BTS Sleep Course. Module 10 Therapies I: Mechanical Intervention Devices. (Prepared by Debby Nicoll and Debbie Smith)

Transcription

1 BTS Sleep Course Module 10 Therapies I: Mechanical Intervention Devices (Prepared by Debby Nicoll and Debbie Smith) S7: Patient monitoring and review Aims Where problems can occur Clinic review protocol How you assess the patient Managing problems Follow up & ongoing maintenance Hypoventilation / overlap syndrome

2 Patient monitoring and review AIMS are to:- Monitor the patient s use and therapeutic effect at prescribed intervals i.e. follow up clinics Evaluate response to treatment Manage problems associated with CPAP use Make recommendations for continuation or change in mode of treatment

3 Patient monitoring and review WHERE PROBLEMS CAN OCCUR Initial CPAP set up Addressed at CPAP induction session First few nights at home Telephone support via Sleep Nurses Booklets and written information, Q & A Other CPAP users (Support Group/ helplines) SATA First few weeks Access to clinic Routine clinic review Ad-hoc appointments Longer term problems and maintenance issues

4 Clinic review protocol How you assess the patient Place patient s CPAP trial in context with patient s notes Today s weight Today s ESS? still snoring Compliance since last visit State of equipment!!!

5 Clinic review protocol Place patients CPAP trial in context with patient s notes Original diagnosis assess severity of OSA Original ESS assess level of sleepiness What was the aim of CPAP? If clinician was unsure, there may not be a response to CPAP?Borderline / diagnostic Any relevant past medical history or current medical problems Presence of concurrent COPD or morbid obesity (patient may be at risk of developing respiratory failure due to Overlap Syndrome)? Previous machine compliance hours Previous weight

6 Clinic review protocol Check weight (? any significant increase or decrease) If significant increase, re-measure neck size and check for control of symptoms as pressure may be inadequate. Try increasing pressure by 2cms H 2 0 or a period on auto-titration to assess compliance / leak If significant decrease, pressure could be lowered (although not essential) If very significant decrease, re-measure neck size and consider whether CPAP is still required. Trial off CPAP, oximetry following *3 nights without CPAP or sleep study following 3 nights without CPAP

7 Clinic review protocol Check ESS and assess any change in level of sleepiness ESS Total score of 9 or below is considered normal Ask patient for situational examples demonstrating change in sleepiness Assess whether partner, family, friends, work etc. have noticed any change Observe patient s level of alertness during interview Is it a problem that needs addressing?

8 Clinic review protocol ESS low, good compliance & no snoring (ESS < 9 and Compliance >4hrs/ night) ESS high, poor compliance & snoring Problems using CPAP

9 Clinic review protocol If continuing snoring is a problem? (ask partner if present)? Losing pressure Check for significant mask or mouth leak try chin strap or full face mask If no significant leaks then pressure may not be adequate Increase pressure & review in 2 4 weeks If not sure, assess symptom control, may need auto-titration to confirm OSA control

10 Clinic review protocol Assess compliance Note hours from compliance meter on machine & calculate usage in hours per night (manually or using a database programme) Minimum of 4 hours per night can be used as a general guide for most patients? Is input required to try and increase compliance? Discuss optimal usage and usage strategies

11 Clinic review protocol Compliance monitoring cont. Older style machines only have machine running time not actual mask on time? The future is smart cards which most manufacturers now incorporate into their machines store patient information & machine usage data. Patient can either send the card off to the company or take it into their sleep unit for reading of the results Appropriate adjustments can then be taken & a plan of care and follow up arrangements made

12 Patient monitoring and review DVLA Patients diagnosed with OSA who had significant daytime sleepiness prior to treatment should have informed the DVLA. They are also advised to inform their insurance company after DVLA have responded. If sleepiness is controlled by CPAP then they can recommence driving. This applies to both group 1 and group 2. If patients are continuing to experience daytime sleepiness, they should not drive. Sign and document in notes.

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14 Managing problems on CPAP treatment

15 Managing problems on CPAP treatment Excessive Sleepiness Mask problems Is the pressure adequate? Mouth leak Nasal problems Psychological problems

16 Managing problems on CPAP treatment If Excessive Sleepiness is a problem:- Check compliance Check for mask / circuit leaks Check machine still set and functioning at correct pressure Check for mouth leaks? Auto-titration machine to check pressure adequate (1 7 nights) Overnight oximetry to check existing pressure controlling OSA Consider medical review to assess other causes of sleepiness (e.g. PMLS, depression, medication). Use of a sleep diary could be useful Poor sleep hygiene Could sleepiness be due to another cause(s) e.g. stress, depression, shift work, change of lifestyle or sleeping habits Advise not to drive if sleepy (see DVLA regulations)

17 ESS high and compliance good Pressure inadequate Depression PLMS Pain Sleep disturbance other cause Medication Shift work ESS low and compliance poor? Significant weight loss Check collar size Repeat sleep study / home oximetry Objective sleepiness test Patient lying!

18 Are there any mask problems Poor fit Discomfort / bruised, red, broken skin Barrier /antiseptic cream Check fit, re-adjust headgear Mask leak / part missing? Check mask, size & fit, provide alternative. Check cleaned correctly? greasy Eye problems Solutions Forehead adjuster Alternative seal Alternative mask Nasal pillow type Oral interface Full face mask Consider dental appliance Alternate masks while affected area heals

19 Is the pressure adequate? Snoring controlled? Mask problems & Mouth leak? If snoring and no leak raise pressure by 2 cm water Overnight oximetry Auto-titration machine

20 Other Problems Mouth leak (blowing through lips/dry mouth and throat) Common post UVPPP Check nasal patency advise / change nasal sprays if required Chinstrap Full face mask Heated humidifier Nasal problems (Sneezing/rhinitis/nasal congestion) May be due to mouth leak increasing air flow via nose dries & damages nasal mucosa Chin strap Increase room temp & humidity Nasal sprays Heated humidifier Full face mask

21 Other Problems Psychological problems Patient is claustrophobic, anxious, panicky Dislike mask on face Difficulty breathing through nose Difficulty tolerating pressure Give reassurance and make time, *change mask, advise use of ramp, reduction or increase in the pressure. Encourage partner / carer to attend Offer support from other CPAP users / patient support groups If appropriate, refer to a counsellor

22 Follow-up & ongoing maintenance If the patient has on-going problems, book nurse / technician or medical follow-up clinic appointments as required Correspondence and reporting Ensure letters are sent to the appropriate persons and filed in patients notes e.g. GP, referring clinician, reporting clinician, carer if applicable. Respect usual confidentiality and legality guidelines.

23 Follow-up & ongoing maintenance Generally patients need replacement mask, tubing and headgear annually Equipment can be sent via the post or the patient attends an annual clinic appointment depending on *Trust policy? Machine servicing annually * depending on Trust policy

24 OSA COPD Obesity 1 = LOW RISK VENTILATORY FAILURE 2 = MODERATE 3 = HIGH RISK

25 Obesity hypoventilation syndrome / overlap syndrome Is the patient at risk? Morbidly obese History of smoking COPD Check for symptoms of hypercapnia Dusky / ashen colour in morning Morning headache Morning confusion Ankle swelling Check SaO2 If < 93% (and symptomatic), capillary/arterial blood gases. Useful to have baseline SaO2 for comparison. If hypercapnia present Consider NIV

26 Patient monitoring and review NIV users - The same applies as for CPAP patients but in addition:- Check oxygen saturation (pulse oximeter) and compare with patients usual saturation If Sa O 2 low and / or return of sleepiness, morning headaches, ankle swelling, increasing SOB check all equipment & consider other causes as for CPAP patients Consider overnight oximetry If concerned, discuss with doctor and consider blood gases (ear-lobe or ABG) and? admit to chest ward. Consider spirometry If no problems, review patient 6 monthly in routine clinic for machine servicing & replacement of any equipment