Good morning, everyone. Thank you so much for coming. There is an evaluation I was asked to remind you guys to do on the app, and this year I'm trying this different method of giving you some resources as opposed to, you know, you having to email us to figure out because you want this slide or that slide or that article. So I put it's the shared drive through the University of Chicago, OneDrive. It does expire in about a month, so it should have some of the slides, the workflows that we do, so that way, you know, you can have them for later, and I'll be uploading more stuff to the slides after this session. Also, as a gauge interest, if you have something, we're a small group, so just feel free to speak up, and I'll be happy to add it to this shared resource. So we are going to get it started, Henry Arantes and myself. We have worked together for many years, and Henry's one of our lead techs. He trained with Mary Karskadon. She just gave a talk at the ISS conference, so that's where that picture is amazing and also, like, super funny, and she, you know, obviously, major researcher in the field and essentially invented the MSLT, so it's one of those techs that is, like, traditionally grow from research to application, and it's a very helpful resource to me, and he works with our techs to teach them and keep them up to date with the more difficult studies these days. That's me in med school. I actually was a sleep technician in med school, and that's how I fell in love with sleep. So I kind of been through the life titration of the patients. These are the learning objectives that you have in the slides, and we're going to get started. I was supposed to bully Lisa, but then now I'm going to chose Michelle and Ashima. So we're going to get started with the hypoventilation, with the ventilation. That's where the lungs came from. It's the icons. Okay. So this is the ear. You're in the middle of the study. You get the call by the tech, and they're telling you, patient had some sleep apneas. I split them to CPAP, and they're hypoxia. They're desaturated. And then as the time goes on, that goes worse, so they decide to call you. So what do you want to see, Ashima and Michelle? Quick. We have 10 minutes. Choose one. Which one? REM right. Okay. You got it. Next. Anyone can say if you guys are up for it. All right. Which one? Anticipate. Okay, what else you wanna know? Okay. We have last one. And what I can tell you, patient histories, they have COPD, BMI 32. Okay. And so let's vote with our hands because the responses. So at this point, do you tell the tech to continue CPAP and just go up on the CPAP, your 5-6, or do you tell the tech to switch to BiPAP? So who wants to do one? Okay. A few hands. I see. Who wants to do two? A few other hands. Okay. We're about half-half. I like it. I will give you a third option. They continue the CPAP, just throw in some oxygen. Okay. One hand there. One another hand changed. Okay. Great. So our tech decided to switch to BiPAP, 8 over 4, lower pressures. And I'm just going to go as the titration evolves, okay. So here, what do we do, right, IPAP or EPAP? Technically we want to work on IPAP to improve suspecting this is hypoventilation, right. I'm assuming the tech is suspecting this is hypoventilation, go up on the IPAP. Same. So they actually did a really good job in the sense of adjusting IPAP versus EPAP. There were some obstructive apneas that started happening more frequently. So then they started to go on the EPAP as well. But they didn't do that, you know, just keeping the pressure support 4 and going up and up and up automatically. Sorry, I do move a lot. You'll hear that. So now you're at 17 over 6. They call you again. And it's N2 supine. Do you ask them to keep going or do you ask them to just stay put? What do they need to do? So at this point, my expectation is the tech recognizes the very high leak, right. You're having some hypopnea events, but there is a large leak. They should go in the room and fix that leak because other than that, it's going to get into escalating pressures, worsening leak, patient wakes up, then post-arousal centrals is going to get ugly. So they actually did fix the leak and ultimately we ended up on 20 over 8 on REM supine. Good oxygenation. So you know, I guess these are the, did I do this right? One second. Okay. So these are the patients. We don't have CO2 monitoring for every study, right. We wish we did, but we don't. And there are some labs that just don't have CO2 available. So the clinical history can help quite a bit. This is a patient who had some obstructive apneas, then profoundly desaturated in REM, a history of severe COPD. So in that case, the exploration of BiPAP, I think, was a good call. As you can see, they responded well. And if you have a patient that would have been a hypoxic in wake, then you tell them to add oxygen there, they just have hypoxia. So it's the mechanism of hypoxia and working with the techs. So what I try to do is anticipate that from the clinical history and then write it in my comments, like details, for the techs to be prepared to, so empower them to make that decision in the middle of the study. Okay. How much time? Seven. Okay. I have three more minutes. So the other reason to switch CPAP to BiPAP is your pressures are too high. They're still having events. I'm going to challenge that for a second. If you have a CPAP of 20, SATs are 82, and CO2 is 62, what would you do? What is what we do? We keep them there and send them home on CPAP? We switch them to BiPAP? Hands? Yeah, I think that's what we most do, or, you know, sometimes they'll be BiPAP and oxygen. So there was a case series that we published, it's only three patients, but it was a unique case because it was a protocol. So in this protocol, if you were randomized to CPAP, you stayed on CPAP no matter what, and you were sent home, and then that patient was then brought up back for a sleep study on the same home settings. So this is the baseline studies. These patients had very severe obstructive sleep apneas, and you see that the time under 90 was pretty low, saying, like, these were very hypoxic and hypercapnic patients. And they were sent home on that prescribed CPAP, no added oxygen, no BiPAP, even with these numbers. And then when they came back for titration, they actually had significant improvements in their hypoxia. So, you know, the theory is that you're not ventilating. You're not. But you are stenting the basis of the lung open with EPAP, keeping the throat open, and recruiting, and you're improving VQ matching. So in the very obese patient, that same case of switching to BiPAP so early may not have made sense. You may have wanted to go up on your CPAP first, and then consider at that point, because we don't have any more evidence. But it seems like even if you keep them on CPAP, they will resensitize the respiratory centers, and the ventilation part of it will improve. They'll dump some of the serum bicarb they have retained. So just keeping an eye on that. That would be another, like, more difficult thought. And the last one is our classic treatment emergent centrals, right? Centrals matter, hashtag. This is our baseline study. This is as we went up to 20 over 15 because of events. Clearly the events were central, and there was no backup rate added, right? So it happens quite a bit that the pressures get escalated first before a backup rate is added. So making that in the comments to your tech, it's like, if centrals develop, if you have someone that you're concerned, then before you escalate to pressures, add a backup rate. Now we do have to show sometimes for treatment emergent the insurance that S failed, that's a pain. So I said, like, okay, try S. If centrals are more than 5, majority, put ST before you increase the backup rate. And then IPAP for hypopneas, EPAP for obstructive apneas. So that's what I had for you. Centrals matter. This is Brewer looking at the text, like, increasing the pressures. And then now it's more important, right? Because the ASM switched the TE, CSA diagnostic criteria, so I encourage you to review that. The ICSD3TR. So we cannot just jump straight to a diagnosis backup rate from the titration, and we need to kind of send them home, CPAP, prove they still have the centrals, and then have the central sleep apnea diagnosis re-reviewed. And you know, there's a lot of debates around that, but the purpose of the talk is to highlight that and bring it to your attention. So I'm going to pass it on to Henry, and again, if there's comments or questions, feel free to speak up. We're a cozy group. »» Thank you, Dr. Lostra. Thanks everybody. I mean, my brain is still in Chicago times, which is actually advantageous at noon now. So there. So should be a little bit better, a little bit more awake. But yeah, as Dr. Lostra was mentioning, there was a lot of, then we get a call, then we get a call, and you get a call to see what you need to do. And this is what we're trying to get better, to the point where the technician doesn't feel the need to always call you guys in the middle of the night to find out what to do. So discussions on past approaches and so forth, as far as, okay, here's a passport. You have CPAP. When to switch to bi-level? You're switching it right away because of what? You saw a central event. Or because the patient claims to be intolerant or not comfortable. Maybe you didn't spend enough time with mass desensitization. Or maybe you went straight to oral nasal, as in number three right here. But another matter that's very important when it comes to a decision to actually switching from CPAP to bi-level is what channels are you looking at? And is the tech at the time confident enough to know what they're doing and what they're seeing in order to make the next move? Because again, this is live and we all know we have limited time. So tapping into your software to understand exactly what its capabilities are and what the technician can do is going to be extremely valuable. So you want to think about maybe updated approaches, approaches that, you know, you're not just switching to bi-level simply because you have central apneas or so forth, but what if you've controlled everything? You've controlled obstructive, but you're still hypoxic, just like Dr. Lastra mentioned in some of our previous slides. Then suddenly you're starting to think about, okay, do I switch to bi-level, do I add O2 or whatnot? But these are the things we want to put down into policies, dedicated policies, that the technologists can refer to as opposed to just constantly trying to check what you would do. First of all, that doesn't give much confidence to your technician body to begin with if they always have to call you. So it's a matter of us getting to a point where a protocol becomes very detailed, not very detail-oriented, but one that they can actually turn to and feel comfortable with. This example, for instance, is what I'm going to talk about in just a second, is adding additional channels to your montage in order to actually see what the pressure and what the treatment is going for. So here in this case, example here, you see a pressure channel there and you see a trigger channel. In blue, you see the pressure channel showing you the pressurization of the channel of the actual system from EPAP to IPAP and so forth. This is extremely important to the point that you understand that you're able to do that and you're able to do that with your sleep acquisition system. A lot of people just say, okay, just put a CPAP set pressure. And all you're seeing is what the pressure is, what you've actually put in on the machine. That doesn't give you much information as how the actual treatment is going. In this case, if you have a pressurized channel that actually is masked pressure, then suddenly you can see the IPAP and the EPAP and when the system is changing. And that's going to be extremely valuable to see whether you're seeing arousals with it or anything else. So I think it adds a tremendous complement to it. Same thing with the red section you see there. You see the trigger channel. The upticks tells you right there, right there and then when IPAP was, when a breath was delivered under ST and then it cycles back down with the downward tick. This information can be very valuable when you're doing advanced modalities because you know that the system is actually pressurizing and delivering a breath. If you don't have these channels, it takes a very skilled technician to actually pick it up without, besides picking up the phone to call you to find out what's going on. So I think it's just very, very important for you to come to the realization that you can do these things to your studies to make things easier, not just for you when reviewing, but also the technician when they're performing it live. Like we said, traditional CPAP protocols just tells you increase by two any time you see obstructive events or obstructive hypopneas or so forth. So these are not one size fit all. There are many studies out there that you're going to need to concentrate on something more specific. So here are some of the resources too that you can look into as to what we're discussing right here for ventilation as well. So the channels themselves, here are four channels. Now I'm referring to, depending on your software, don't assume that you cannot add these channels to your montage. You know, you have to look into it and see its capabilities. And if you have a technician who is tech savvy, which is not all of them, but if you have that, tap into that. See what channels you can add to it. And in order to get mass pressure, not CPAP set pressure, but mass pressure. Trigger and cycle. As you can see here where we just discussed, upticks, downticks, cycling, the actual breath being delivered. You can see it live. And these things, you know, if you can't see it, again, tech supports with some of the companies that you have with acquisition can set you up. So it's not just your report generation portion that matters when it comes to these things. So if you want the technicians to really gain some confidence on what they're doing at night, please consider adding things also such as tidal volume, calibrate it to your system and machine so that you can see ventilation live as it works. But I cannot reiterate more the importance of you having this information transferred or translated to the technician body so that they understand, give them frequent feedback on what they're doing. Because if they don't, they're just going to keep calling and keep calling and then really probably not do the best job that you think they should be doing. If you have cases that you're dealing with obesity hyperventilation, CO2 becomes an extremely important measurement during the night as well, not just your SpO2. So if you have the luxury of having transcutaneous monitors, we can't like Dr. Lodge would say, we don't have it for all. But if you do for some of them, it's actually a very, very beneficial thing to do. And what I mean by CO2 is not just CO2 during the night, during a setup, a hookup, if you have a transcutaneous monitor, you already want to set that up during the hookup so that you get a good calibration signal and you understand what it is, what the patient's doing while awake, then this is going to be incredibly important as they transition to sleep. Because remember, if you increase by 10 millimeters per mercury, all of a sudden, you're really confirming an obesity hyperventilation. Speaking of which, when it comes to protocols, you have an OSA protocol and you say, okay, you start with CPAP titration. Patient doesn't have any treatment, emergent central sleep apnea, you continue with CPAP and then you have a follow-up after downloading it and so forth. Things are great. But if you have treatment, emergent central sleep apnea, that you're noticing central events, then suddenly you're starting to think, do I continue with CPAP for a little bit longer to find out whether it resolves itself as just as you heard what Dr. Lostrass mentioned, or do you consider bi-level ST or ST or advanced modalities to see if it improves, especially if the patient is non-compliant. So these things are not just for you guys or insurance companies that are reading studies. They're incredibly important for a technician to gain confidence on how the structure of the center takes place. This is very, very important, I can't stress enough, because it gives them a sense of not just inclusion, that they're going to do a good job. So treatment, emergent central sleep apnea protocols, one of the things you might want to have is a dedicated one for it. Not just a vendor-based, what ResMed tells you what to do or Philips tells you, no. One for your center that tells you, you increase not by two, but you're increasing by one. You're considering bi-level and spontaneous mode before you even think about bi-level and spontaneous time mode with a respiratory rate. So these are things that you can put into your protocol, preferably with examples that will give the technicians a lot more confidence. So same thing if you decide to create an obesity hypoventilation protocol or a neuromuscular, whichever it is. But when you have this information and you have the luxury of having the CO2 being monitored at the time, it can also give, here's an example, you're doing a titration and you're seeing that the SpO2 is showing hypoxia, but you're not, as a technician, looking at it like, is it something slightly off the finger, or is it something with the SpO2 that is wrong? Can I check on that? If you have a CO2 that actually complements that signal, you feel a lot more confident about what you're doing, and they'll go in and just put it. So there are a lot of technicians that will be hesitant to do something like that because they're a little bit intimidated by some of the units. But if you explain to them the relevance and importance of them, I believe you're going to get a lot better technician response to it. So that's basically my part. And I'm- We'll bring Ashima now. Thank you so much. Thank you, guys. Thank you. You know, I think one, I don't know if you feel the same, but I think one of the main challenges is our sleep technologists. So some of these concepts may be very foreign to them. And so I think first making sure that they understand the concepts will empower them to then create protocols and even engage in them in the protocol. The other part that I find complicated, sorry I know I talk a lot, is that the insurance crap, right? So we have this to show the BiPAP-S with centrals failure. And so I've had techs go from CPAP to ST. I'm like, that's the right thing to do. But now I cannot qualify them for equipment. So just making sure they understand the dark side of the sleep medicine world. Okay, Ashima, thank you. Are we asking questions again? You can speak up now. That's all right, I'm gonna sit here. They're both backup rate devices, right? So in regards to approving the device, you have a backup rate device, it can go either way. If the patient has an EF less than 45%, I obviously, right, will not go to ASV, so I'll go to ST. In my experience, ASV works better at controlling central apneas, and it prevents that overtitration that the text do to the 25 over 21 with a backup rate of 12. And I've had text titrate to 20 backup rate, so now I'm putting a high of up to 16. Right, so Ashima, I'll have her do the presentation, then we'll recap for the question. That's my case too. That's okay, no problem. Aloha everyone, thank you for joining us. I know we have a competing sessions, a lot of competing sleep sessions, so we really admire that you are here with us. So I'll be talking about difficult titrations, showing you the darker side with examples that are away from the usual protocols. So we have to just make sure that we are anticipating them, and as discussed, make sure the texts are knowing that before the night, so that they are ready to troubleshoot things. I have no conflicts of interest, and just for basics, I think we all understand this well, but just so that we all are on the same page. We all know EPAP is the lowest pressure set in the circuit, and that helps with upper airway patency, and improves oxygenation to some extent. IPAP is the highest pressure in our system. The trigger is this red thing over here. Okay, so the trigger is the red thing over there, which is when you have to switch from your EPAP to IPAP. Now just remember, if it is spontaneous, the patient is breathing on their own, it is usually flow-triggered, but if it's machine-triggered, especially in your backup rate patients, it will be time-triggered. And rise time is the green thing over there, how quickly the system gets pressurized, and then the inspiratory time is the time spent in that higher pressures, and then you have your cycle when IPAP needs to be switched over to EPAP. And depending on what kind of lab you have, whether it's ResMed or Raspironics, I just want to emphasize this fact that in bi-levels, if it's RAD device and you have a Philips lab, you have to just understand that the spontaneous breaths are patient, so whatever TI time you have set will not be going to those spontaneous breaths, but in time breaths, which is machine-triggered breaths, you will get your TI time. This is only for the RAD devices, obviously with the home vents and the EVOs coming along, they have improvised that. So if you have a ResMed lab, the TI-Min and TI-Max will help you, and you will have something called modified TI time, which will be given to both spontaneous and time breaths. In that, the TI-Min will matter, because that is when it'll cycle off in most of the breaths, okay? So with this understanding, I just want to highlight we haven't revised our bi-level titrations for a while, and I hope that is one of the task force coming up soon from ASM. This was last revised in 2008. They don't really talk much about hyperventilation or what we should be doing with CO2s, but this is a flowchart that we all have, and it says start at IPAP of eight over four, which usually might not be the case, because sometimes you're switching over in your lab from CPAP to bi-level. So what do you tell the techs at that point? I usually tell them whatever the CPAP, if it was 15 and you're switching over to bi-level, make that your EPAP and add four to it. But some labs I know will take CPAP 15 as kind of a median, and they will add two to IPAP and subtract two to make it an EPAP and probably start over 17 over 13. I feel like both are fine. It just depends on the physician and the providers what they are doing in their lab. That could be one approach. Now, we all, I know Henry already emphasized this, EPAP and IPAP in bi-level has to go up for your obstructive apneas, and you will go up only on IPAP if you're having red eyes, snoring, or you have, I think I mentioned hypopneas already. So this is usually what it'll look like. This is your snoring part, and this is your inspiratory flow limitation when you're going up on your IPAP, not your EPAP and IPAP together, okay? With this as a basis, I'll go to my first case. So this is a 17-year-old patient with Pompe's disease, comes back to your sleep clinic with worsening snoring, witnessed apneas, her BMI is 10, in a setting of significant macroglossia and worsening hypotonia. The other significant details is she had a scoliosis and had a surgery for that, but her FBC is still 12%. She had a PhD three years ago, which showed moderate obstructive apneas with pretty severe hyperventilation. She was new to our system. I wasn't sure why the backup rate wasn't added at that time because she was still hypercapnic, but either way, she was titrated over 16 over 12 and comes back to us with worsening obstructive symptoms because of her macroglossia and hypotonia. This is your hypnogram from that night when she comes for repeat titration in our lab. So you can see the first part is your sleep stages, and then the third part over there is your respiratory events. So the patient was started over bilevel. Then you have your CO2 monitoring, which is your second last. I wish this was. It does show. It's just a little weak. Yeah. Oh, I got this, okay. So this is your CO2s, and that's your pulse ox. So you can see overnight, the titration was started. The technician got concerned at point A. So you can see that the patient started off with bilevel, and just because I know it's very small print, it was started over 14 over eight. The tech went up on your IPAP to 15 and then to 16 because of higher CO2 levels. Then they started seeing more obstructive events, and at that point of time, the tech just went up on the EPAP and kept the same IPAP. You start seeing an increase in CO2, and he gets very concerned. So at 16 over 12, the CO2 starts going up. So at that point of time, empowering your technicians. So what should we be doing? Should you be adding a backup rate at this point, increasing your IPAP, increasing both your IPAP and your EPAP, or increasing your EPAP or adding a TI time, or increasing your TI time? For my lab, it all depends what you came up with in the beginning. In all honesty, this patient could have been put on IVAPs from the get-go without getting to the sleep lab for titration, and I would have put in an automatic algorithm and seen how things had improved, even from the clinic itself. But since this was a sleep study protocol, that's why I have this example over here. I don't know if others have other opinions about it, but that's useful. Any strong opinions for one? Yes. So there are case reports and there is, I think, two articles that I saw that they have worsening obstructive events because of the macroglossia and the hypotonia of oropharynx in Pompe's disease patients. So even if we are thinking everything is hyperventilation, they still have some obstructives. And so it will really force more centrals, because in every group, you're getting out of an EPAP of 13 and somebody with a BMI of 10. That's true. Yeah, that's true. Can everyone hear? Can you repeat the question? You want to come? The question was, because the patient has Pompe's disease and her BMI was 10, will adding EPAP of 13 be appropriate, or are you adding more up? We're causing more centrals and having a hereditary reflex, which will lead to that eventually, and making the trigger more difficult for the patient. So the EPAP should probably be close to six or four, depending on the situation. This is where AWIPS makes a difference. You remove the tech from the room, and the machine does it. That's why we have to teach our techs, so the machine is not better than our techs in the lab. No, but I get the point. Depending on the situation, this was, it could be also obstructive. But in this case, the take-home point was that the hypoventilation will worsen if you're not increasing your pressure support and you're just going up on your EPAP and not increasing your IPAP will reduce your pressure support and worsen your hypoventilation. So that was kind of the take-home message from here. I understand the Pompe's disease and having obstructors will complicate the case. But this is helpful because I tell them, IPAP for hypopneumatic ventilation, EPAP for apneas. But then when I say EPAP for obstructive apneas, I don't tell them, and then go up on the IPAP to keep the pressure support, you know? So I think adding backup rate could have been reasonable at some point if there were centrals. You can't get it without that. At this point, increasing the EPAP and IPAP will still keep your pressure support the same so it won't really address the hypoventilation that much. And going up on EPAP, as we discussed, will worsen your hypoventilation and it's going up for apneas. But if it's pseudo-obstructives, you're worsening your situation even further. Can you define pseudo-obstructives? So the pseudo-obstructives, basically what will happen is if the patient is weak enough and your diaphragms are not working properly, the tug that happens is not there that well. So if you're not scoring them properly and you don't have your EMGs, oh, sorry, Dr. Wolf. Can I just give a little... Sorry. That's true. I should remember that tagline for next time. But the take home from this case was hyperventilation part of it. So increase the pressure support. Just going up on your EPAP and not changing your IPAP will not do much. So in this case, they had gone up on your pressure support and eventually the hyperventilation started improving and the obstructors were not there. Say that again. For this patient? 12%. That is true. Well I would have done a backup rate on this patient and just made sure that the EPAP was slightly lower and just followed them up with noninvasive. To be honest, this is because we're going to run late. I already know we're late. And Drake is beyond, way beyond this scope. So, yes. And there is a ton more optimization of NIV that can happen. Right. Right. So moving over to case two, it's a 45-year-old male with past medical history of morbid obesity with a BMI of 50, comes to your sleep lab with classic symptoms. In lab was ordered, got denied. He ended up getting an HSD with severe sleep apnea and hypoxemia. Finally, the insurance approves it. That's your hypnogram from that night. So again, you have your sleep stages up top. Then you have your respiratory events in the second block. And this is what the tech was doing for the night with your pulse ox over there. And then you have the pressures and you have your positions at the lowest part of it. So just in nutshell, the patient was started on CPAP, got switched to bilevel because of persistent hypopneas and hyperventilation. And then at this point, when the pressure support was increased enough, he started having treatment, what Jorge was talking about. So you started having a lot of centrals over here. And then the patient was switched over to ASV in that same night. So this is a case we were just discussing like five minutes ago. So what will you do? You're the sleep provider. How will you educate or how will you protocolize or what will you do next for this particular patient? Will you prescribe an auto-ASV? Will you repeat the titration with a backup rate at this point or will you figure out a pressure from what the study had shown in the past or you'll bring back for VAPS titration? Because they're shy, we're going to have to either pinpoint. In interest of time, I'll just go forward. So we were just for discussion and this was brought again. The mechanism for ASV is to stabilize your breathing. It is not a ventilation mode. It will not help with your hyperventilation. During the night, you have to remember this patient was hypercaptic to begin with. This was an OHS case. You cannot switch to ASV at the end of the night. The reason for centrals at that point of time was you had blown off too much PCO2. Your pressure support was way too high. You were very close to the apneic threshold. So either you figure out from that night what pressures would have worked properly or you bring them back for an ST titration at that point. So for ASV, it is to stabilize. It is used for periodic breathing or your chain stokes. It is contraindicated in your hyperventilation patients. So your bilevel ST, as we discussed, it is a ventilation mode and the backup rate could be used in your primary centrals, opioid-induced, or OHS cases. So in this case, there was a sweet spot in which you had some REM sleep, the CO2s were getting down, and you had a decent control of your respiratory events. It was around 18 over 14. So that was what was prescribed to this patient. Without backup rate. Without backup rate for now, yeah. So as I discussed, ASV will not be recommended. Repeat titration could have been done if you could not figure out what pressures will work. And I just put in italics the discussion about how much backup rate will be good, whether low or high. There are review articles to talk about it. I won't dwell into it too much today. And then bringing back for WAPS titration, again, there are studies out there that compare bilevel ST and WAPS. There hasn't been much of a difference between your CO2 or O2 levels or your EPFORTH or your improvement in your FVC. So either of them will work in this case. So the take-home point, prevent over titration. If you have reached that stage, try to cut back on your pressure support. If the centrals are still persisting, you could not figure out what pressures will work, bring them back for a backup rate, not an ASV titration. »» Thank you. While we swap, we can have comments. »» I still have one more case, but I can leave it. That's fine. »» Yes. Sorry, Ashi. But that was an awesome case. »» Okay. This is a toxic breathing, opioid-induced. »» We will give you the slides in the QR code, so scan it. And we'll be happy to stay after to chat. It's not projecting yet. There we go. Okay. »» Hi, Ali. Thank you for putting this talk together. So I'm going to cut my talk down pretty short so that Lisa has some time here. You know, it seems like a long time ago, for a while, AVAPs or VAPs therapy was being used quite a bit in sleep labs. And I think that almost every patient came out with a VAPs modality. But I would say in more recent times, I don't think VAPs is a common mode that we titrate in the sleep lab because the advances in technology has gotten so much better with NIV. And I would say from my own practice, I rarely use VAPs titration these days. But for those of you who do do it, I'm hoping that this can help you. So these are my objectives. So first thing to know is that, you know, the VAPs modality is a pressure support ventilatory mode targeting tidal volume or alveolar ventilation. And you need to know the software that your lab's using, and some labs have both, whether it's the OmniLab or the ResMed treatment lab system, because the OmniLab has the VAPs as an accessory mode. You have to pick a parent mode first. And then there's the AVAPs AE, which is a standalone mode. So my techs always pick AVAPs AE because they forget that if they want to use ST or pressure control, they have to turn on the VAPs mode. And then for the IVAPs, that's a standalone mode, so you don't have to pick any parent mode. It's also helpful to know, as a provider, you need to decide what you want to use for your patients. You know you're going to put a patient on a RAD device versus a home mechanical ventilator. So those are how you decide which modality you want or which type of mode you want to put in the sleep lab. So indications for VAPs, I think, first and foremost, it's going to be for neuromuscular respiratory failure. You could use it for patients with hyperventilation who failed SRST mode. And then, rarely, you can use it as a troubleshoot titration protocol for dyssynchrony that you can't fix in the home setting. Most important that, before you put a patient on a VAPs titration, the patient, this is for neuromuscular disease, the patient, or any other hyperventilation, the patient should already have met criteria for a respiratory assist device or a home mechanical ventilator, such as ALS. You can't just go straight to a VAPs titration otherwise. One thing to keep in mind is that a central sleep diagnosis will qualify for a VAPs titration because it is a device with a backup rate, right? However, be sure that when you're using VAPs for a central sleep apnea, you are treating the hypercapnic types of central sleep apnea and not the hypocapnic, which is periodic breathing or shingles respiration, in which VAPs is actually a contraindicated mode. So this is a process for titration and neuromuscular disease borrowed from Lisa Wolf, and we'll go through this really quickly here today. So first, chart review. Make sure you know the patient has a neuromuscular disease diagnosis. Is there evidence of respiratory impairment? Are there PFTs, FEC of 50% or less, MIP of less than negative 60, or arterial CO2 greater than 45? So if you see that, patient's pretty in late-stage disease. So those needs, cartoon needs to be met. And then look at the medications, see if there aren't any medications that can impact breathing. Your sleep rooms, accommodations. These are very complex patients with a lot of care needs, right? Is there a Hoyer lift, hospital bed, suction devices, are caregivers always needed? Do you have the space for them? And then just plan and start your times because these patients may have transportation issues. Moving on to montage. This is key here. So consider adding accessory muscles to the montage to better detect respiratory efforts. Scoliosis can be a problem because it can impact the belts. At the CO2 surrogates, transcutaneous and end-tidal. If possible, get your ABGs or VBGs before the patient goes in the sleep lab. And then consider doing the low extremity leads because arousals can be seen here if the patient has electrical activity in the legs. And then they all have fasciculations as well, so keep that in mind. Here is the extended montage that I like to add to my neuromuscular patients when I do titration. So you can see these are, you can just tell your sleep techs to start these and you can show them where to do it. And then for your protocol, I would just add this as part of the neuromuscular protocol. Okay, and I can share this with you offline if you need it. It's going to be on the QR code. So titration protocols, three most important parameters. So goals here to upper airway patency, like these are, this is not invasive, so you have to keep the upper airway open before you can ventilate the patient. But then after that, your goal is to improve gas exchange, improve ventilation, and then decrease work of breathing, that's the key factor here. You need to be sure at the end of the night that the patient's work of breathing has improved. So titration software differences, right? So AVAPs on the left, and you can see that it targets tidal volume. You have to choose a primary mode, whether it's S, ST, pressure control, and then you add the AVAPs. Remember, AVAPs, A-E, I can't stress enough, is a mode that's only on the ventilator. So if you have an AVAPs, A-E titration, you're looking at prescribing a home ventilator. And then, as you know, the A-E is autotitrating EPOP. The IVAPs is targeting alveolar volume or ventilation, and then there's no need to choose a primary mode. The key here is that it offers a T-I-min and T-I-max, as the last two speakers have discussed extensively. And you can adjust the inspiratory time by adjusting the T-I-min. And then there's also IVAPs A-E, which is available on the home mechanical ventilator as well. So your tidal volume target, right? So this is a chart, and you can get anywhere, but our sleep techs have this on the walls of their control rooms, and this is how they use to get their tidal volumes. It is an ideal body weight calculation. And then for the alveolar ventilation calculation, this is a little more complex for a lot of sleep techs. So this is the website to get into. You just go there. You enter the height. You enter the target backup rate. In neuromuscular disease, it should be 15, but you can titrate up as necessary. We prefer to input the tidal volume, and so we use ACCs per kilo ideal body weight. You can use six for patients with really restrictive neuromuscular disease, and then you hit calculate, and then the alveolar volume pops up. So there it is, okay? So then you enter that in, okay? So here are the settings for AVAPs. And again, you can just, you know, take this and copy it down. But again, choose primal, turn on AVAPs, ACCs per kilo, your EPAPs start low and stay low. That's the key. Most of my patients don't need to go more than four or five. IPAP min start at eight, and then IPAP max, I start at 12 to 15, and you can go up to 30 as needed. You want to have that delta between IPAP min and max high so the machine can do its job in finding that tidal volume. And then make sure you don't max the ceiling out, right, by keeping the IPAP max very high. And then your goal is to really achieve ventilation, right? So make sure the rate is less than 16 to 18, SpO2 is high, there's no hypoxemia, and you're achieving that tidal volume goal, and backup rate of 12. Here are some minor settings that are also very important. The inspiratory time, it's not a TI min, TI max in the AVAPs, only one. So you have to set that. Usually 1.0 to 1.2 is what I usually do. And then the rise time for BOBAR patients, I go a little higher between four and six, otherwise I keep it at three. Inspiratory trigger, this is where the patients cannot trigger, they have diaphragmatic weakness, so you want to go to one liter per minute, which is a very highly sensitive trigger, meaning that it's easy for them to trigger by using one liter per minute. Normally it's around four liters per minute. The home ventilators can go down as low as 0.5. And then the inspiratory cycle should be set around 10 to 20, but I usually go a little low between 10 to 15%. Do not use, in neuromuscular disease specifically, auto-track mode. And then, because auto-track is really designed for like an obese man with OSA, so it's not really designed for neuromuscular patients. And then I don't use the auto-backup rate as well, because again, these algorithms were not designed for neuromuscular disease. This is not a minor setting, but again, AVAPS AE, again, if you're gonna do this, then make sure you know that you're targeting a home ventilator for your prescription. But again, AE is not necessary for neuromuscular disease, like I don't really use high EPAP for these patients. Here's the IVAPS major settings, very similar goals, very similar numbers. Difference is that for the pressure support, instead of IPAP min, it's pressure support min. You start four as well, and then again, your goal is to improve ventilation with these same parameters. Pressure support max instead of IPAP max, again, you don't want to max out that ceiling. You want to keep the ceiling high so that the machine has the chance to get that alveolar ventilation goal. And then the backup rate is 15. Here are the minor settings for IVAPS. So here, you have the TI min and TI max. So I usually, you target by controlling that TI min. So I usually set it around 0.8 to 1, or 1.2, and then the TI max, you keep high, like around 2 or 3. The rise time, again, same as the AVAPS. Trigger here, it doesn't give you a flow per minute. You set it as high to very high, meaning that it's very easy for the patient to trigger. And then cycle, it doesn't give you a percentage like the AVAPS, so you set low to very low. And then do not use these learn targets. The IVAPS has learn targets because, again, the software, it wasn't designed and it wasn't tested in neuromuscular disease. And one thing to know is that if you use these learn targets, the neuromuscular patients, they have ineffective breathing and trigger, and they have high work of breathing. So these learn targets learn that and keeps going throughout the night if you let the machine do that. This is why you have to control it to standard degree. So you've seen this before. You can see the differences. If you're using just a TI mode alone, you have to remember, you have to set that TI. Otherwise, the spontaneous breath and the time breath, you can see here, they appreciate the tidal volume difference when you're setting that TI, when you're controlling that TI. So in a device that has a TI min, TI max, or a pressure control where inspiratory time is controlled, then every single breath has a more consistent tidal volume. When to increase pressure support. So again, when tidal volume is low, when your CO2 surrogates are still elevated, when you feel like the least doesn't show that the respiratory muscle rest has been achieved, so you want to improve work of breathing, or when you still have persistent hypoxemia. So this is a part of a hypnogram that you can appreciate here that there is persistent hypoxemia. Tidal volumes are low. Patient's tachypneic. Hypoxemic. So there's a high work of breathing, as well as improper ventilation. So this is when you want to increase your pressure support. Some things to keep in mind is the mass leak. That's really important. When the mass leak is very high, it is difficult for the machine to achieve the targets. When there's a discrepancy between the device, estimates of tidal volume, and the clinical scenario. So the tech should be checking for that leak. For example, if you keep increasing pressure support, but the tidal volume doesn't go up, you got to look at that mass leak and see what's happening there. So I think one of our speakers mentioned that. And then also, remember to change from ST to PC mode if you are using the AVAP so that you can control the TI time. In the morning, the technologist should document the CO2 at the end of the titration. Also they need to really put down the major and minor settings. I know my techs forget the minor settings all the time, and that's really critical in neuromuscular disease. Document the mask and the size, and then the provider will then be able to decide a RAD device versus a home mechanical ventilator. A RAD device is a respiratory assist device, by the way. And then this is just summary flow for your VAPS titration. Remember, before you start VAPS, you have to make sure that the patients are in met criteria for a VAPS device, right? And then you choose your primary mode. You titrate, and you monitor for effective ventilation, reduction in work of breathing, and then you move towards your final setting. So same settings, just moving towards the target numbers. I think that's it. Thanks. Thank you. We'll switch to high-flow nasal cannula, and I think, you know, I'm excited about it because I do think there is a future of high-flow nasal cannula used in sleep, and we're going to maybe use it in the lab, and the one that knows this is Lisa Wolff. Hey, guys. So I have six minutes. For technology that I think you probably haven't seen and you probably don't have in your lab, anybody have a high-flow in their lab? Yeah. And you're both pediatricians, I'm assuming, yes? Yeah. So what we're saying is that there is a future here for adults to have high-flow in their labs. So we actually added high-flow to our labs. Basically what I want you to see here is that high-flow does not have to be done with oxygen. We're used to using high-flow nasal cannula to improve oxygen delivery, say, in a post-critical care patient. What we're talking about here is using high-flow to do CO2 washout and to improve end-expiratory lung volume and to reduce work of breathing and respiratory rate. Now the black sort of protocol that you're seeing up there shows that the high-flow nasal cannula actually does rinse out of CO2 in the dead space areas here between the nose and the vocal cords. Now that would typically be considered dead space because you couldn't really rinse CO2 out there. But with the use of high-flow, we now can. And because we're using flow without adding additional oxygen, we don't have to worry about CO2 retention. So we really do get some CO2 washout. And the next thing is to think about if you're going to bring this in your lab, what do you need in your lab in order to do high-flow? So a couple of things. First of all, you'll see that the bands that I have up there are RIP bands or respiratory impedance plethysmography. See how the bands have the little electrical wires in them? So they're actually directly measuring volumetric change by looking at stretch. Now why do I need that? I need that because I can't measure flow at the nose. Because the high-flow has so much flow, I can't see what's going on that way. Same thing. I can't really see CO2. So getting a transcutaneous CO2 monitor is super important. And so our montage should consider RIP belts and a Sentec. Then the next thing is scoring. So what we say here, and you'll see some examples here, and this is a high-flow recording from our lab, what you'll see is that 4% SATs are scored as a hypopnea. And if there's a desaturation with less than 4% but an audible score, we'll allow that to be scored as a hypopnea as well. And we want to see an absence of respiratory effort for 10 seconds based on the RIP belt. So it's a little bit different than traditional scoring would be. And then the next thing is exactly how to do the titration. Now, I have two options for flow titration on this slide. And you'll be able to have copies of both. Now, the first one is the one that we actually wrote for our lab looking specifically at adults. We start at 15 liters per minute of flow. And I know you pediatricians are like, oh my God, that's so much flow. You're going to collapse everything. And the pediatricians typically start at 5 to 10. But in adults, we start at 15. An increase by 5 liters per minute as needed until obstructions are gone. We make the changes about every 30 minutes, but not every 30 minutes of sleep. Because we really don't want to run out of room here. And we're going to max out at 60 liters per minute. If the respiratory rate is greater than 20 to 25, that also means that there's ongoing dyspnea. And you should consider increasing by 5 to 10 liters per minute. Now, the other protocol that I have here is a European protocol that has been published and monitored. So you have either one at your disposal for your techs. And the other thing is oxygen. So we can add oxygen if needed. The benefit here is that we don't have to worry about CO2 retention if we do add the oxygen. But it's a last resort. We really try to avoid it. Here are some of the patient types that have received this protocol effectively. And there are publications behind it. The first is the use of high flow in children. The real benefit here is that we don't have to worry about loss of midfacial advancement. Have any of you guys had patients transition to you that have moon-shaped faces? We recently had to do two osteotomies to move facial bones forward for these children. So in kids who are very young, considering the use of a high flow nasal cannula is great because it will not cause retardation of midfacial growth. This is a well-known study looking at post-stroke patients. So for those of you who have seen Dr. Yagi's data, really emphasizing early treatment of sleep apnea in those that are post-stroke. But you're worried because you either can't get a sleep study or they have severe bulbar disease or cognitive factors that are preventing that early use of CPAP therapy. Think about high flow as an option. It's very effective in reducing the apnea hypopnea index in this patient population, but in a safer manner. The next is COPD. So for those of you who have been struggling with, I'm not putting my guy on 25 over 4, for those of you who treat both COPD and OSA, this is a recent trial looking at the use of high flow as an alternative. The beauty is that it really helps to reduce readmission rates and the number of exacerbations. People in the states will accept it as therapy without concern. We don't get as much CO2 reduction with it, which may ultimately impact the fact that we're not seeing good survival here. But it is something in the future. Because we basically have no more time left, and I have to give a talk in the next room in three minutes, I want to reinforce that there is one significant downside to doing high flow therapy for sleep disordered breathing in the lab. And that is that we have seen central apneas come up as a result of this therapy. So why do they get central apneas? There's a couple of things. One is that we may actually bring the CO2 down so quickly that they are having mandatory centrals. Two, we may be getting enough pleural stretch that Herring Brewer is becoming a problem and we're getting central apneas. And three, and I can tell you I've seen this before many times, is that there may be patients we're using this on because they have cognitive issues, right, developmental delay, Hunter's disease, Down syndrome, all of those kinds of things. And after we move the obstructions, we realize that due to the central factors in these patients, they had underlying centrals anyway. But in those patients that are so desperately in need of therapy, I'm okay with a couple of centrals there because it's better than a tracheostomy. And if you look at who has been described at having this benefit from high flow therapy, there's an interesting patient group. These are elderly patients. It's hilarious. In this study, elderly is defined as over 55. I refuse to admit to being elderly. Yeah, right? But in these guys that have moderate OSA and they're older in age and they don't tolerate a mask and we're really struggling with how to treat them, you'll see from this group here in the teal that's above 50 that they do very well with this therapy. So this is something I want you guys to file away in your what to do for the difficult patient. And lastly, with my this is how I do it Lisa Wolff hat on, it's great for patients that have profound bulbar dysfunction because you don't have to worry about the posterior pharyngeal upper airway dilation that causes failure in people who have Parkinson's, ALS, post-stroke. And for your pediatricians out here, great in cerebral palsy for the same reason. So this is another reason why high flow can be great in some of these challenging populations. So thank you guys for staying till the end. I know I had to rush through.

evaluation app

shared drive

Henry Arantes

sleep technician

hypoventilation

ventilation

treatment options

clinical history

titration protocols

CO2 monitoring