"The Ins and Outs of Home Noninvasive Ventilation" Amanda J Piper (12/01/2021)
December 09, 2021ID7253
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.