by Helen Schaar Corning RRT, RCP RC Educational Consulting Services, Inc. 16781 Van Buren Blvd, Suite B, Riverside, CA 92504-5798 (800) 441-LUNG / (877) 367-NURS www.rcecs.com
BEHAVIORAL OBJECTIVES UPON COMPLETION OF THE READING MATERIAL, THE PRACTITIONER WILL BE ABLE TO: 1. Explain the most common sleep disorders, including obstructive sleep apnea (OSA). 2. List the indications and the contraindications for home CPAP. 3. Describe the benefits of CPAP for treatment of OSA. 4. Identify safety precautions for home CPAP. 5. List the most common controls on home CPAP devices. 6. Explain how the ramp setting operates. 7. Describe how to utilize Auto-CPAP. 8. Summarize the benefits of C-Flex with CPAP. 9. Explain how the memory card is beneficial when used with CPAP machines. 10. List ways patient comfort and compliance can be improved for those using home CPAP machines. COPYRIGHT 2005 BY RC EDUCATIONAL CONSULTING SERVICES, INC. TX 6-008-654 AUTHORED (2005) BY HELEN SCHAAR CORNING, RRT, RCP REVISED (2009) BY HELEN SCHAAR CORNING, RRT, RCP ALL RIGHTS RESERVED This course is for reference and education only. Every effort is made to ensure that the clinical principles, procedures and practices are based on current knowledge and state of the art information from acknowledged authorities, text and journals. This information is not intended as a substitution for diagnosis or treatment given in consultation with a qualified health care professional. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 2
TABLE OF CONTENTS INTRODUCTION... 4 SLEEP DISORDERS... 4 CENTRAL SLEEP APNEA... 5 MIXED SLEEP APNEA... 5 OBSTRUCTIVE SLEEP APNEA (OSA)... 5 TREATMENT... 6 INDICATIONS FOR HOME CPAP... 7 CPAP CONTRAINDICATIONS AND CAUTIONS... 8 BASIC HOME CPAP MACHINE SETTINGS... 11 HOME CPAP MACHINE GENERAL SPECIFICATIONS... 12 RAMP SETTINGS... 13 AUTO-CPAP OR AUTO SMART CPAP MODE... 14 C-FLEX MODE... 16 THE CPAP MACHINE MEMORY CARD OR SMART CARD... 17 CONCLUSION... 17 SUGGSTED READING AND REFERENCES... 18 This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 3
INTRODUCTION There are many types of sleep disorders including: obstructive sleep apnea (OSA), central sleep apnea, restless leg syndrome, and narcolepsy, to name a few. Home CPAP machines are one of the treatment options available for OSA. The use of home CPAP machines is steadily increasing as more and more patients are being diagnosed with obstructive sleep apnea. Physicians and other healthcare professionals have become much more educated over the past decade about sleep disorders including obstructive sleep apnea. There now exists extensive educational data available for clinicians to better understand sleep disorders. There has also been a lot of progress in treatment for sleep disorders, including technically-advanced home CPAP machines. These machines have more options, and more settings, and they are more comfortable for the patient. Thus tolerance and compliance is improving. This course concentrates on the newest modes available on home CPAP machines used to treat obstructive sleep apnea. The newer modes include Auto-CPAP and C-Flex. The ramp setting and memory cards are also discussed. A brief overview of sleep disorders is included, plus general home CPAP machine operation. A basic understanding of home CPAP machines is assumed. The target audience is respiratory therapists, polysomnography clinicians, and nurses who work with patients using home CPAP machines. SLEEP DISORDERS An estimated 40 million people suffer from some type of sleep disorder every year. 1 A sleep disorder can be a physical condition, a psychological condition, or a combination of the two. For those suffering from sleep disorders, sleep is disrupted repeatedly resulting in sleep deprivation. There are many types of sleep disorders, which will be discussed in this course. Accurate diagnosis of the type of sleep disorder usually requires polysomnography testing. Sleep disorders include: Insomnia Hypersomnia Narcolepsy (Isolated Sleep Paralysis) Nocturnal Myoclonus (Restless Leg Syndrome or RLS) Nightmares, Night terrors, and Sleepwalking Sleep Apnea: Obstructive, Central, or Mixed This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 4
The signs and symptoms of a sleep disorder occur during the day due to these abnormalities that occur during sleep. The recognizable symptoms that occur during the day are in Table A. 2 Table A: Daytime Symptoms Of A Sleep Disorder Hypersomnolence Lessened alertness Shortened attention span Inability to concentrate Inability to focus Confusion Irritability Headaches Memory loss Hallucinations Central sleep apnea is a neurological disorder in which the brain fails to signal the muscles to breathe. During sleep, there is cessation of respiratory effort and thereby cessation of breathing. The apneic episode may last from a few seconds, to two minutes or longer. This is a rare disorder, and different from OSA. Central sleep apnea is contributed to the mechanisms that control breathing located in the thalamus area of the brain. Central sleep apnea can also be caused by primary brainstem medullary depression, a tumor of the posterior fossa, poliomyelitis, or idiopathic central hypoventilation. In OSA there is an airway obstruction causing the sleep apnea. In central sleep apnea the airway is clear, but the chest muscles and diaphragm stop working due to no signal from the brain to breathe. Eventually the lowered level of oxygen in the blood signals the brain to awaken the sleeper so he or she will restart breathing. The accumulated sleep deprivation has detrimental effects as listed in Table A. The treatment for central sleep apnea includes antidepressant drugs and low level oxygen therapy via nasal cannula during sleep. CPAP therapy has been tried for patients with central sleep apnea with mixed results. Some patients experience less episodes of sleep apnea while on CPAP, some display no improvement, some experience more frequent episodes of sleep apnea. Mixed sleep apnea is a combination of central and obstructive sleep apnea. This is a rare disorder. Mixed sleep apnea can occur initially as central sleep apnea, compounding to an obstructive apnea if the airway is also blocked after the brain has signaled to breath. The therapy is a combination of therapies for central and obstructive sleep apnea. OBSTRUCTIVE SLEEP APNEA (OSA) f the three types of sleep apnea, obstructive is the most common form. Obstructive sleep apnea (OSA) affects an estimated 5 in every 100 people. 1 Physical abnormalities are the Omain causes of OSA. Causes include being overweight, excessive fatty deposits in the This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 5
airway, excessive pharyngeal tissue, an overly large tongue, and a congenitally small airway. OSA most commonly affects overweight, middle-aged men. OSA also affects overweight women, though to a lesser degree. The main problem is excessive soft tissue in the airway restricting the flow of air. OSA is a life-altering and life-threatening condition that occurs when a patient stops breathing repeatedly during sleep due to airway obstruction that prevents air from entering the lungs. Sleep is repeatedly disrupted by apneas, which deprive the patient from reaching the deeper stages of sleep they need. The apneas can occur more than 20 times per hour. Without obtaining normal sleep, cycling through the needed sleep stages, these people are left feeling daytime sleepiness most or all of the day. Hypersomnia and the other daytime symptoms listed in Table A affect the daily lives of these people. If left untreated, sleep apnea can cause high blood pressure and heart problems. Ultimately, the patients quality of life is adversely affected. In obstructive sleep apnea, the obstructed airway blocks airflow. As the effort to breathe increases, and the diaphragm and chest muscles work harder. Oxygen levels fall, blood pressure rises, and the heart can beat irregularly or even pause for several seconds. At every incidence of stopped breathing, the person must awaken momentarily to resume breathing by activating the throat muscles to open the airway. A person with sleep apnea stops breathing for a time period ranging between 10 seconds and 3 minutes, and this occurs repeatedly during sleep. For a diagnosis of sleep apnea, each episode of abnormal breathing must be at least 10 seconds and occur at least 5 times per hour during sleep. This is referred to as the Respiratory Disturbance Index (RDI). Most signs and symptoms occur during the daytime hours. One prominent nighttime sign of OSA is loud snoring due to a narrowed airway. Though many sleep apnea patients snore, not everyone who snores has sleep apnea. There are many other causes of snoring. Snoring is a noise produced when the uvula vibrates during breathing, from efforts to force air through the narrowed airway. Sleep apnea can also occur in children. In infants, sleep apnea has been linked to Sudden Infant Death Syndrome (SIDS). In older children, sleep apnea occurs as a result of being overweight, or, having very large tonsils and adenoids. Signs in children include snoring, squeaking, thrashing, and excessive sluggishness during the day. Snoring is never normal in a child and should be reported to a physician. A tonsillectomy can be performed to alleviate the problem for children where enlarged tonsils and adenoids are the problem. Weight loss is the solution if the child is overweight. Treatment for adult OSA depends on the type and severity of apnea. The most common treatments for OSA include weight loss, CPAP therapy during sleep, oral appliances, and corrective surgery. Weight loss and CPAP therapy are among the top remedies prescribed by physicians. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 6
Medications that work as respiratory stimulants can relieve sleep apnea in some patients. These drugs include certain antidepressants and certain asthma drugs. Oral appliances are successful for some patients. These oral appliances work by propping the airway open by moving the jaw, tongue, and soft palate forward. Surgery is an option to correct physical abnormalities. Uvulopalatopharyngoplasty (UPPP) removes excess tissue at the back of the throat. The UPPP is not always successful at relieving sleep apnea, and there are negative side effects. Somnoplasy is a non-invasive procedure that uses low power and low temperature radio frequency energy to reduce the size of an enlarged tongue. Sometimes multiple treatments are necessary. This is performed at the physician s office with local anesthesia, and successfully relieves sleep apnea in some patents. One last resort is tracheostomy, and is only used for severe cases of sleep apnea when all other treatments fail. In this case the trach is usually capped during the day, and uncapped for sleep to bypass the obstruction in the upper airway. INDICATIONS FOR HOME CPAP Continuous Positive Airway Pressure (CPAP) is a spontaneous mode of ventilation that provides a positive airway pressure throughout inspiration and expiration, keeping the baseline pressure above atmospheric at all times. The continuous positive pressure provides a pneumatic splint that opens obstructed airways in many OSA patients. The primary indication for home CPAP is for the treatment of adult Obstructive Sleep Apnea (OSA). CPAP has become one of the primary medical therapies to treat OSA. Weight loss is also a first choice remedy if excess weight is the main problem. However, weight loss attempts are sometimes unsuccessful. Also, the time required to lose the excessive weight may be quite lengthy; many months or even over a year. When weight loss attempts are unsuccessful, or if the necessary weight reduction will take a long time, CPAP therapy can be utilized. The appropriate level of CPAP to treat OSA can best be determined by titration performed in a sleep laboratory with polysomnography testing. For the majority of patients, OSA is eliminated with CPAP pressures ranging between 7.5 cm H 2 O and 12.5 cm H 2 O. 2 CPAP has many other indications unrelated to OSA. CPAP is an appropriate mode of ventilatory support for patients who have adequate spontaneous ventilation, but suffer from persistent hypoxemia due to physiological shunting. By keeping the airway pressure above atmospheric throughout the breathing cycle, CPAP improves oxygenation by restoring or elevating the patient s functional residual capacity (FRC). CPAP is also used to treat cardiogenic pulmonary edema and atelectasis. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 7
A Home CPAP Machine Courtesy of ResMed and Excel Home Care Supply CPAP CONTRAINDICATIONS AND CAUTIONS The following pre-existing conditions may contraindicate the use of CPAP. 4 Pneumothorax Bullous lung disease Pathologically low blood pressure Bypassed upper airway Pneumocephalus Head trauma Abnormality of the cribriform plate Cerebral spinal fluid leaks Infection of the sinus or middle ear (usually indicates temporary discontinuance of CPAP until the infection is cleared). The following are warnings, cautions, and safety instructions for CPAP machines: The CPAP machine is not indicated for life support. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 8
The adult CPAP devices are not indicated for use on infants or children. The patient/family must be instructed on safe and proper operation of the equipment and accessories. The patient/family must be instructed on the proper cleaning and maintenance to be performed on a regular schedule. This is most important for those using a humidifier, as the cleaning process involving the circuit and mask must be done frequently, every other day in some cases. For those not using a humidifier, cleaning may be as simple as wiping the mask daily and cleaning or changing the circuit semi-annually. The CPAP device itself usually only requires wiping with a damp lint-free cloth regularly. The filter(s) must also be cleaned and/or changed on a regular schedule. One should follow the manufacturer s instructions and institution s guidelines for cleaning and maintenance schedules for the CPAP machines. When the CPAP is operating at low pressures, some of the exhaled CO 2 can remain in the mask and be inhaled. To minimize the risk of rebreathing CO 2, verify that exhalation ports are present, open, and clear to exhaust CO 2. Also, instruct the patient the device should be turned on as soon as the mask and headgear are placed on. Do not use the mask and headgear for more than a minute while attached to the circuit if the CPAP device is not on. Also, always use the manufacturer recommended accessories. There should be no smoking in the same room as the CPAP machine. Preferably there should not be any smoking in the home. A fire hazard exists, especially if the patient is using supplemental oxygen. Cigarette smoke can also deteriorate the device due to tar buildup within the CPAP machine, resulting in malfunction. The CPAP machine should be located away from heating and cooling devices. Assure the filters and vents of the CPAP device are not blocked by bedding, curtains, walls, or anything else. The air must flow freely around the device in order for it to function properly. With mask CPAP, pressure necrosis on the face and gastric insufflation are potential problems. The patient should report to the clinician or physician if these problems occur. The patient should report any problems related to nasal mucosal dryness. A humidifier can be added to the CPAP device to remedy the situation. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 9
A Home CPAP Machine Courtesy of ResMed and Excel Home Care Supply General safety and efficient operation of the CPAP machine can be assured by following regular cleaning and maintenance schedules as recommended by the equipment manufacturer and the clinician s employer. This also includes changing filters regularly and inspecting the electrical cord periodically for safety. Part of the cleaning maintenance is performed by the patient/family, while the more technical maintenance is performed by the clinician. The clinician must also visit on schedule to assure the equipment is being used, maintained, and cleaned properly. The patient and/or family/caregiver must be thoroughly instructed on the safe and proper use of the device and accessories. They also must understand the equipment cleaning and maintenance schedule and be able to perform their part of this process. They must be oriented to the device and given both verbal and written instructions about the device. They should be notified of all the precautions, warnings and safety instructions listed above. They should also have a number to call whenever they have questions or problems. Nasal CPAP Mask With Headgear Courtesy of Excel Home Care Supply This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 10
Nasal Pillows With Headgear Courtesy of Excel Home Care Supply NasalAire Courtesy of Excel Home Care Supply BASIC HOME CPAP MACHINE SETTINGS Settings are programmed into the CPAP machine by the clinician according to physician s orders. Most settings should not be changed by the patient, unless they are instructed to change settings by the physician/clinician. (An example is the C-Flex setting, which patients are sometimes instructed to adjust for comfort). Most home CPAP machines come with a safety feature built-in that minimizes or eliminates the possibility of a patient accidentally changing settings, just by pressing buttons on the machine. One common safety feature is to press two certain buttons on the CPAP machine while simultaneously plugging the electric cord into the machine. This is sometimes the only way to enter the setup mode and change settings. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 11
The control buttons found on most home CPAP machines include: On / Off Ramp described in the next section. Humidifier this is an option that can be used to reduce nasal irritation and dryness by adding moisture (and heat if needed) to the airflow. Alarm silence Disconnect or low pressure alarms are available on most CPAP machines. These alarms are sometimes disabled (due to the annoyance factor) for home CPAP patients using nasal masks or nasal pillows. In case of disconnect or low pressure, the patient is still able to breathe through their mouth. Whenever in doubt, alarms should be enabled. Patients with full face masks should always have audible alarms enabled for safety. Most CPAP devices also have an alarm setting for machine malfunction that cannot be deactivated. Depending on the equipment, the screen may also display a message like system error #. If this occurs, instruct the patient to reset the device. This can be done by turning off and unplugging the machine; wait 15 seconds, then plug it back in and turn it back on. A different electrical outlet can also be tried. If the system error alert alarms again, the patient should contact the home care clinician. If applicable, the patient should write down the system error # displayed. If the error cannot be immediately corrected, the patient should not use the CPAP device. The home care provider should replace the CPAP device with one that is operating properly and the malfunctioning machine must be serviced. Two buttons for changing settings. Sometimes represented by arrow keys. The clinician uses these two buttons for programming settings into the CPAP machine. Options here include setting the ramp, CPAP pressure, Auto-CPAP pressure range, C-Flex, and alarms. Most CPAP machines have a small visual display area. The CPAP level and other settings can be viewed there. Oxygen can also be added to the CPAP if required. HOME CPAP MACHINE GENERAL SPECIFICATIONS The general specifications for most home CPAP machines are listed here. These specifications represent a compiled average of specifications from CPAP machines with similar characteristics. 2,3,4,5,6 Size of device: About 10 (L) x 6 (W) x 5 (H) Weight: 3.5 to 5 pounds Pressure range: 4 cm H 2 O to 20 cm H 2 O This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 12
Maximum flow: About 35 LPM Ramp: Pressure drops to between 4 cm H 2 O and set CPAP. Set pressure reestablishment time ranges from 5 to 45 minutes Auto-CPAP range: Minimum setting between 3 cm H 2 O and a point just below the maximum CPAP level. Maximum setting between the minimum pressure and 20 cm H 2 O C-Flex settings: 1, 2, or 3 expiratory pressure relief. Setting of 1 gives the least relief, and setting of 3 gives the greatest relief Operating temperature: 40 to 95 degrees F Storage temperature: 0 to 130 degrees F Humidity range: 18% to 90% non-condensing Maximum alarm sound pressure level: 30dB AC power consumption: 100-240 VAC, 50/60 Hz, 1.0 A max (Most home CPAP machines can also be operated using a DC power cord, enabling operation through a stationary recreational vehicle, motor home, or boat. A DC battery adapter cable enables the device to be operated with a free-standing 12 VDC battery. RAMP SETTINGS The ramp is a comfort setting that can be used with CPAP. The ramp allows the patient to press a button that causes a temporary decrease in pressure. This lower airflow pressure allows the patient to fall asleep more easily. The pressure then gradually builds up over a time period to the prescribed CPAP pressure. The patient can press the ramp button as often as they wish. It is usually used when the mask is first put on, so the patient has a low CPAP level to start. Many patients can fall asleep much easier while the CPAP is at low pressure, then the pressure gradually builds back up to prescribed level after they are asleep. For example, a patient may have a prescription for CPAP of 10 cm H 2 O. The ramp can be set by the clinician to start at 4 cm H 2 O, and build up to 10 cm H 2 O over a 30 minute period of time. Each time the patient presses the ramp button, the pressure will drop back to 4 cm H 2 O. The pressure will then gradually increase to 10 cm H 2 O over 30 minutes. The pressure will remain at 10 cm H 2 O until the machine is turned off, or until the ramp button is pressed again. With a physician s order, the clinician can set the ramp to whatever is comfortable for the patient. The lowest available ramp pressure is 4 cm H 2 O on most machines. The ramp time is generally adjustable between 5 and 45 minutes in 5-minute increments. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 13
Auto-CPAP Machine With Humidifier Courtesy of ResMed and Excel Home Care Supply AUTO-CPAP OR AUTO SMART CPAP MODE The Auto-CPAP mode also called Auto Smart CPAP 6 delivers continuous positive airway pressure (CPAP) that is automatically adjusted to meet the patient s needs. The Auto-CPAP can be used to facilitate sleep studies and help determine the most appropriate CPAP level for the patient. It can also be used in a split-night study. In a split-night study, a low CPAP level is used for a prescribed period of time, after which Auto-CPAP mode is activated and remains on for the remainder of the night. An Auto-CPAP system works by monitoring the patient s airway and automatically delivers the appropriate therapeutic pressure. The patient receives the minimum pressure needed to prevent sleep apnea. The pressure adjusts to the patient s changing needs throughout usage time, and adjusts automatically to changes in sleep positions and sleep stages. This mode can also compensate for mask leaks. The typical pressure range is between 3 and 20 cm H 2 O with preprogrammed minimum and maximum pressures suitable for each patient. The unit identifies the ideal pressure needed to splint the airway open at any given point in time. The unit responds to changes in the airway, and compensates for leaks that typically occur during a typical night s usage. Clinicians use this technology as a tool to automatically adjust pressures (automatic titration) or to vary pressure settings over time. The auto-titrating CPAP machines are flowbased, leak tolerant devices that utilize algorithms and multiple parameters to actively identify and provide the ideal pressures. Flow patterns are analyzed to determine when a change in pressure will benefit the patient. Auto-CPAP levels are programmed into the CPAP device by the clinician as prescribed by the physician. Minimum and maximum CPAP levels must be set. For example, with a minimum Auto-CPAP of 8 cm H 2 O and a maximum Auto-CPAP of 12 cm H 2 O, the CPAP machine will automatically adjust pressure between 8 and 12 cm H 2 O throughout the usage time. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 14
The minimum available setting for Auto-CPAP pressure is between 3 cm H 2 O and a point just below the maximum CPAP level. The maximum available setting for Auto-CPAP pressure is between the minimum pressure and 20 cm H 2 O. Auto-CPAP or Smart CPAP machines with automatic titration are good devices for patients with challenging breathing patterns, because of the highly sophisticated algorithms. Most have a pneumatic sensor, while others have a hall-effect sensor. Both sensors have proven track records of excellent patient sleep-event analysis. Design objective is to dynamically get the pressure back down to the lowest suitable level, as soon as the data sampling and conversion and mathematical algorithm will allow. This design to always give the lowest required pressure, gives the benefit of a lower mean pressure. Auto-CPAP also cuts down the need for additional titrations of CPAP level at a sleep laboratory. With regular CPAP, a patient may need to go for another overnight sleep study to re-titrate if their pressure needs change. Alternately, when a patient s needs change, Auto-CPAP or Smart CPAP can be utilized to assess the ideal CPAP level. The CPAP levels used and the duration of time at various settings throughout the night are recorded on a computer chip or card (smart card described later). This recording can then be analyzed by the physician to determine the most appropriate CPAP setting for the patient. CPAP Machine With C-Flex And Mask Courtesy of Respironics and Excel Home Care Supply This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 15
C-FLEX MODE C-Flex is designed to increase patient comfort for those using CPAP therapy. 5 C-Flex provides a very brief drop in pressure during exhalation that allows the patient to exhale more easily. C- Flex tracks each breath and delivers variable pressure relief only at the beginning of each exhalation, and quickly returns to the prescribed CPAP pressure. C-Flex ranges from 1 which is a small amount of pressure relief, to 2 which is a moderate amount of pressure relief, to 3 which is the greatest amount of pressure relief. C-Flex tracks and reacts to every patient breath throughout the usage time. The device has the ability to adjust the C-Flex on a breath-by-breath basis to give the patient optimal pressure relief during each exhalation. The amount of pressure relief is determined by the patient s expiratory flow, and the C-Flex comfort setting of 1, 2, or 3. The amount of pressure relief in each of the three C-Flex settings (1, 2, or 3) is variable, as it tracks and reacts to each breath. As the setting is increased, from 1 to 3, the amount of variable relief increases. C-Flex also compensates for mask leaks and will automatically adjust the pressure to compensate on a breath-by-breath basis. In C-Flex, the pressure drop is very brief, and only at the beginning of each exhalation, quickly returning to set pressure for each breath. With typical CPAP, the patient experiences a slight spike in pressure when they exhale. This occurs due to the patients expiratory flow colliding with the CPAP pressure causing a slight spike or increase in pressure. Mask leaks typically occur during this spike in pressure. C-Flex minimizes or eliminates this pressure spike and leak at the point of exhalation. This also minimizes the patient s sensation of difficulty exhaling or even suffocating. Many patients state the C-Flex makes the CPAP feel more like normal breathing. Apneas generally occur at the end of the exhalation cycle, and by that time C-Flex has already returned to set pressure to ensure the pneumatic splint necessary to prevent the apnea. C-Flex is not usually available unless the CPAP pressure is 4 cm H 2 O or higher, since the patient is already on a low CPAP level. The problem of difficult exhalation is generally an issue with increased CPAP levels. For example, a patient with a prescribed CPAP of 8 cm H 2 O may do well with a C-Flex setting of 1. A patient with a prescribed CPAP of 12 cm H 2 O may need a C-Flex setting of 3 to feel easier exhalation. The patient can be given access to change the C-Flex setting while using their CPAP to find the C-Flex level that is most comfortable for them, depending on the physician s orders. C-Flex improves patient comfort and compliance by addressing a very common complaint among CPAP users, that it is uncomfortable or difficult to exhale against the continuous positive airway pressure. The level of patient discomfort was found to be a major obstacle to patient compliance on the typical CPAP machine without C-Flex. In a two-week trial of 60 patients, 98% found the C-Flex very comfortable compared to CPAP without C-Flex. The average patient This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 16
compliance increased from 65% with regular CPAP, to 85% with a CPAP device that had C-Flex available. 5 THE CPAP MACHINE MEMORY CARD OR SMART CARD The memory card is also referred to as the smart card. 4,6 The card is inserted into a slot in the CPAP device and records the date, time and CPAP usage/compliance information. Short-term detailed events and long-term trends are recorded. Data storage capacities vary, and can be 6 months or longer. This memory card can be given to the physician at any time for an evaluation. The memory card gives important information about patient compliance, tracks patient progress, and monitors the auto-titration if applicable. The pressure used, and the duration of time at various pressures is recorded. This is especially useful in the Auto-CPAP mode to assess the most appropriate CPAP level for the patient, especially if that was not specifically determined during a sleep study. This can eliminate the need for another sleep study. These cards can also be used to record answers for the Quality of Life questionnaire (FOSQ). 7 This test is designed to evaluate people with sleep disorders. This helps health care professionals evaluate if the therapy has improved the quality of life, and the effectiveness of the therapy. Questions ask about how the sleep disorder (especially excessive daytime sleepiness) affects the ability to perform normal daily activities, and then about improvements in the ability to perform activities after using CPAP for a certain period of time. The test questions can be answered directly into the smart card by pressing appropriate buttons on the CPAP device that generally ask yes or no questions. The patient can also be given a paper form to fill out. Smart cards are periodically removed by the patient or the home care clinician to be given to the physician for assessment of the data. A replacement card is then inserted into the machine. If the machine does not have a smart card inserted or the card is full, it does not affect the proper operation of the CPAP device. CONCLUSION Obstructive sleep apnea (OSA) has been shown to impair many aspects of a person s life. CPAP and weight loss are the top choices of physicians for treating OSA. For some patients who are overweight, the return of energy and alertness in the daytime, restored by utilizing CPAP, can give the motivation to lose the excess weight. Many patients benefit greatly from CPAP if they are compliant. Comfort and compliance continues to improve with advances in medicine and equipment including the newest CPAP modes of C-Flex and Auto- CPAP. The newest nasal masks and nasal pillows on the market are also helping to improve patient comfort and compliance. The newest medical technology utilized with CPAP help to promote compliance, which in turn, can greatly improve the patient s quality of life. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 17
SUGGESTED READING AND REFERENCES: 1. About.com: Sleep Disorders. (2008). Are You At Risk for Insomnia? (On-Line). Available: http://sleepdisordersabout.com. 2. Wilkins, R., et al. (2003). Egan s Fundamentals of Respiratory Care. 8 th edition. Mosby, Inc. 3. Gold, Warren M., et al. (2002). Atlas of Procedures in Respiratory Medicine. Publisher: WB Saunders Company. 4. Respironics, Inc. (2008). Virtuoso LX Smart CPAP System with Encore SmartCard. Product Literature. (On-Line). Available: Respironics.com/productlibrary/virtuoso. 5. Respironics, Inc. (2008). REMstar Pro with C-Flex CPAP System. Product Literature. (On-Line). Available: Respironics.com/productlibrary/remstarpro.. 6. Respironics, Inc. (2008). REMstar Auto Smart CPAP System. Product Literature. (On- Line). Available: Respironics.com/productlibrary/remstar. 7. Baldwin, Carol, et al. (2001). Sleep. Quality of Life and FOSQ. Vol 24 (1):96-105, 2001. 8. Lewis, Sharon, et al. (2003). Medical Surgical Nursing. Publisher: Elsevier Science. 9. Czervinske, Barnhart, Sherry. (2002). Perinatal and Pediatric Respiratory Care. WB Saunders Company. 10. Arky, Ronald MD, et al, Medical Economics Staff. (2004). Physicians Desk Reference. 58 th Edition. Medical Economics Company, Inc. 11. Oakes, Dana, et al. (2006). Respiratory Home Care: An On-site Reference Guide. Health Educator Publications, Inc. 12. Murray, John F., et al. (2001). Textbook of Respiratory Medicine. 3 rd Edition. Elsevier Science. 13. Wyka, Kenneth A., et al. (2001). Foundations of Respiratory Care. Publisher: Delmar Learning.. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 18
POST TEST DIRECTIONS: IF COURSE WAS MAILED TO YOU, CIRCLE THE MOST CORRECT ANSWERS ON THE ANSWER SHEET PROVIDED AND RETURN TO: RCECS, 16781 VAN BUREN BLVD, SUITE B, RIVERSIDE, CA 92504-5798 OR FAX TO: (951) 789-8861. IF YOU ELECTED ONLINE DELIVERY, COMPLETE THE TEST ONLINE PLEASE DO NOT MAIL OR FAX BACK. 1. Which of the following are the most common contributing factors for developing obstructive sleep apnea? a. Restless leg syndrome b. Obesity and excessive fatty deposits in the airway c. Nasal surgery d. Thalamus malfunction 2. What is a primary indication for home CPAP for adults? a. Central sleep apnea b. Restless leg syndrome c. Obstructive sleep apnea (OSA) d. Ventilatory failure 3. CPAP can be contraindicated for which of the following conditions? a. Pneumothorax b. Pneumocephalus c. Bullous lung disease d. All of the above This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 19
4. Important instructions to provide the patient/family for safe and proper operation of CPAP includes: I. The CPAP machine can be used for life support II. Do not block the exhalation ports III. Do not leave the mask on while attached to the circuit with the machine off IV. Be sure to follow the cleaning and maintenance schedule including changing filters V. Do not smoke in the same room as the CPAP machine a. I, III, V b. I, II, IV, V c. II, III, IV, V d. I, II, III, IV 5. The pressure range found to eliminate OSA in the majority of patients is: a. 4 cm H 2 O to 8 cm H 2 O b. 7.5 cm H 2 O to 12.5 cm H 2 O c. 12 cm H 2 O to 22 cm H 2 O d. 10.5 cm H 2 O to 20 cm H 2 O 6. How does the ramp setting operate? a. The ramp is a comfort setting that allows the patient to push a button to temporarily decrease the CPAP pressure. The pressure will build back up to prescribed level over a 5 to 45 minute time period unless the ramp button is pressed again. b. The ramp is a comfort setting that allows the patient to push a button to change their CPAP pressure to any setting they feel most comfortable for the duration of their sleep. c. If the patient pushes the ramp button, they will have a drop in pressure at the beginning of every exhalation for the duration of their sleep. d. If the patient pushes the ramp button, they will switch to the Auto-CPAP mode This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 20
7. Which of the following are true of the Auto-CPAP mode? I. Pressure is automatically titrated between set minimum and maximum parameters II. Can be used to facilitate sleep studies and help determine the best CPAP pressure for the patient when used with a memory card for the physician to evaluate III. Algorithm uses multiple parameters to identify and provide the ideal pressure IV. Patient can change their minimum and maximum pressure whenever they feel the need V. Responds to changes in the airway and compensates for leaks a. I, III, IV b. II, III, IV, V c. I, II, III, V d. I, II, III, IV, V 8. Which of the following are true of C-Flex? a. C-Flex provides a momentary drop in pressure at the beginning of every inspiration that allows the patient to inhale easier b. C-Flex provides a momentary drop in pressure at the beginning of every exhalation that allows the patient to exhale easier. c. C-Flex provides a variable range of minimum and maximum pressures to provide the ideal CPAP pressure with each breath and to facilitate sleep studies d. C-Flex provides a temporary drop in pressure for 5 to 30 minutes to allow the patient to fall asleep easier 9. What are the benefits of using a memory card or smart card? a. Can record auto-titration pressures that a physician can later evaluate b. Helps in the assessment of the best CPAP pressure for the patient c. Can record short term detailed events and long-term trends d. All of the above 10. Which of the following can help improve patient comfort and compliance with home CPAP? a. Utilize C-Flex with CPAP b. Utilize the ramp with CPAP c. Both a and b d. None of the above This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 21
11. Cigarette smoke can deteriorate CPAP machines due to tar buildup within the device, and this can result in malfunction. a. True b. False 12. Sleep disorders include all of the following except: a. Insomnia b. Osteoarthritis c. Narcolepsy d. Restless Leg Syndrome 13. C-Flex is not usually available unless the CPAP pressure is 4 cm H 2 O or higher because: a. The patient is already on a high level of CPAP. b. The problem of difficult exhalation is generally an issue with lower CPAP levels. c. The problem of difficult exhalation is generally an issue with higher CPAP levels. d. None of the above. 14. Some common treatments for OSA include CPAP therapy during sleep, and the following: a. Weight loss b. Oral appliances c. Both a and b d. None of the above 15. When the CPAP is operating at low pressures, some of the exhaled CO 2 can remain in the mask and be inhaled. To minimize the risk of rebreathing CO 2, verify that exhalation ports are present, open, and clear to exhaust CO 2. a. True b. False HC: Test Version B This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 22
ANSWER SHEET NAME STATE LIC # ADDRESS AARC# (if applic.) DIRECTIONS: (REFER TO THE TEXT IF NECESSARY PASSING SCORE FOR CE CREDIT IS 70%). IF COURSE WAS MAILED TO YOU, CIRCLE THE MOST CORRECT ANSWERS AND RETURN TO: RCECS, 16781 VAN BUREN BLVD, SUITE B, RIVERSIDE, CA 92504-5798 OR FAX TO: (951) 789-8861. IF YOU ELECTED ONLINE DELIVERY, COMPLETE THE TEST ONLINE PLEASE DO NOT MAIL OR FAX BACK. 1. a b c d 2. a b c d 3. a b c d 4. a b c d 5. a b c d 6. a b c d 7. a b c d 8. a b c d 9. a b c d 10. a b c d 11. a b 12. a b c d 13. a b c d 14. a b c d 15. a b HC: Test Version B This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 23
EVALUATION FORM NAME: DATE: AARC # (if applic.) STATE LICENSE #: RC Educational Consulting Services, Inc. wishes to provide our clients with the highest quality CE materials possible. Your honest feedback helps us to continually improve our courses and meet CE regulations in many states. Please complete this form and return/submit it with your answer sheet. Thank you. YES NO Were the objectives of the course met? Was the material clear and understandable? Was the material well-organized? Was the material relevant to your job? Did you learn something new? Was the material interesting? Were the illustrations, if any, helpful? Would you recommend this course to a friend? What was the most valuable portion of the material? What was the least valuable portion of the material? Suggestions for future courses: Comments: What is your specialty area? Credentials? How did you hear about RCECS? This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 24