Every Download Tells a Story. Lizabeth Binns PA-C University of Michigan Sleep Center October 2, 2015

Transcription

1 Every Download Tells a Story Lizabeth Binns PA-C University of Michigan Sleep Center October 2, 2015

2 X Xx Mx X X x X X X X Conflict of Interest Disclosures for Speakers 1. I do not have any relationships with any entities producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients, OR 2. I have the following relationships with entities producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients. Type of Potential Conflict Grant/Research Support Consultant Speakers Bureaus Financial support Other Details of Potential Conflict 3. The material presented in this lecture has no relationship with any of these potential conflicts, OR 4. This talk presents material that is related to one or more of these potential conflicts, and the following objective references are provided as support for this lecture:

3 Objectives Understand features of different CPAP machine downloads Have knowledge of research studies comparing PSG to data downloads Understand what information can be obtained from downloads Analyze downloads and determine if information will assist therapy (case presentations)

4 Before Downloads Are you using your CPAP? Yes How much? Every night and all night Doe it leak? No Are you snoring? No Do you have any apneas? No Ok good. I ll renew your prescription and see you next year.

5 Why CPAP Downloads? Insurance companies require adherence for payment of PAP machines and supplies OSA is a chronic disease that needs to be monitored Downloads can help to resolve treatment problems Provide medical/legal documentation of use

6 Compliance/Adherence Tracking PAP All current machines provide this information Fairly straight forward and usually correct

7 Adherence Tracking Official American Thoracic Society Statement: Schwab, et al March

8 PAP Machines with Compliance Only Resmed S9 Escape Philips Respironics REMstar Plus Philips Respironics DS 150 Devilibiss IntelliPAP Standard Fischer Paykel SleepStyle 234

9 Resmed Escape Compliance

10

11 Philips Respironics Compliance

12

13

14

15 Compliance Tracking problems Software required for most PAP machines Need to establish access/passwords to online software No data card in PAP machine Cards aren t in correctly Patients can t find card or forget to bring in Pap machine says Do Not Remove Card

16 Problems Information for more than one patient on card Dates are wrong Wireless information not transmitting Registry of patient not established to obtain wireless information

17 Advanced Event Tracking PAPs Philips respironics REMstar Pro (M Series, System One 60 Series) Resmed Elite (S9, Air Sense 10) Generally Auto PAP Resmed Escape (AHI only) BiPAPs, VPAPs, ASV, AVAPS Fisher Paykel Icon Devilbiss IntelliPAP Plus

18 Data Software Philips Respironics Encore Pro SP Philips Respironics Encore Viewer Patient Resmed AirView and Rescan SP Resmed MyView Patient Fisher Paykel InfoSmart Both Devilbiss SmartLink Therapy Management Both SleepyHead Free, open source

19 Advance Tracking Uses Track progress and performance over time most useful Spot potential problems Measure therapy after making changes mask, pressure, chin strap, or positional therapy

20 Advanced Event Tracking Limitations Proprietary information Varies among companies No set standards Summary provides average over time look at detailed data AHI measured with pneumotachograph (lacking nasal pressure, thermistor, EEG, thoracoabdominal belts or oximetry)

21 Remember! DME will receive same reimbursement for compliance or advanced detection PAP When ordering PAP machines if you want advanced data be sure to request it.

22 Advanced Event Detection PAP AHI Leak Vibratory Snore RERA Periodic Breathing

23

24

25

26

27

28

29

30

31

32 Sleepy Head Software Free downloadable software Window, Mac OS and Linux Not web based Clinic use notes, reports, office name, patient account numbers Resmed S9 and 10, PR System One, FP Icon and Devilbiss IntelliPAP Oximetry and breath by breath analysis

33

34 Event Detection Official statement of the ATS, March

35 Event Detection Anytime flow meets manufacturer s definition scored as event Lacking EEG or pulse oximeter (some have capability)

36 Clear Airway Apneas No way to determine effort Some PAPs do not distinguish between Obstructive and Central Apneas - AI APAPs drove need to develop algorithm for pressure induced central apneas Early APAP did not increase pressure for CA above 10 cm Respond to OA and ignore CA

37 Clear Airway Apneas Resmed and PR use different algorithm to test patency of airway Resmed Forced Oscillation (many small oscillations) Philips Respironics Pressure Pulse (Two 2 cm quick bursts of increased pressure)

38 Unknown Apneas Leak greater than 30 L/min Resistance not known PAP can t differentiate between OA and CA

39 Leaks

40 Resmed leak Detection Large leak greater than 24 L/min nasal mask (36 L/min FFM) Mr. Red Frowny Face leak rate high 30% or more of the time

41 Philips Respironics Leak Depends on model of PAP Depends on pressure - <10 cm large leaks flagged earlier than > 10 cm Depends on mask used

42 Leak Significance PAP may be unable to maintain therapeutic pressure PAP may be unable to track breathing -PAP measures subtle changes in back pressure - Large leaks cause signal noise - Disturbs flow rate data making scoring of apnea/hypopneas impossible

43 Snoring/Vibration No microphone (sensitive to mask and fans) Resmed amplitude and frequency of oscillations in flow rate curve. Assigns a snore number PR System One Only in Auto-Mode, time stamp but no amplitude PR increases by 1 cm until leak stops or max pressure

44 RERAs Philips Respironics System One Auto mode only Proprietary algorithm based on statistical analysis of wave flow for RERA on PSGs

45

46

47

48 2010 Study 70 patients comparing Resmed S8 AutoSet to manually scored PSG Apnea > 75% reduction in airflow. Hypopnea >50% reduction Mean AHI Mean AI PSG S8 Journal of Clinical Sleep Medicine, Ueno, K et al 54

49 Study Conclusions Greater severity of OSA on baseline study and mask leak increased difference between S8 and PSG Mouth breathing caused decrease in airflow and increased AHI on S8 Central apneas weren t detected with confidence on S8 Suggested <10 AHI might be acceptable

50 2011 Study-Respiratory Event Detection by a PAP Device Compared AED algorithm with PSG Resmed Auto M Series modified to identify apneas on PSG 119 subjects (29 put on sub-therapeutic to increase data available) Sleep, Berry, RB et al 56

51 Study Conclusions AED overestimated AHI when PSG scored low AED AHI <10 highly predictive if PSG <10/hr AED AHI >10 moderately predictive if PSG >10/hr Good agreement on obstructive apneas but less for hypopneas

52 2012 Study: Predictors and Accuracy of Data Download 190 subjects on Resmed AutoSet Spirit 6-16 cm water titrated on Auto-CPAP High AHI on diagnostic study less accurate AHI on Auto-CPAP Poor correlation between PSG and APAP measures of hypopneas at therapeutic level SLEEP, Huang, HC, et al 58

53 2015 Study: Detection of Upper Airway Status and Respiratory Events 45 subjects with events scored on PSG OSA and Complex Sleep Apnea on Philips Respironics REMstar System One Auto AHI on AED tended to overestimate on PSG with events < 10/hr AED detected detected airway obstructed 87.4% of PSG apneas Clear Airway apneas (15.8%) scored as OA AED<10/hr strong evidence of good treatment, not good with specific type of event Sleep. 2015,April 1. Qy, L., et al 59

54

55 ATS Conclusions Usage reliably determined Residual events difficult to interpret due to difference among manufacturers Very low or very high values appear to be clinically meaningful Need to understand different definitions from each manufacturer Should have standardized nomenclature on tracking systems

56 ATS Research Strategies Needed Which PAP system is most accurate? What is clinically significant leak threshold? What is usefulness of vibratory snoring, periodic breathing, RERA? What are medical/legal ramifications of interpreting data downloads and using to make treatment decisions?

57 Artic Explorer 54 M 2007 PSG AHI 31, 10 obstructive, 140 hypopneas, 5 central apneas 2008 BiPAP 15/8 Retitrated to 18/12

58

59

60

61

62

63

64

65

66

67 High Altitude on ASV

68

69 High Leak

70 Ramping to fix leak

71

72 Dehn

73 ASV Dilemma 82 F PSG AHI 44.6, mostly hypopneas, 3 centrals PAP (9/4/2013) Complex Sleep Apnea Recommended ASV Max 25, EPAP max 18, EPAP min 12, PS max 7 and min 0 cm water

74

75

76

77

78

79

80 BiPAP ST

81

82

83

84

85

86 Leak after bathroom break

87

88 Ice Cream is Best!

89

90

91

92 P N F N FL

93 Defective CPAP

94

95

96

97 Malfunctioning CPAP

98

99 I really didn t take my neighbor s CPAP!

100

101

102 I really did use it!

103

104 Wrong Pressure/Compliance

105

106

107

108

109 Wrong pressure/right pressure PSG 4/24/ O2 sat min -70% BiPAP 22/19 cm water Never could use BiPAP, referral from cardiologist

110

111

112

113

114

115

116

117

118 I Share My CPAP

119

120 Multiple Personality PAP

121 Positional/REM data

122 9/20/2015

123 9/21/2015

124 9/22/2015

125 9/23/2015

126 9/24/2015

127 9/25/2015

128 9/26/2015

129 Why did I want a new CPAP? Difficulty using Auto-CPAP 5-9 cm water Wants quiet machine

130

131

132

133

134

135

136

137

138

139

140

141 What s wrong with alcohol if I use my CPAP?

142

143

144

145

146

147

148

149

150 Comparing Home Study to Data Download Downloads showing obstructive apneas Wife reporting no snoring and apneas had lack of chest wall movement

151

152

153 Steps for viewing data Verify name and dates Make sure PAP machine matches to what was ordered Verify pressures Look at compliance and summary data Then look at detailed data that tells more of the story Listen to the patient to obtain most of the story!

154 Homer has Narcolepsy?

155 Thank You!