“NIPPV for Sleep Dysregulated Breathing and Sleep Apnea” by Umakanth Katwa for OPENPediatrics

NIPPV for Sleep Dysregulated
Breathing and Sleep Apnea, by Dr. Umakanth Katwa. Hello, everybody. My name is Umakanth Katwa. I’m a Pediatric Pulmonary
and Sleep Specialist at Boston Children’s Hospital. Today, I’ll be speaking on
use of non-invasive positive pressure ventilation for
treatment of sleep apnea and dysregulated
breathing in children. So in my talk today,
I’m going to begin with some basic physiological
aspects of sleep and respiration. I’m going to discuss a little
bit about non-invasive positive pressure ventilation
delivery devices, and then we’re going to talk
about some basics of sleep therapy and bi-level
therapy in children. Physiologic Effects of Sleep. So first, let me start with the
impact of sleep on breathing. So what happens to the
breathing when one sleeps? To understand that, we’re
going to start with what happens in normal patients. There is relative
hypoventilation. That means you tend to take
a shallower breath when you sleep. There is slight decrease
in hypoxic and hypercarbic respiratory drive to breathe. Hence, it leads to a reduction
in your tidal volume by 25%. For example, if
somebody is breathing at a tidal volume of 500
ML, their tidal volume decreases by 25%
when they sleep. Their partial pressure
of oxygen in the blood goes down very minimally by
about 3 to 5 millimeters, and the carbon dioxide rises
by about 3 to 6 millimeters of mercury. And hence, the pH of
the blood is maintained with this change in PaCO2. These changes are exemplified
or attenuated in REM sleep. However, even though there is
a drop in tidal volume in PaO2, there is no significant
change in your saturation. If you look at the diagram,
which is an oxygen dissociation curve, where partial
pressure of oxygen is plotted against
the oxygen saturation, you can see that on
the flatter top part of the curve, a drop in your
partial pressure of oxygen, the saturation
doesn’t change much. And now what happens in the
neuromuscular disease patients? These so-called normal
changes in respiration during sleep become
much more exemplified, leads to Frank hypoventilation. They tend to take a much
shallower respiration, tend to re-breathe their
own carbon dioxide, and unable to increase
their ventilation. Hence, their carbon
dioxide increases further, and there may be a
further drop in saturation because the drop in tidal
volume is much more remarkable. So now let’s talk about the
impact of disordered breathing during sleep. So what happens to
sleep if somebody is not breathing properly
when they are sleeping? That leads to a lot of
sleep disturbance, typically micro and macro arousals. There can be even
frank awakenings. Ultimately, this leads
to significant sleep fragmentation. There is reduced in the
amount of REM sleep. A child has about 30
to 50% of the REM sleep depending on what age. An infant tends
to have about 50%, and adults tend to
have about 20 to 25%. And REM sleep is very important
for your memory, consolidation, and the neuronal
pruning, and development. Hence, your REM sleep
tends to go down. There is further worsening
of your gas exchange and respiratory events
during REM sleep. So your upper
airway, which tends to lose tone during REM
sleep, has increased tendency to collapse. Your Functional Residual
Capacity, which is FRC, tends to go down. Hence, your oxygen reserve
in the lung goes down, and your respiratory
drive is variable. Hence, you have
a varying degrees of tidal volume
during your REM sleep. Because of these
changes, you have significant daytime symptoms
like fatigue, tiredness, sleepiness, morning
headaches, poor memory recall, learning difficulties,
and shortness of breath. So before we talk
about how we’re going to treat different
sleep disordered breathing, let’s overview, what does the
spectrum of sleep disorder breathing in childrens entails? The most common ones are
the obstructive sleep apnea, which is a spectrum
of disordered breathing due to airway
obstruction, can range from primary or
habitual snoring which means a patient
snores but doesn’t have a classic
obstructive sleep apnea. Two, an Upper Airway Resistance
Syndrome, also called as UARS. This is a slightly
more severe degree from a snoring perspective. They have a flow limitation, but
this causes significant sleep fragmentation. And then you have Frank
obstructive sleep apnea where airway completely collapses. Coming from a obstructive,
moving to central sleep apnea. So it entails your classic
central sleep apnea because of various neurological
issues, like Chiari malformation, central
hypoventilation, such as seen in
neuromuscular disorders, or periodic breathing,
as seen in some of the newborn and
premature babies. Sometimes, these
patterns can coexist, giving rise to a mixed
pattern of sleep disorders. So other type of sleep
disorder breathing include sleep
tachypnea, that somebody is breathing faster than
typical during sleep, as seen in patients
who are morbidly obese or in patients who have
restrictive lung disease. Sleep hypoxemia, particularly in
childrens with underlying lung disease, severe asthma,
chronic lung disease, or cystic fibrosis. These patients have a normal
saturation while awake, but as soon as they fall asleep,
develop hypoxemia. These patient may need
treatment with oxygen. Sleep hypoventilation,
these patients have normal carbon dioxide
and saturation while awake, but during sleep
the CO2 tends to go up, and typically about
50 for more than 20% of the time during sleep. Complex sleep apnea,
these patients who develop central sleep
apnea after treatment of their obstructive
sleep apnea. There are various dysregulated
breathing during sleep, as seen in patients with
Joubert syndrome, Rett syndrome, and in situations like
Biot’s breathing, erratic respiration, and some of
the neurological disorders and diaphragmatic
flutter, where they can have ineffective
ventilation and leads to sleep fragmentation and
gas exchange abnormalities. So this is a diagram
of an upper airway. I think we need to
understand that, and this will help
us to understand, how the positive
pressure therapy works. So here we are seeing a
diagram of a saggital view of your larynx and upper airway. It involves the nasal pharynx,
the soft palate, the velum. There is a tongue
over there, and there is a retroglossal space. The space behind the
tongue is the airway, which has highest propensity
to collapse and cause obstructive sleep apnea. And below that,
there is epiglottis. If the tongue falls back,
it pushes the epiglottis and completely closes
your laryngeal inlet leading to frank apneas. So the other important concept
to understand in childrens whenever we treat sleep apnea
is a concept called Pcrit, or a critical closing pressure. I’m going to just simplify and
use few words to describe this. A critical closing
pressure is the pressure at which your airway or
upper airway collapses. Typically, it needs
a significant amount of negative
pressure, which leads to collapse of the airway. Now in this diagram,
you see the first graph which shows the critical
pressure of infants and then compares to
childrens and adults. On this graph, you will
see an x-axis and y-axis. On x-axis, you see the pressure
required for the airway to collapse starting from
zero and goes all the way to minus 40, and on the y-axis,
you see the maximum inspiratory flow per second. Interestingly, infants have
the least collapsible airways compared to children and adults. Infants require much
negativer air pressure, up to minus 30
centimeters of water, for the airway to collapse. The more negative the pressure,
the more stable the airway. The less negative the pressure
or more positive the pressure, the more unstable the airway. Hence, obstructive sleep apnea
in a typically healthy infant is very rare. While you see that
in adults, they require less negative pressure,
as much as minus 10 to 12 centimeters of water
can collapse the airway. And this can be
generated during sleep. And hence adults have higher
risk of developing sleep apnea. And that can depend
on your muscle tone, upper airway muscle tone,
particularly genioglossus, and also your body habitus. And now this is a sleep study
of a child who has sleep apnea. You can listen to the audio and
you can see a clear snoring. And the events mark with the
blue bars are the ones which are obstructive hypopneas,
where the patient has respiratory effort,
but the flow is reduced and then, there is a sudden
gasp of air, which are recovery breaths and then the
patient goes back and sleeps and further develops this
recurrent, cyclical obstructive sleep apnea. [SNORING BEGINS] [SNORING ENDS] [SNORING BEGINS] And this is a drug-induced
sleep endoscopy in a child who had
severe sleep apnea. If you look at
this video, you can see that there is a
significant lateral collapse. And you can see the fluttering
of the lateral pharyngeal wall, which is consistent with
snoring in this child. So this child had tonsils
removed for sleep apnea, but the patient had
persistent sleep apnea. So when we did a drug
induced sleep endoscopy, is a procedure where
you give light sedation to the patient just
to induce sleep. So it can mimic
the natural sleep without losing the complete
upper airway refluxes, but the patient is sleeping
and breathing on his own, without any respiratory support. We put a scope in the
nasal pharynx and point towards the laryngeal inlet
and see how the airways behave. In this video, you can clearly
see there is a lateral wall collapse. So now, understanding
the video, it is a cartoon of the
upper airway diagram and shows how a
positive airway pressure therapy helps the airways. It’s basically stenting. It is a pneumatic stent,
which stabilizes the airway. First, it causes
pharyngeal unfolding. It reduces the compliance
of the upper airway, decompress the airway. It opens the airway and also
causes hiatal retraction and stabilize the airway. So combination of
these things leads to stabilization
of the upper airway so that the airway is patent. It doesn’t collapse and you can
breathe through those airways. So what is the goal of a
positive pressure therapy? First, to improve the symptoms. If somebody is
symptomatic because of the disordered
breathing during sleep, you want to help them. Then you want to treat the
upper airway obstruction. That means, if
you’re doing a sleep study you want to make sure that
their obstructive sleep apnea index is less than one per hour. This can be done by using
positive pressure which stents open the airway
and stabilizes the larynx as we discussed in
our previous slide. The Apnea Hypopnea Index,
also called as AHI, is the marker of the severity
of obstructive sleep apnea. It is the total number of
obstructive events, divided by the total duration of sleep. The next goal is to
improve the gas exchange. This happens by
increasing the FRC. By giving a positive pressure,
you recruit the alveoli, you open up the lung, and there
is a better residual capacity. Hence there is
better ventilation. You enhance the tidal volume. Your carbon dioxide goes down. The goal is to bring
it to below 45. And the goal of saturation
is to keep it around 96. It also reduces the work of
breathing and respiratory muscle fatigue. So you’re augmenting
the respiration by a positive pressure,
so that the body has to work harder when you have
an obstructed airway because it is fighting the resistance
of the airway collapse. When you prevent the
upper airway collapse, when the airway is patent,
the respiratory mechanics are more efficient and it
reduces the work of breathing. It improves the sleep quality. We learned in the previous slide
that a disordered breathing can cause significant
sleep fragmentation. And because of the
poor sleep they get, they tend to have a
significant daytime symptoms. And hence, by giving
them a stable airway, stable respiration, you
can stabilize their sleep and hence you can treat their
daytime symptoms of sleepiness, tiredness, and fatigue. And it also improves
your cardiac function. And if somebody is stressed
out because they’re having poor sleep,
because of poor breathing, that increases your
sympathetic drive. You tend to be
more stressed out. And it also reduces your
sympathetic drive, hence patients who are treated
with positive pressure therapy for
obstructive sleep apnea tend to have a better
sympathetic tone. Hence their blood
pressure and other things tend to be much
more normal range. CPAP. Now let’s start with continuous
positive pressure ventilation. So what are the indications
or clinical indications for using CPAP in children? The most common indications
are obstructive sleep apnea. Typically, in a child has
severe obstructive sleep apnea, we use this as a bridge therapy
until a positive intervention or a more definite intervention
such as surgery is done. Or sometimes we
use CPAP when there is no surgically treatable
lesion for that patient. Residual sleep apnea. A child who had a sleep
apnea underwent procedures like adrenal tonsillectomy. In spite of that, there is
a significant residual sleep apnea, we’ll use CPAP, which
is considered the second line of therapy after surgery. In some childrens,
even though there is a surgically
correctable lesion, the surgery is contraindicated. Either the patient
is unstable, or there is some disorder which prevents
the patient getting anesthesia. So then the CPAP becomes the
primary treatment for them. Or in extreme, in some
of the situations where parents refuse a
surgery, we use CPAP for treatment of sleep apnea. Central sleep apnea, like,
and periodic breathing are other indications
for using CPAP, but we typically don’t use in
the very severe central sleep apnea. If there are some milder
degree of central sleep apnea, by improving the FRC, they can
improve the oxygen reserve, which improves
oxygenation, and hence you can treat the
central sleep apnea. Mixed sleep apnea. So these patients
are predominately obstructive in nature. Because of the recurrent
obstructive cycling, they can get
post-arousal centrals. So by treating
obstruction by CPAP, you can treat the
centrals because you’ve stabilized the sleep. In some situations,
post-extubation, after a suspected
patient with OSA, you want to give
him temporarily. And in some patients
who are very tachypneic and has increased
work of breathing, you use CPAP as a temporizing
measure to improve the FRC and reduce the
work of breathing. And sometimes in patients
with extreme tracheomalacia, where the airway is completely
collapsing during expiration, you want to give a
positive pressure to keep open the trachea for
better pulmonary clearance and also delivery
of the medicines. So these are some of the
challenges we encounter when we write about CPAP prescription. In children, for OSA,
although there are no clear cut guidelines, but
an AHI of 1 to 1.5, which is considered abnormal,
may be an indication to cover the CPAP from
an insurance perspective compared to adults. Adults need to have an AHI
of at least 5 with symptoms or 15 per hour without symptoms
for an insurance company to cover for the CPAP. The insurance typically needs
a documentation of the OSA on a PSG, so you
invariably end up doing a sleep study, in lab
sleep study for childrens and a home based sleep
study for adults. And then, if you’re using CPAP,
they will also want to know, did you do a titration study? What pressure worked? So they want to see
that you actually did a study, that the
CPAP was effective and efficacious, hence
they can cover it. So these are the things you need
to keep in mind while ordering for CPAP. So what are the type
of CPAP therapies? Up until now, and
mostly in children, we use a single
setting CPAP, like CPAP of 5 centimeters of
water and the patient is on 5 centimeters
of water, irrespective of what stage of sleep
the patient is in, or 10 centimeters of water. That is called single
pressure setting. Then the next one is auto CPAP. Typically what you do is you
put a range for the machine, like 4 to 15
centimeters of water. So these are the
smart machines, which can sense the patient’s flow
or an impending obstruction or snoring and automatically
adjust the pressure. So when the patient
is falling asleep, it is at the lowest pressure. And as soon as the patient
goes into deeper sleep, and even in REM sleep, when
the obstruction increase, the pressure automatically
increases to the point, top sections are taken care. And when the patient is in
different stages of sleep, which may require a
different pressure, the pressure comes down. So it is much more friendly with
the patient’s breathing effort. And typically we have
used this in some of the older and
teenage patients. And CPAP with C-Flex
or C-Flex plus, these are some of the mechanisms like
expiratory pressure relief. For example, when you
apply CPAP 10 to 15, it’s pretty high
pressure for a child. So you’re breathing in with
that pressure of 10 centimeters and you’re breathing out
against 10 centimeters. And sometimes it can
be very uncomfortable. By using this pressure
relief, the companies have come up with an algorithm
relief of 1, 2, and 3. Doesn’t necessarily correlate
with the degree of centimeters of water pressure, but it does
drop your expiratory pressure to certain extent. If it was 10 maybe
like 8 or 7, so that your breathing
is much more smoother and against less resistance. And there are other
modes we typically don’t use in older childrens. It has been used and tried
in neonates and infants, in the NICU. These are bubble CPAP. And sometimes you can use a high
flow nasal cannula such as RAM cannula to deliver the flow. When the high flow is given
at a little bit higher rate, it does deliver some
degree of positive pressure and it does act like a CPAP. So what are the common
settings one uses for CPAP? The minimum settings
are four and five. In our sleep lab, we
start at 5 centimeters of water and titrate upwards. What is an optimum
setting for CPAP? A setting is considered
optimum ideally when it eliminates all the
snoring, the flow limitations, and all the obstructive
events, including in supine REM sleep when your obstruction
tends to be worse, and also improves gas exchange. If you’re doing a
sleep study, your AHI, which is an Apnea Hypopnea
Index should be less than 1. That is optimum and ideal. So what is the maximum
setting one can use? Typically in a child who
is less than 12 years old, we go up to 15
centimeters of water. In a child more than
12, we can go up to 20 centimeters of
water, but by this time it becomes very uncomfortable. We may consider switching them
to a bi-level ventilation. What are the practical
consideration of ordering a CPAP study? So we get asked
multiple times that, what are the things I need
to worry about or take into consideration into an
order when I order a CPAP study? The in lab titration
study to identify the appropriate pressure for
a child is the gold standard. During titration, we start
with the lowest pressure and see how the child does. If there are obstruction
on top of that pressure, we increase the pressure
by 1 centimeters. We wait for about five
minutes for the breathing to acclimatize and
stabilize on that pressure. For a child less
than 12, any apnea, indicating that the airway
is completely collapsing, meaning the pressure
is ineffective, we increase the pressure
up until you completely resolve the apneas. Then, if there are
hypopneas, and hypopnea is a respiratory event
where the airway collapses but it does not
completely close, or some milder
respiratory events or some ambiguous events. So the goal is to eliminate
all this obstruction and also the snoring. In a child more than 12 years
of age, you use two apneas and similarly, goal is to
eliminate all the obstruction. The airflow during the
CPAP titration study is measured by internal
sensor called C-flow. We need to have good
carbon dioxide signals. When the child doesn’t
tolerate nasal cannula, we use transcutaneous monitors. We need to have
a good saturation probe send us signals. We have a snore
microphone to make sure that the snoring is eliminated. And we have good respiratory
effort belts to see the effort. And the scoring
parameters are same as we used for a diagnostic study. This is the CPAP prescription. And these are some of
the salient features you would like to
add in a CPAP script so the insurance company can
dispose the right machine with the right setting. First, you would like to
talk about the indication, like obstructive sleep apnea. You would like to write
the goal of the therapy is to treat obstructive
sleep apnea. Duration of the
therapy, invariably, we tend to write it as lifetime. But if you’re planning to
write for a short term, you can write 6
months or a year. Instructions, we usually write
to use the device during sleep or naps, depending on the age. If you would like to write
the details for the machine, you can write the type and
the make of the machine. Then the most important thing
is the pressure settings. You can write the
standard setting at 10 or 12
centimeters of water. Or an auto CPAP, you write
a range of the pressures, meaning from 5 to 15
centimeters of water. Pressure relief, you may
write required or not. If, yes, you can write the
setting of one, two, or three. You write the mask, the type of
the mask, nasal or full face. About the humidification,
you’d like it or not. And then if you
write humidification, you write the level
of humidification. If you want to set a ramp
for the pressure to rise, you can write between
15 to 20 minutes. The tubing types, regular
or heated tubings. Most of the time,
if available, we use heated tubings to avoid
condensation of the tube. And then you write the refills
for the mask and the tubings, which are typically supplied
within 3 to 6 months. BiPAP. Now, coming from a CPAP to
bi-level positive pressure therapy are also called
as BiPAP therapy. So what is the difference
between Bi-level and CPAP? In Bi-level, there
are two settings. In CPAP, there is only one. It’s a continuous
one pressure setting. In a bi-level, as
the name suggests, there are two pressures. There is an expiratory
positive airway pressure, which is similar to your CPAP,
an inspiratory positive airway pressure, which only is
delivered when you breathe in. So there are sensors
in this which senses your inspiratory
effort at the beginning of the inspiration and
delivers the pressure, which is your IPAP. And hence it tends
to synchronize with your respiration. It improves, similar to
CPAP, upper airway patency. And also in addition to
improving your upper airway patency, it augments
your tidal volume. It delivers a
bigger breath, which is the most important feature
of a bi-level ventilation, compared to CPAP, which
typically does not augment your tidal volume. And hence, it is extremely
useful in patients with restrictive lung
disease and neuromuscular disorders, who tend to take
a much shallower respiration. This provides non-invasive
positive pressure ventilation, particularly in childrens
with central sleep apnea or extremely
shallow respiration, where they are not able to
generate enough tidal volume, you can put them on a
backup rate, whatever rate depending on the
age of the patient, and can maintain that
minute ventilation. As you know, the
minute ventilation depends on the respiratory
rate and tidal volume. You can change
and play with this by either increasing
the respiratory rate or changing the tidal volume
by increasing your IPAP. So what is the
rationale for using bi-level positive
pressure ventilation? One, upper airway
collapse really does not occur only during
inspiration, but also during expiration. Your EPAP acts like CPAP
and stents open the airway, so at the end of
inspiration, the airway is sufficiently patent
to generate inspiration and trigger your IPAP. If your airway
completely collapse, you may not be able to hear your
BiPAP or bi-level ventilation. What are the different
modes of bi-level therapy? The bi-level therapy
can be spontaneous more, which it just, tangos with
the patient’s respiration. It can be spontaneous
and timed more. You can put a particular time. It can deliver the rate. It can be an auto mode, or
you can also set up a volume, tidal volume targeted mode. So it delivers a particular
tidal rather than a pressure. The previous modes
I discussed with you are all pressure based. The volume based
one will assure you that it delivers
a certain volume and automatically
adjusts the pressure. The pressure mode, the pressure
is stable, the volume changes. So again, these are the two
thing, the spontaneous mode, the timed mode. We talked about it. And you can also control
your inspiratory time. So, regarding how to
use bi-level therapy. First, you have to understand
what you’re treating. If you are using bi-level
to treat obstructive sleep apnea alone, because
the pressure on the CPAP are so high, then you just need
a bi-level spontaneous mode. You don’t need an S/T mode. If you’re using a
bi-level therapy in a patient who has
central sleep apnea, and needs a backup rate when
the patient becomes completely apneic, you need to
use bi-level S/T mode, because it can
give a backup rate. Then, based on the
titration study, you can identify what was the
IPAP and what was the EPAP. If you want to augment
your tidal volume, it is important that
you keep enough of an IE difference of the delta. I typically try to keep
a delta of 6 or higher for augmenting your
tidal volume in patients with hypoventilation. But for patients with OSA, at
least 4 and above should be OK. The difference
between IPAP and EPAP is considered pressure support. For example, if somebody has
an IPAP of 12, an EPAP of 6, the pressure support would be 6. That means 6 about the EPAP. Then you use the backup rate,
depending on the patient’s age. We try to keep the
backup rate as close to the normal resting
sleep respiratory rate for that patient at that age. Most of the childrens who
are two years and above tend to have a respiratory
rate less than 20. So we may keep the respiratory
rate between 15 to 20 or sometimes higher
depending on the situation. So this is an example
of how we write. We’d start with
an IPAP of 8 or 4, I:E difference of 4 and above. Then you want to keep
the maximum difference you want to maintain. If you want to maintain the
maximum difference of 10, you are to write in
your prescription during titration study. And the typical maximum
IPAP we use is 30, and the maximum EPAP, we use 20. And beyond that
there is a chances that you may cause more trouble
and becomes very uncomfortable for the patient or
the child to use it. And the respiratory rate
can vary from 8 to 30, depending on the
clinical situation. So, what are the
conditions where you need to use a backup rate? As I mentioned before, somebody
with a central sleep apnea. Or sometimes they may not have
a many central sleep apnea, but intermittently, they are
having this prolonged sleep apnea. Somebody having bradypnea,
that means the respiratory rate during sleep is about three
to four breaths per minute. So those are the patients you
need to use a backup rate. In patients with
neuromuscular weakness, they are just so
tachypneic, they’re taking such a
shallow respiration, they’re ineffective
in ventilating. In that situation, giving
them a backup rate, they tend to ride the
ventilator and tend to maintain the gas exchange. If somebody with a
restrictive lung component, a backup rate may
also be not a bad idea because the inspiratory effort
may be so shallow that it may not trigger a BiPAP. Patient with obesity related
hypoventilation, extremely morbidly obese, tend to
be tachypneic during sleep and also tend to take a
very shallow respiration. So a backup rate may be helpful. And also conditions
such as complex sleep apnea, which is a
mixture of both central and obstruction, and typically
sometimes the centrals may appear after
treating the obstruction. When adequate ventilation
and muscle rest is not obtained with the
maximum pressure support, sometimes when
you’re just keeping on increasing your
pressure support, you’re still not able to
get a good ventilation. You may consider
adding a back up rate. Inspiratory time, we typically
keep between 1.2 to 1.6 second. Depending on the
respiratory rate you choose, the inspiratory time can vary. So percentage of IPAP
time is about 30% to 40%. 30% of IPAP time in
obstructive lung disease and 40% of the IPAP time
for inspiratory time in chest wall diseases. So next, we’re going to talk
about the indication of use of oxygen during non-invasive
positive pressure ventilation. Typically, when somebody’s
awake saturation is less than 88 on room air, those
patients inevitably need oxygen, both
awake and during sleep. But during a CPAP
titration study, when the pressure support
and the respiratory rate has been optimized, and you
eliminated all the obstructive and central events, but
the patient saturation is less than 90% for
about 5 minutes or more, or it is less than
88% persistent for more than 2 minutes, we
will consider adding oxygen. The idea of adding oxygen
is to improve the FiO2 and increase their oxygenation
and hence oxygen saturation while your positive pressure
ventilation has failed to improve oxygenation in spite
of optimizing the respiration. We start with a minimum oxygen
flow at 0.25 liters per minute. And we titrate in 0.25
liters per minute increments to maintain the
saturation about 94 to 96% as requested by the
ordering provider. What are the timings to
follow-up titration sleep studies? That depends on the
underlying conditions and what you’re treating. So once somebody
starts, if somebody gains significant weight,
you have a patient, you started on CPAP, of
say 5 centimeters of water, the patient comes back after
one or two years doing well. And you see that the patient
has gained about 20 pounds or 25 pounds, and now, either
struggling to use CPAP or is snoring while
on CPAP, indicating that he may need more pressure. In that situation,
you may need to do it. In younger children,
like infants, who tend to typically
outgrow it if they don’t have any other craniofacial
abnormalities, you want to repeat
it at a sooner date, between 3 to 6
months to make sure that underlying
respiration has stabilized so you can discontinue the
positive pressure ventilation. Or you see that the
patient is progressive from a neuromuscular
standpoint, you may have to do a retitration
to optimize the gas exchange. And not only the
gas exchange to make sure that the
sleep is stabilized under positive pressure
ventilation hence, the sleep study is very useful. If somebody is using but
his sleepiness and tiredness and other symptoms
of sleep apnea recur while they’re
using, in addition to checking the compliance to
make sure that they’re actually using, before you bring this
patient back to the titration to see that what’s going on. And after surgery,
the patient undergoes a surgical intervention
while on CPAP, you want to repeat four to
six weeks after surgery to make sure the underlying
sleep apnea has resolved so you can stop the therapy. For the BiPAP prescription. You’d like to write the
indication, the goal of the therapy, if you’re
writing for hypoventilation, is to correct carbon dioxide. If the duration of the
therapy is required, typically write lifetime, or
the duration you intend to use. Instruction, is to use
during sleep or naps. Again, machine, make, model. The settings are important,
depending on what mode you use. If you use S/T mode, you’d
like to write the rate. If it is a spontaneous
mode, you can just write the inspiratory
positive airway pressure, which is IPAP, and then EPAP. But typically keep the
delta between 4 to 6. The backup rate if required,
you write rates per minute. Inspiratory time
can be determined based on your indication. Then go for pressure relief,
mask type, humidification, similar to the
CPAP we discussed. And then mask
refills and tubings. So this is a
cartoon which shows, based on the different
modes of CPAP and BiPAP, and underlying
conditions, you can use this in various
respiratory situations. Other points to address. Sometimes, in addition to
treating, you’re treating, not only the respiration
during sleep, you’re also treating
their sleep. You may need some
adjunct medications to help them to tolerate,
if there is anxiety. Mostly in adults
and some teenagers, we may use melatonin to help
them rework with their sleep schedule modification
so that their sleep hygiene is optimized. Sometimes the
third party payers, they want to see that
the patient is actually using the machine. If they don’t use the machine
for more than 3 months, the insurance companies
may take away the machine. In that situation, you may need
to repeat another sleep study, and then give them the CPAP. This tends to be very expensive. Hence, to make your patient
understand all this, and it is, it’s important that
you discuss these things very carefully in the beginning. It’s a glass half full approach. I would accept somebody
tolerating few hours rather than aiming for
eight hours from day one. As they follow up with
you and you work with them with various aspects of
sleep, breathing, machine, and the mask, you maybe achieve
the full glass of compliance and success of therapy. So this is a compliance report. You can see that, based
on the particular date for this patient, this
is each bar indicates that the patient was
using CPAP, and what is the duration of the usage. And it gives you a graph like
that, out of the range of days. For example, in this
situation 129 days. Days with device
used, was 129 days. The days without the
device was 0 days. Hence, the compliance was 100%. And you can also
see the evidence, usage is about 4 hours to
46 minutes in this patient. And it also gives you the
maximum pressure used. It also gives you
the leak and also gives you the residual AHI. That means, in spite
of this patient being on pressure of 8
centimeters of water, you can see at the
bottom, that the AHI, which was still 3 per hour. And that may be acceptable
for older child, adolescent and adults. And for a younger
child, you may have to relook either by
increasing the pressure, so that you can eliminate
these residual obstructions. Types of Masks. There are various masks
used for childrens. And recently there has been
so many masks in the market, it is very important
for us to be familiar. There are only few masks,
which are used for infants, such as Respironics WISP
pediatrics small nasal mask and MiniMe 2. Sometimes we use a
bubble CPAP mask. And people sometimes use
a thick nasal cannula, such as a RAM cannula. In children, there are
several masks available. And teenagers, we use
the smaller vision or the medium version
of the adult masks. This is your Respironics
WISP Pediatric Nasal Mask. It comes with three
size masks in a packet. One is for the infants, one is
for the child, small children, and one is for the teenagers. And this is a fancier
mask, which is very child friendly and only a nasal mask. It has a Velcro
adjusting headgear. These are the other
masks, which are produced by another
company called ResMed. These are Pixi
Pediatric Nasal Masks. These are various
mask mentioned here with the appropriate headgear. Headgear is a very
integral and important part of the CPAP interface. If you don’t select a right
headgear, the mask may be loose and may come off or if it is
too tight it may cause sores. These are also some
of the different masks we use in pediatrics, such as
Nonny Pediatric Nasal Mask. So thank you very much
for listening to me. I hope I have tried to
address some of the issues and some other modes
of ventilations, and if you have any questions,
please send it to me. Thank you. Please help us improve the
content by providing us with some feedback.

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