD only and black and those
23:05with both COPD and obstructive
23:07sleep apnea on the Y axis.
23:09Now these are not randomized data
23:12and you know they had this blue
23:14curve which were people who got
23:15CPAP and were adherent to CPAP
23:17and they did much better than
23:19those with COPD and untreated OSA.
23:21But but these are not randomized data.
23:23We don't have randomized data to show this.
23:27But we have some hints that there
23:29are things there and actually a tool,
23:31Malhotra, my boss and mentor and friend,
23:34we have a grant starting to sort of
23:36study this population in a little
23:37more detail in terms of what's the
23:39optimum therapy for these folks.
23:40Let
23:43me skip over this.
23:44The other thing that's
23:45interesting is Sunil Sharma,
23:47who many of you may know, you know,
23:49has really been an advocate for sort of
23:50moving Sleep Medicine into the hospital.
23:52So when he was at Thomas Jefferson.
23:55They really tried to expedite
23:58assessment of sleep apnea,
23:59treatment of sleep apnea.
24:01And they, they then looked at
24:02people who had COPD or heart
24:04failure or just sort of all comers.
24:06And what they found is that
24:08when patients with COPD,
24:09they're admitted for COPD exacerbation,
24:11you diagnose him with sleep apnea,
24:13send him out on C pap.
24:14Those who use the C PAP over the next
24:17period of time had fewer ER visits
24:19and fewer admissions to the hospital.
24:21So again.
24:22Some data that you know,
24:24some hints in the data,
24:25again, nonrandomized,
24:26confounded by the healthy user effect.
24:30But treating OSA may make
24:33people with COPD do better.
24:36And the last thing I'll say about sort
24:38of sleep apnea and COPD is that let's
24:40say you have a patient with COPD and
24:42you miss the obstructive sleep apnea,
24:44just give them oxygen okay.
24:46So maybe you get a recording
24:49overnight of overnight oxymetry.
24:50And what you're seeing here is somebody
24:53who's going up and down quite a bit,
24:56but you can make them look better.
24:57By giving them oxygen,
24:58you can prevent that drop
25:00in oxygen saturation.
25:01The problem is that when you do that,
25:04if you measure the pH or the PA CO2 during
25:08their obstructive events by giving oxygen,
25:11you can drop the pH,
25:13You make the event longer and the P
25:17CO2 rises by the end of that event.
25:19So the problem is here,
25:20if you have someone with overlap
25:22syndrome and you just give them oxygen,
25:25you may actually make their
25:26ventilation a little bit worse.
25:27P CO2 goes up,
25:29pH goes down.
25:30So in fact one of the things you
25:32ask about when you give oxygen to
25:34a patient with COPD is, you know,
25:36do they start reporting headaches,
25:37things like that.
25:40OK. So again, if you take
25:43care of patients with COPD,
25:44think about OSA and treatment of
25:46OSA might improve COPD outcomes.
25:48So the, the stuff that I wanted to
25:50finish with is really this topic
25:53of chronic noninvasive ventilation
25:54and we'll go over that for the last
25:56sort of 15 minutes here and then
25:58see if there's any discussion.
26:01So just by, you know, clarification,
26:04I just want to be clear that if you are
26:06taking care of patients in the hospital,
26:08they have COPD, they're in the ICU
26:10and you're putting them on bi PAP,
26:11you know we have great data that that's the
26:14right thing to do, prevents intubations,
26:16prevents reduces mortality.
26:18But up until recently, we did not
26:20know if that was a good idea at home,
26:23you know, might make sense.
26:25We should. You know, I've,
26:26I've shared with you that COPD,
26:28you know, at baseline is a disorder of
26:31ventilation that gets worse at night.
26:33Why shouldn't we ventilate
26:34these people at night?
26:36Part of the problem is I think we
26:38don't know what to target when we
26:40talk about noninvasive ventilation.
26:41So if we give people oxygen.
26:44OK.
26:44We're going to target a sad in
26:46the low 90s or whatever and we
26:48can kind of adjust that not with
26:50non invasive ventilation.
26:51It's not totally clear,
26:53you know how hypercapnic you have to be,
26:56what pressure or what mode we should use,
26:58how adherent do you have to be to therapy?
27:01And then what's the goal of therapy?
27:02Is it to make people feel better?
27:03Is it to reduce the CO2 level?
27:06You know what,
27:07what are we trying to accomplish?
27:09And so I'll just highlight
27:10two studies which took.
27:12Very different approaches to how to
27:15prescribe noninvasive ventilation
27:17in patients with hyper capmic COPD.
27:21And so the first study is by
27:23Doug McAvoy and colleagues.
27:25And for this study,
27:26they really used sort of bilevel PAP,
27:28you know,
27:29and when I'm in the ICU and the
27:31resident says let's start by Pap,
27:32they tell the respiratory
27:33therapist and the RT says,
27:34well, what do you want me to do?
27:36And the resident says 10 / 5,
27:38you know, they,
27:38they don't really think about it.
27:40That's just kind of what they start at.
27:42So this was an RCT.
27:43They took people with not
27:45very severe hypercapnia.
27:47They put people on an IPAP of 13,
27:49epap of five on average spontaneous mode,
27:52and wearing that device for
27:54about 4 1/2 hours per night.
27:57You can see the survival curves here.
27:59And there wasn't really a difference.
28:01So when you kind of take people
28:03who aren't that hypercapnic,
28:05you don't really drive,
28:06You don't really push too
28:08hard on their lungs.
28:09You don't change how they
28:11do in terms of outcomes.
28:13The other things is that in this
28:15study the quality of life got worse.
28:17So there's nothing worse than like
28:19giving somebody a treatment that
28:21doesn't affect a heart outcome
28:22and they feel worse with it.
28:24And that's the contrast with
28:26a different approach for using
28:28noninvasive ventilation.
28:29And this approach has been called the
28:32high intensity noninvasive ventilation.
28:34And this is where you use
28:36bilevel path with a backup rate.
28:39And you titrate the settings until
28:41you get a drop in the PA CO2.
28:44So Wolfram Windish,
28:46who was in Freiburg,
28:47and I forget where he's moved
28:48on in Germany. But for years he
28:50would publish sort of case series
28:52of these kinds of patients.
28:53And he would start them on noninvasive
28:56ventilation at night and try to get the
28:59PA CO2 from 50 down to more normal range.
29:03But to do that, you know,
29:05he would use inspatory pressures of high 20s.
29:09In a backup rate of 21 and you know
29:12these are not settings that were
29:14typically using at least in our clinic,
29:16I don't know if anyone else
29:18is sort of following this,
29:19but he would report amazing
29:21outcomes with this.
29:22It wasn't until 2014 though that we
29:24had a randomized trial that sort of
29:26showed the benefit of this approach or
29:28at least tried to show the benefit.
29:30So this is a study by Cone Line
29:33and colleagues.
29:33Wolfram Windage is the second author.
29:35They took severe COPD patients,
29:38P CO2 of 52 or greater.
29:40They excluded people that
29:41they thought had sleep apnea.
29:43You know,
29:43basically you couldn't be too heavy.
29:45And they wanted people to use
29:47an IV for six hours per day.
29:49They did this high inspatory pressure
29:51approach and they tried to get the CO2 down.
29:54And what's amazing is the
29:56separation in the curves here.
29:58So if you look at the
30:00survival curve over one year.
30:02First thing,
30:02in the control group of
30:03these really sick patients,
30:04a third of them die after a year.
30:07But if you give noninvasive ventilation,
30:09you can see,
30:10you know,
30:10a dramatic reduction
30:14in mortality and the quality
30:16of life also improved.
30:18Now it it'd be hard to sort of say
30:22that the intervention is separate from,
30:25you know, these hospitalizations and
30:26extensive follow up that people had,
30:28but you really do have to take notice
30:30in these group of people who die.
30:32You know with a very high mortality,
30:34you know this is a big difference just to you
30:38know show you again these high pressures.
30:40Their mean inspitory pressure was about
30:4222 backup rate, 16 breaths per minute,
30:44mean usage of six hours per day,
30:47P CO2, you know this is converted
30:49these values from KILOPASCAL to tour,
30:52but they went from 58 down to
30:54about 49 in the treatment group.
30:56And so, you know,
30:57when I look at these numbers,
30:58I'm like, wow, how did they do this?
30:59You know, SAVE had 3.3 hours per day of use.
31:03So why is the use so good in this study?
31:06And partly maybe because it is a study.
31:09They also brought people into
31:11the hospital to initiate therapy.
31:13At least in talks, they've said,
31:15you know, Germans are Hardy people
31:17and willing to put up with this.
31:19So who knows about that?
31:21But, you know,
31:22the other thing that we have to consider
31:24is that people actually feel better.
31:26When we're able to kind of rest
31:28their lungs and reduce their CO2.
31:30And so maybe that's why they feel better.
31:33But again, these two studies,
31:34the McAvoy and the Conline,
31:36show 2 very different approaches
31:39to how you're going to prescribe
31:41noninvasive ventilation,
31:41what's the goal of therapy?
31:44And it does show benefit.
31:47I will just say another study by Murphy
31:49and colleagues that was published in 2017,
31:52did this same approach.
31:53And I'll just skip ahead to their outcomes,
31:56But by giving people noninvasive ventilation,
31:59this wasn't powered for mortality.
32:01It's a smaller study,
32:03but you could delay readmission,
32:05which is a hot topic in terms
32:07of cost and Medicare criteria,
32:09things like that.
32:11So again, we have two studies that
32:14show this high intensity approach,
32:16reducing 1,
32:18reducing readmissions,
32:19another reducing mortality.
32:21And so both of those studies led
32:23to new guidelines by the ERS and
32:26by the American Thoracic Society
32:28as I mentioned this earlier.
32:30And so I'm just going to go through,
32:32we had five questions in this guideline.
32:35I'm just going to go through that
32:37relatively quickly because these are,
32:39you know,
32:39what we think people should do and
32:41I'll just give you a sense of how
32:42we approach some of these questions.
32:44So the first question was you know,
32:46looking at all the data right,
32:47because for these clinical
32:49practice guidelines you often do.
32:51You know,
32:52a meta analysis and and systematic review.
32:54And so we said should people
32:57with chronic stable hypercapnia,
32:59with COPD,
33:01should we use noninvasive ventilation.
33:03And you know you you come up with
33:06these forest plots and you can
33:09see that you know not totally
33:12statistically significant,
33:13but we thought in terms of
33:14mortality and then forest
33:15plots in terms of hospitalizations,
33:17quality of life and dyspnea, all of the.
33:21Different domains that we looked at
33:23favored noninvasive ventilation.
33:24So we ultimately came out with a conditional
33:27or a weak recommendation that patients
33:30with chronic stable hypercapnic COPD
33:33should be on noninvasive ventilation.
33:35And just some of the terminology
33:37when you make a conditional
33:38recommendation or strong recommendation,
33:40you can see on the slide here.
33:43But even a conditional recommendation
33:44suggests that most patients
33:46should consider the intervention.
33:50And just as a, you know,
33:51thinking about when you make these
33:54clinical practice guidelines,
33:55you have to think you know
33:56what are the barriers,
33:57you know what's this going to cost?
33:58Do we have enough people
34:00who know what they're doing.
34:01We also think about whenever we
34:03answer one of these questions,
34:04we we try to address what
34:06else would we like to know.
34:08And of course we'd like to know who are
34:09the patients are going to benefit the most,
34:11you know,
34:12what's the mechanism.
34:13And I think a big question is what
34:15are the modes or settings that we're
34:16going to use for this, you know are we.
34:19You know how in the US are we
34:21going to implement this?
34:22And the ERS guidelines actually
34:24addressed this directly.
34:25They recommended fixed pressure mode.
34:27So they didn't talk about Vaps or
34:29volume assured pressure support.
34:30They said here's your IPAP,
34:32here's your EPAP, here's your backup rate.
34:35As a corollary question,
34:36we had five questions.
34:38The first was, you know,
34:39should we use noninvasive
34:41ventilation and COPD? We said yes.
34:43Another question was should we
34:44use the high intensity version?
34:46And we said yes, and.
34:49You know,
34:50I'll sort of skip over that a little
34:53bit in terms of the discussion in
34:56terms of when to start therapy.
34:58I think the only thing that we
35:00were a little bit different than
35:02the Europeans is most of the data
35:04comes from patients who are kind
35:06of quote UN quote stable.
35:08But there is a argument to be made like
35:10why not start people in the hospital,
35:12you know,
35:13if we know that getting people on
35:15noninvasive ventilation reduces
35:17the next admission like.
35:19You know,
35:19and that that can happen frequently.
35:20Like,
35:21why wouldn't you start noninvasive
35:23ventilation in the hospital?
35:24It's convenient.
35:25They're often already on
35:27noninvasive ventilation.
35:28You can get them acclimated.
35:30But but that approach has been
35:34investigated and there really wasn't
35:36a difference when you started
35:38noninvasive ventilation early.
35:40And this was the socalled rescue
35:42trial by Peter Wickstra.
35:44And what's interesting is that a
35:45lot of people who are hypercapnic
35:47during an exacerbation,
35:48many of them no longer a hypercapnic
35:52after their exacerbation that
35:54seems to go away.
35:55So about, you know,
35:57one in one in four patients will resolve
35:59their hypercapty after acute exacerbation.
36:02So the problem with starting an
36:03IV in the hospital is you may
36:05be jumping the gun a little bit.
36:07And so far that approach has
36:08not been shown to
36:09improve outcomes.
36:13OK. So we said, you know,
36:14you should wait two to four weeks after
36:16someone comes in for an exacerbation,
36:18see if they're still hypercapnic and then
36:21and then think about starting therapy.
36:24I think the two questions that are kind
36:26of the most interesting to think about,
36:28I'm curious to hear what the audience thinks.
36:29But you know, do you need to bring
36:32a person into the sleep lab to
36:34initiate noninvasive ventilation and,
36:38you know, the background is that.
36:39All the studies I'm showing you,
36:40when almost all of them are done in
36:42Europe and people come into the hospital,
36:44they get admitted to the hospital
36:46for weeks to titrate this up,
36:48build it here and that kind of stuff.
36:52And so we thought there might be good
36:53reasons to bring people into the laboratory.
36:55But there's a lot of barriers too, right?
36:57It's hard to get these people in.
36:58They're often very sick.
36:59We don't know what the goal is.
37:01Like, in one night,
37:02are you supposed to, you know,
37:04crank the pressure up so much that
37:06they get the CO2 better in one night?
37:09And we also don't want to delay care.
37:10You know,
37:11especially during COVID,
37:11it was very hard to get people
37:14through the sleep lab.
37:16So our recommendation was you
37:17didn't need to come into PSG to
37:20titrate noninvasive ventilation.
37:21And I would say our practice
37:23here is just if we can,
37:24we start patients at home and
37:26kind of titrate up the settings
37:28remotely as we're able to.
37:31A similar question in our last question in
37:34our clinical practice guideline was you
37:36know do you need to do a sleep study to
37:38look for OSA because again the European
37:42studies excluded people that are heavier.
37:44We know that the USA is number one in
37:46obesity. We have a ton of sleep apnea.
37:48I showed you the data that you'd
37:50want to think about OSA.
37:51So you know, should we think about OSA the,
37:55the barriers for that though or that
37:58again you're you're delaying care,
37:59you're getting people in for a.
38:01You know in lab study is going
38:02to be kind of tough.
38:03So we said that patient should
38:06undergo screening for sleep apnea.
38:08But we deliberately did not talk
38:10about PSG or anything like that.
38:11So we want people to think about OSA,
38:14any of you that take care of
38:16patients in the ICU who come in as
38:18labeled as having COPD and you say,
38:20you know they're £400 and you say how
38:22many years did you smoke and they say 0.
38:24You know,
38:24we miss other diagnoses all the time
38:27when we don't think about OSA&amp;OHS.
38:29So again,
38:30our suggestion was to think about OSA,
38:33but you didn't need to do an inlap study.
38:36So again, we've run through a lot,
38:38but the writing on the slide in
38:40blue is kind of what I want you
38:42to take away from this.
38:43You know,
38:44we're talking about COPD
38:46because it's really common.
38:47The Physiology is leads
38:49to oxygen desaturation,
38:51but often in the setting of hypoventilation.
38:54And I want you to think about OSA
38:56and the overlap syndrome and again
38:58there are relatively recent data
39:00that noninvasive ventilation is
39:02the way to go for these patients
39:04that have high resting Paco twos.
39:06So that is in some ways kind
39:09of the end of the formal talk.
39:12But you know what's interesting is
39:14that we made these recommendations
39:15in our clinical practice guideline,
39:17but as those of you know,
39:18it's actually really hard to get
39:20a bilevel with a backup rate.
39:22For patients that have Medicare
39:24and and most insurances and so
39:26you know this is the process,
39:28you know you go,
39:29you have to document the Hypercapnia,
39:31perform sleep oximetry,
39:32you have to rule out although
39:33you don't have to do formal sleep
39:35testing and then you get a bilevel
39:37machine but no backup rate.
39:39And then there are these two
39:41different scenarios you can go down
39:43before you can get a backup rate.
39:46But you know all I'll say is that.
39:48We're giving people a therapy
39:50that we know doesn't work.
39:51And we said you have to use this
39:53for like a few months before we'll
39:55get you to a therapy that works.
39:57And so the work around, you know,
39:59don't tell Medicare,
39:59but I'm pretty sure many of us end
40:01up doing is you can just prescribe
40:03A ventilator for chronic respiratory
40:05failure based on, you know,
40:07hypercapnia and you can just send
40:09somebody home
40:10with a trilogy or an astral rather than
40:12go through and get a much cheaper device.
40:15And so this is a crazy system.
40:17And you know, we all hate it and case
40:20management hates it and you know,
40:21it's just it's sort of annoying.
40:23So there's this mismatch between
40:25optimal care and clinical practice.
40:28And so, you know, we,
40:30we think a backup rate is critical,
40:31but it's hard to get in the US It's easier
40:34to get a much more expensive ventilator
40:36than to get a fancy bilevel machine.
40:38And you know, the the person that
40:40has really spearheaded this effort
40:41is Peter Gay from the Mayo Clinic.
40:43His picture there.
40:44And you know, he really has
40:46been trying to get what he says.
40:48You know, our mantra is we want
40:50to get the right therapy to the
40:51right patient at the right time.
40:53And because I participate in this
40:55clinical practice guideline,
40:56he asked me to be involved in
40:58this technical expert panel.
41:00Christine Juan,
41:00you know a bunch of people
41:02around the country,
41:04including many of folks from
41:06your institutions participated.
41:07And the idea was we wanted to change the.
41:11The CMS National Coverage Determinations
41:14or NCD's and these are the documents
41:16that say who are we going to cover,
41:18what are we going to pay for And many
41:20of the private payers go off of the
41:23Center for Medicaid and Medicare Services.
41:25So this was sponsored by Chess,
41:27but a TS American Academy,
41:30Sleep Medicine and American Academy of
41:32Respiratory Care were involved as well.
41:34And we started with a virtual conference.
41:36Ultimately we we produced a series
41:39of white papers that said you know.
41:42Here's what the NCD's look like now.
41:44Here's the hoops you got to jump through.
41:47Here's what's wrong with that,
41:49based on new evidence or just the
41:51pain points that that is created.
41:52And here's what we would propose
41:55as new guidelines.
41:56Of the areas we looked at,
41:58COPD was one of them.
41:59But we looked at thoracic
42:00restrictive disorders.
42:01So this is neuromuscular disease,
42:03obesity, hypoventilation and some
42:05tweaks to OSA and then central sleep apnea.
42:08So we said here's what we think
42:10CMS ought to do.
42:11Based on the science and they came back,
42:14we we submitted all of these
42:16and they said yes,
42:17we will look at COPD.
42:18We are going to reconsider that whether
42:20or not we have this right for COPD.
42:22And even though we have all these
42:24congressionally mandated timelines of how
42:26quickly we need to address these things,
42:28we're really busy.
42:29And so we can't tell you when
42:30we're going to do that, OK.
42:32And then the other disorders that we put
42:36in some revisions suggested revisions for.
42:38They said,
42:39you know,
42:39we don't think we need to weigh in on this.
42:42There are local concerns or local
42:45coverage determinations and you could
42:48talk to durable medical equipment,
42:50Medicare,
42:50administrative contractors which
42:52cover different regions of the
42:54countries and try to address these.
42:56So for me as kind of coming as more of
42:59a researcher and you know now thinking
43:01about how do you implement these things.
43:03It is a mess. So on the right side here,
43:06you know, I think we were all were
43:07taught in like 6th grade civics.
43:08You know how a bill becomes a law,
43:10how do you get new regulations
43:13into medical practice and get that
43:15paid for is really difficult.
43:17And you know, what I'm finding is
43:20that change doesn't happen quickly.
43:22Few people seem to know how you
43:24actually do this and and probably
43:26you need to partner with a lot
43:28of other people to get it done.
43:30But all I will tell you is.
43:32From our work on this,
43:33we're we're pushing forward with the COPD.
43:36We keep calling CMS every few months
43:38and say hey where are we in the queue,
43:40we want to get this done.
43:41And then there are other the other
43:43diseases we that we I mentioned briefly we
43:46are presenting that to the LCD's as well.
43:49So anyway I'll stop talking here,
43:51this is my last slide I think.
43:53But again for COPD it's
43:56insufficient ventilation.
43:57NIV at night is associated
43:59with improved outcomes so.
44:00If that's not your practice,
44:01you're not thinking about that.
44:03I would start you thinking about
44:05that how you actually do that.
44:07I think there's a lot of questions.
44:08And then finally again just think
44:10about sleep apnea, which is,
44:11you know,
44:11a disease near and dear to my heart.
44:13So I will stop there and say thank you
44:15and happy to answer any questions.
44:26Thank you so much. So. You know,
44:30it's unfortunate because I think in terms
44:32of prescribing A bilevel with backup rate,
44:35most providers in the country are
44:37probably a lot more comfortable doing
44:39that than prescribing trilogies or or
44:42other more advanced ventilators especially
44:44if they're asleep physician without a
44:47pulmonary critical care background.
44:49So not only are they forcing physicians
44:51to sort of use more expensive machines,
44:53but also potentially you know.
44:57Limiting care to people based on,
44:59you know, training and things like that,
45:01I I think a lot of providers may not
45:03be willing to do that, unfortunately.
45:07Yeah, I I totally agree.
45:10I don't really want to
45:11endorse Medicare fraud.
45:12So I want to be careful.
45:13But you know, as an ICU doctor,
45:16you know, not in the sleep clinic,
45:18you know, I think in the ICU it's like
45:21how do we get this patient home safely?
45:24And and so that is a real.
45:26Problem and obviously also I
45:28talked about COPD but obesity,
45:30hypoventilation,
45:30you know I think Bobbik Mowglisi
45:33has great data that getting a
45:35backup rate improves outcome.
45:36I mean we should be doing that
45:38and you're right there are all
45:39these barriers but as you said,
45:42I think you know like in our sleep
45:45clinic there's a couple providers who
45:47do more of the ventilation at night and.
45:50And it's not that they're
45:52smarter than anybody, you know,
45:54it's they have an interest and
45:55they know the intricacies of the,
45:57you know, the nuances of the paperwork.
45:59That's the part that I think makes
46:01it really difficult sometimes.
46:03And yes,
46:03we would like to break that down
46:05and I would just love it if we
46:06could move the goal posts on this.
46:08But it's,
46:10I mean there's nothing more
46:11frustrating than CMS being like,
46:12yes, we think this is a great idea.
46:15But like don't call us, we'll call you.
46:17I mean we're in sort of lingo there.
46:19Well, thank you for your excellent
46:21and important work on this subject.
46:24It's sort of reassuring to know that
46:26there are good people doing good work
46:29and this difficult domain of translating
46:31good clinical practice into you know,
46:35something we can actually
46:36do with insurance, you know,
46:38overcoming these insurance barriers.
46:41There was one other comment I had
46:42before I wanted to do the questions
46:44which is regarding what you were
46:45saying about starting Pap in the
46:46hospital may not improve outcomes
46:48compared to starting later.
46:50Just anecdotally when we started
46:53our inpatient service,
46:54I I anecdotally I felt like patients
46:57who started their CPAP in the
46:59hospital with a non sleep team
47:01versus those who came into our clinic
47:04and got their Pap in the clinic,
47:05I felt they did better long term.
47:08If they did it as an outpatient
47:10in the clinic and they had better
47:12adherence and I I don't know if
47:14that's because they were overwhelmed
47:16in the hospital and they had a
47:18lot of other things going on,
47:19other changes to medications,
47:21rehab,
47:21other things they were doing that
47:23made it difficult to focus on CPAP
47:26as fully or I don't know if it was
47:28because the people prescribing the machine,
47:30the RT's and other people
47:32were less sleep oriented.
47:34Compared to like the patients in
47:35our practice where we you know we
47:37talk a lot about the adherence,
47:38the mask types and they have a
47:40sleep specific RTI don't know if
47:41you have any insight on that or
47:43anything else to add to that
47:47not a I I share your observation
47:49and and the root causes.
47:51I would say that in the hospital we
47:54essentially have you know the Mark 1
47:56mod 1 full face mask as our default
47:58and our R T's are really busy and
48:01stretched then and so often times it's.
48:04Try bi pap on that patient and
48:06they go in and they, you know,
48:08they're looking when the patient says I
48:09I don't want to do it, they're like up,
48:11they're not tolerant to it.
48:12So I would just say that what we've done
48:15differently here is that if we have a
48:18patient that we're going to initiate
48:19on noninvasive ventilation, we call our,
48:22we have a respiratory therapist,
48:24that's her job.
48:25We call her in,
48:26she meets with the patient and she doesn't.
48:28We don't put the load on our.
48:30Sort of normal clinical team
48:31in the hospital because they
48:33don't have the equipment,
48:34they don't have the time to do it and
48:35some of them don't have the knowledge.
48:36So that's how we've gotten around that.
48:39Problem is we pull in somebody
48:41from the outpatient clinic,
48:42they sort of bridge that divide and
48:44they come in and I think that has
48:47been that's been very helpful for us.
48:49Is your outpatient go ahead.
48:51I was just
48:52going to ask is your outpatient
48:53clinic near the hospital or is it?
48:56Yes, it's a it's a half mile away
48:59And so that's that works for us.
49:02She's also just, you know,
49:03her name's Crystal Hawkins.
49:04I mean she just is, you know,
49:06a phenomenal and she also will talk to,
49:09you know, if there's an ICU physician
49:11who's not comfortable with this stuff,
49:13she'll be like either she'll talk to
49:15myself for a couple of, you know,
49:17Jeremy Orr is probably in Bernie son
49:19who are big folks that do a lot of this.
49:21She'll either pull them in or she'll
49:22just tell like the provider like
49:23here's how you order this, you know.
49:25Which again I think it's helpful.
49:29OK, that's great.
49:29And then I wondered in terms
49:31of standard by level settings,
49:32when you start the by level with
49:34a backup rate as an outpatient,
49:37is there a recommended pressure
49:38support range that that you use,
49:41You do you do the auto by level
49:43with a you know set min epap
49:46Max iPad pressures or you know,
49:49I just wasn't sure if you had a.
49:53I'll sort of say two things to give
49:55guidance and and I think it addresses
49:57two of the comments in the chat.
50:00So you know I think when you talk
50:03about BI level with an auto EPAP,
50:07you know the question is do
50:09we underestimate EPAP levels?
50:10I think we sometimes do.
50:13The other question was about tolerance
50:15to BI PAP you know appears to be poor,
50:18you know even with 8 / 4 you
50:20know little old ladies I.
50:22I think whatever you start at,
50:24you need to stay on top of it.
50:25And so you know I will set
50:29kind of moderate settings,
50:30maybe I'll say you know 15 / 5
50:32and then arrange on the EPAP.
50:33I'm checking in and this is where
50:35Crystal also comes in And we've
50:36been able to take advantage of some
50:38of those remote monitoring codes
50:39which maybe you guys use as well.
50:41And we're going to titrate the EPAP
50:43to make sure we're treating any OSA.
50:46And what's interesting and I
50:49I excluded it for time.
50:51There are data that that high
50:53intensity approach that the adherence
50:55is actually better than with
50:56sort of lower standard settings.
50:58And so just because somebody's
50:59having a tough time with it here
51:01and sometimes I actually will,
51:03I'll say okay,
51:04let's push it higher And and I guess
51:08maybe paradoxically or or you know,
51:10not intuitively,
51:10I think they actually do better
51:12sometimes at the higher pressures
51:14because they're actually able to offload
51:16some of the respiratory work of breathing.
51:18But but again I think the key is.
51:21Whatever you set with,
51:22you know after a couple nights see
51:24what they're doing and you know it's
51:26a process over time in that first few
51:27weeks I think is really critical.
51:29We sort of split that between the
51:31docs and again we are fortunate
51:33enough our ventilation clinic has
51:35a fulltime RT more than more than
51:371FT E actually signs that great.
51:40Yeah.
51:41Would
51:41you guys consider publishing A
51:43clinical paradigm of what you do and.
51:47I would, but I would leave it to
51:48Bernie and to Jeremy Orr. But yes,
51:50I think we would be happy to do that.
51:53You know the, you know,
51:54just an interest of again
51:57Doctor Jeremy Orr and myself is
52:00really the remote monitoring.
52:01The amount of data you
52:03captured is phenomenal.
52:04Now we have no idea whether looking
52:06at all that data is helpful,
52:07but but we do use it or I'll just say
52:11it's very interesting to look at you
52:13know and looking at how different.
52:15Muscular dystrophies or ALS,
52:17you can see what's happening over time.
52:19You know, what's the rate of
52:21decline in respiratory fund.
52:22It's really fascinating and it and
52:24we're really interested in in how
52:26you might be able to to document that
52:28using the data improves outcomes.
52:30Well,
52:31thank you so much.
52:32If you can kindly look at the chat,
52:34there's four questions.
52:35You touched on a little bit
52:38already, if you don't mind.
52:41Yeah, I see Clar's question there.
52:45You seem to be implying that there's a
52:47consistent thread between the Inox trial
52:49and the high intensity by PAP trial.
52:51Perhaps Inox was negative because
52:53O2 may have worsened hypercapnia
52:55and high intensity by Pap addressed
52:57this hypercapnia seems like the
52:58important therapeutic target.
52:59Yes, I would Clara, absolutely. I think.
53:02I think that the underlying Physiology
53:05behind the hypoxemia is the hypoventilation.
53:07And so kind of putting the bandaid on,
53:10I mean that's how I interpret it.
53:12You know they they really were
53:14relatively underpowered and it's
53:16it's hard to find these folks
53:18so that but that is my take away
53:23Okay,
53:25thank you. Given the definitions we have
53:27when patients have COPD and hypoventilation,
53:30OHS automatically get gets ruled out.
53:32My only caveat is that the medical chart,
53:35you know the copy and pasting
53:37lies and so people labeled as
53:40having COPD sometimes don't.
53:41So you know, trust but verify and I
53:45think you know again there's been more
53:48than one occasion where somebody is
53:50labeled as having COPDI asked about
53:52smoking and exposures and they've never
53:54had PFT's and you know all this kind of
53:56stuff and I see some sympathetic nods.
53:58Do you have any thoughts on that when
54:01patients might have all three in
54:04terms of practice with initial bi pap,
54:05how high do you usually go with
54:07the I PAP and E pap?
54:09How do you target CO2 reduction?
54:10OK.
54:12So yeah,
54:14I mean I think people can have
54:17essentially all three disorders
54:18what I would what I would go back
54:22to and and this is the art more
54:23than the science I guess.
54:24But you know when I was sort of
54:26talking about you know does this
54:28patient have 90% COPD and 10% OSA,
54:31I'm really trying to make that adjustment
54:33and if I think somebody is 500 pounds.
54:36And you know, I'm going to really
54:39actually try probably with CPAP,
54:40you know, if I really think it's obesity,
54:41hypoventilation and severe OSA
54:43before I go to ventilation. So.
54:46So that's that's just a general gestalt.
54:49But I'd be willing to,
54:51you know to try just keeping the
54:53upper airway open and those folks
54:55before I moved on to ventilation,
54:56if it's,
54:57you know,
54:58really somebody with horrible COPD and yeah,
55:00they're,
55:00they have a little bit of upper
55:02airway collapsibility,
55:03I'm actually going to sort of ignore that.
55:05Say that my standard EPAP of five
55:07is going to address that sleep
55:08apnea and just kind of move on
55:12for initial therapy. You know,
55:15my IPAP of choice is often about 16 or so.
55:18I don't go right to 20.
55:20It depends a little bit how naive or not.
55:23You know, if somebody's used noninvasive
55:25ventilation in the ICU and I kind of have a
55:28sense of their settings and their tolerance,
55:30maybe I'll go, you know,
55:31directly higher than that or
55:32I'll take a more gentle approach.
55:34But again, I think the key is
55:36not so much where you start.
55:37I think it's how you follow
55:39these people once you start.
55:40So even though I agree,
55:43like the sleep clinic, you know,
55:45you never get a second chance
55:46to make a first impression.
55:47I really go into people and I set
55:49the expectation that I'm going
55:51to be monitoring their therapy.
55:52I'm going to make changes and not
55:54to get discouraged if we don't,
55:56you know,
55:56knock it out of the park on the night one.
55:59And then I follow.
56:00I actually don't get a lot of blood gases.
56:02I follow bicarbonates.
56:04Over time, it's just easier for me
56:06to get them in our sleep clinic.
56:07It's very hard to get an APG.
56:14So I'll. I'll take my cue from you.
56:17I see that it's the top of the hour.
56:18I'm happy to go through a couple other
56:20questions or see if people have other
56:23questions, but I just want to
56:24be mindful of everyone's time.
56:29So well, you're muted.
56:32Sorry. Thank you so much.
56:34Well, if you can just do a few more quick
56:36questions maybe Doctor Barrett asked,
56:38should hospitalized the OPD patients
56:40with nocturnal hypoxia and not be
56:42discharged with supplemental oxygen
56:44if the patient with overlaps and over
56:45severe COPD but unable to tolerate PAP,
56:47what is the best approach?
56:49Sure. So you know,
56:52I appreciate how everyone's
56:53going for the really tough cases,
56:55but you're right, they know these,
56:56these are all tough cases,
56:57you know, because they're often
57:00pretty morbid people, so.
57:04You know, that's a really
57:06interesting question.
57:06So you know the Inox trial well,
57:10two things, most Hypox,
57:11many much hypoxemia gets better as you
57:16treat people after an exacerbation.
57:17So you know, if you look at people
57:19who meet criteria for oxygen,
57:21you know when they're discharged
57:22from the hospital and you
57:23follow up in a couple months,
57:24many of them don't no longer meet
57:26the criteria for oxygen therapy.
57:28It also depends on.
57:30You know, what's the criteria?
57:32So yeah, you can get oxygen if
57:34people have 6 minutes less than 88%.
57:36I typically don't bother for that.
57:38You know, I say, you know,
57:40I don't think this level
57:42of hypoxemia is important.
57:44I think different people can draw that line.
57:47But but I think if you're,
57:49you know,
57:50if you're seeing 7 minutes of
57:52Sats less than 88% right after
57:54someone has an exacerbation,
57:55I I would feel very comfortable
57:57not prescribing oxygen for them.
57:59You know,
57:59and I think other people need
58:01to draw the line,
58:01but just because you meet a guideline,
58:04you know, same with HIV6, right.
58:06And and no symptoms,
58:07you don't need to treat that person,
58:09you know.
58:09So I think you can use your,
58:11you know,
58:12your knowledge and experience there.
58:14And so it's hard for me to give you
58:16absolute numbers in terms of nadir percent,
58:19but I'm looking for more robust
58:21hypoxemia than what would just meet
58:24the Medicare criteria in terms of,
58:26you know, someone with severe COPD.
58:29And unable to tolerate PAP again,
58:32if you're just treating sleep
58:34apnea and their major,
58:35you know again if their
58:37major problem is COPDI,
58:38would really try to optimize
58:39that as much as possible.
58:40Yeah.
58:40Then I would go down my sort of next therapy,
58:42oral appliance, you know,
58:44would be my next,
58:45you know,
58:45kind of thought position therapy.
58:47I mean I would go sort of
58:48through the alternate therapies
58:50as best you can and I would
58:51obviously provide education and
58:53acclimatization as much as you can.
58:54But you know it's it's a tough
58:56crowd sometimes with these folks.
58:59And Dr. Heckman,
58:59you had a number of comments.
59:01Was there anything you wanted
59:03to add before we adjourn
59:08and you're on mute.
59:14Sorry, I was waiting for the ability to.
59:16Yeah. I just wanted
59:17to point out that I feel like
59:20we just have to be careful to take in
59:21consideration what the presentation is.
59:22You may have the one initial blood gas.
59:25For someone and therefore it's their
59:28first exacerbation that we have record of.
59:30But you know if they're clearly
59:31a chronic retainer and you can
59:33tell that by the gas, you know,
59:35I think we need to be a little bit more
59:36aggressive at times with these folks.
59:37And my counterpoint also for the wait to
59:40see how they do as a followup is that
59:42these people who are really bouncing
59:43into the ICU for this presentation,
59:45they they keep bouncing back and they
59:47don't have enough stability outside of
59:49the hospital to actually engage in this.
59:51What's what's viewed as a low
59:53priority outpatient work up.
59:54I'm sure you've all had someone go to.
59:56Rehab with this on the agenda and
59:57you schedule stuff and they don't
59:59come because the rehab doesn't
01:00:00consider this a high priority, right.
01:00:02So sometimes it feels like it may
01:00:04be the lesser of evils to bark in
01:00:06a more aggressive therapy out of
01:00:07the gates that you can actually get
01:00:09them than nothing at all.
01:00:11Yeah, I would, I would totally agree.
01:00:13And I think a lot of what
01:00:16we're talking about is,
01:00:16you know,
01:00:17trying to identify what's the,
01:00:18what's the biggest problem in these
01:00:20people that often have multiple
01:00:21medical problems and and trying to,
01:00:23you know, tackle the biggest problem.
01:00:25First, I don't know how, you know,
01:00:27maybe Sunil has spoken at these conferences.
01:00:29You know, as best I can tell,
01:00:31he sort of made an inpatient
01:00:33sleep program by like physically
01:00:34Wheeling people to his sleep lab,
01:00:36you know, himself.
01:00:37And I mean it would be great to
01:00:39reduce these barriers and that
01:00:42that is what we're trying to do.
01:00:44And and I would just say both, I mean,
01:00:47I've seen people on ventilators for like,
01:00:48no, you know,
01:00:49a full ventilator for no reason, you know.
01:00:51And and so I think it goes both ways.
01:00:54But what we are trying to do with this
01:00:56technical expert panel and Peter Gay is like,
01:00:59you know, can we just,
01:01:00can we take away the pain points, right.
01:01:02I mean just like every time we're trying
01:01:03to discharge one of these patients,
01:01:04it's like we reinvent the wheel.
01:01:06We know that they, you know,
01:01:08when when I did sleep consoles a lot more,
01:01:10it's like you know,
01:01:10get him an outpatient PSG.
01:01:12And and we have data on this
01:01:13like none of them show up,
01:01:14you know, for whatever reason.
01:01:16And as you're right,
01:01:17some of them are just back in the hospital.
01:01:19So we got to try to break that cycle.
01:01:24Well, it looks like that is most of
01:01:27the questions you a few additional
01:01:30comments here and commenting on the
01:01:32need for close monitoring and therapy
01:01:35titration as Physiology is evolving
01:01:37which which you've noted and some
01:01:39comments on what a great talk this was.
01:01:41Thank you so much.
01:01:42We really appreciated having you.
01:01:44This was absolutely wonderful.
01:01:48Andre, do you have anything else?
01:01:50No, I I think those are great questions
01:01:52actually, Bob, I was gonna try to
01:01:53pick your brain about something for a
01:01:55couple of minutes if you if you have it
01:01:57after the after the talk. Yeah. Great.
01:01:59I'll stay on. Yeah. All right.
01:02:00Well, thank you, everyone.
01:02:01I really appreciate the
01:02:03time and the questions.
01:02:04Thank you. This was really great.
01:02:06Excellent presentation.
01:02:09Yeah, fantastic. Thank you every
01:02:11much for attending and we'll see
01:02:13you in the fall. Okey doke Gee.
01:02:18I'm amazed how many people
01:02:20you get on at 2:00 PM on a,
01:02:21you know, Wednesday afternoon.
01:02:23Yeah. So this is the nice part of,
01:02:26you know, multiple baskets. Yeah.
01:02:30You know, we have folks from all
01:02:32over Boston area and then here
01:02:34down at Yale and then also some
01:02:37folks from Providence joint.
01:02:39Yeah, so that's it works out.
01:02:41It works out pretty well.
01:02:43Thanks Bob. Great talk by the way.
01:02:48Sure looks like there's a few
01:02:50folks are staying on. Sounds good.
01:02:51I was gonna ask you about So
01:02:54when you follow these people
01:02:56on astrals and trilogies,
01:03:00most of your most of your Dmes do the
01:03:04daily upload so that you can review
01:03:07their trends and data regularly or do
01:03:10they and who reviews. Yeah it is it.
01:03:12Do you have an RT that sort of looks for
01:03:14red flags and communicates with you guys
01:03:17or do you have like an MD that like.
01:03:20Checks, inbox messages or what's
01:03:21your protocol for doing that or
01:03:23or what's your custom.
01:03:25So you know it's really interesting, right.
01:03:29And a lot of this is driven by
01:03:31reimbursement and just you know so,
01:03:33so you know we, we are fortunate
01:03:36in that we've successfully made the
01:03:38argument that this stuff cannot
01:03:40fall onto an MD and that it can
01:03:42be done by a respiratory therapist
01:03:44and we have enough support for.
01:03:46Again, more than 1FT ERT support.
01:03:49So we have tried to get into the
01:03:52practice of having at least you know
01:03:55once a month that they review sort
01:03:57of the data and then and then our
01:04:00docs can sort of ping the RT and say
01:04:02hey I just started this or you know
01:04:05like let's get more frequent checks
01:04:07and that's mostly managed through
01:04:09Epic when our patients come in.
01:04:11For our ventilation clinic,
01:04:12they're also seen by a respiratory
01:04:14therapist as well.
01:04:15So they meet with the with the doc
01:04:17and the RT and so you know things
01:04:21like if people are going really well,
01:04:23we won't routinely check on the
01:04:24most people are getting started.
01:04:26It's you know every 30 day kind
01:04:28of check in until they reach some
01:04:30level of adherence and then more
01:04:34specific targeted therapy we have
01:04:36not had trouble with.
01:04:39Remote monitoring, you know,
01:04:41from our DME's and stuff like that.
01:04:43The other thing I'll say is, you know,
01:04:45San Diego is obviously a big place.
01:04:47But you know, we have people that,
01:04:48you know, live 2 hours to our E you know,
01:04:50they have no, you know,
01:04:52sort of sleep and ventilation services
01:04:53And so the remote and then obviously
01:04:55like transporting these patients and stuff,
01:04:58you know, the remote monitoring has
01:05:00been in my mind a game changer, valuable.
01:05:03Yeah, yeah, yeah.
01:05:04I mean, cuz you can.
01:05:06You can see what's going on.
01:05:07You can change the prescription
01:05:10and and again like,
01:05:12you know,
01:05:13especially like the Duchenne's
01:05:14patients and I mean getting these
01:05:15some of these guys into clinic
01:05:17or getting them in for PSG,
01:05:18I mean that's just not feasible at all.
01:05:20So yeah,
01:05:22yeah, no, that's that's great.
01:05:23I mean I think that we've had sort
01:05:26of variable success at Dme's doing
01:05:28sort of the continuous monitoring
01:05:31specifically for the ventilators because
01:05:33that's more costly to the Dme's.
01:05:36And so it requires to have them
01:05:38some sort of purchase some sort of
01:05:39a plan with the you know resonator
01:05:41Spironics and and so that can
01:05:43can be a challenge but it sounds
01:05:45like you haven't had a hard time.
01:05:46Most of the time you're you're just
01:05:48everyone's on there and you can
01:05:50whenever you go into orchestrator
01:05:51or on your view data's there just
01:05:53shows up and that's great.
01:05:56Yeah. I mean Jeremy Orr would
01:05:57be the one to talk to, but yeah,
01:05:59that has not been an issue, you know,
01:06:02Yeah. Okay, cool.
01:06:03So you know we have Stratika Thapa
01:06:07who is our our faculty here who's
01:06:10actually developing A CPD how better
01:06:13relation program in the sleep center.
01:06:16I might have her reach out to Jeremy
01:06:19if you guys don't mind and maybe CC
01:06:21you and myself and and and Clar and
01:06:24maybe if Jeremy would have maybe
01:06:26like you know 30 minutes or so.
01:06:28Just overview what you guys
01:06:30do just to get a sense of.
01:06:32Avoiding to you know the pitfalls
01:06:34and and tribulations of starting this
01:06:37might be helpful for her and for us.
01:06:38So
01:06:40the only person could you also include
01:06:43Bernie Sun Wu on there because I
01:06:45think in general I think Bernie I
01:06:49think Jeremy does more neuromuscular,
01:06:50Bernie does more COPD with a
01:06:52lot of Oval and they would have
01:06:54you know I think they both have
01:06:56great complimentary information.
01:06:58I I will say though I don't.
01:07:01We had good buy in from our health
01:07:03system which is actually kind of
01:07:05unusual and that was like the secret
01:07:08sauce in terms of the respiratory and
01:07:10was that was that based on the
01:07:13readmission reduction or what was
01:07:14the I was just like you know good
01:07:16altruism from the health systems.
01:07:18This is the right thing to do and
01:07:20so we're going to invest a FTE
01:07:22and an important part of care.
01:07:25Yeah I I really doubt the that part.
01:07:27You know like the altruism is hard.
01:07:29I think readmissions was a problem.
01:07:31I don't know. I don't know how well we
01:07:33tracked whether this bent the curve.
01:07:35You know probably like you you guys
01:07:38we there was a real need we have
01:07:40a rady's Children's Hospital and
01:07:42they have a pretty big Duchennes
01:07:44and other myopathy programs. So.
01:07:47So there was a need and and I think
01:07:51we probably made the argument on
01:07:53readmissions and then because we.
01:07:55You know, we are a little bit of
01:07:57a gorilla with our Dme's locally.
01:07:58And so I think you know in terms
01:08:00of some of the, you know,
01:08:01they generally want our business and
01:08:02want to work with us and I think that
01:08:04made some of the stuff easier in
01:08:06terms of the monitoring, you know?
01:08:07Yeah. Cool. Yeah. Awesome.
01:08:09Well, hey, thanks Bob for sharing.
01:08:11Appreciate it. That's really helpful.
01:08:12I know that you're in the Mickey
01:08:14of so times. Times is valuable.
01:08:17So all right, good.
01:08:18Good to see you. Thanks guys.
01:08:20Take care everybody.
01:08:20Thank you. Bye. Bye.