Thank you, everyone. Good morning. Thank you, everyone, for coming to our session on in the age of recalls, how do we manage these devices? And so our talk has, our session has three components. Dr. Hemant Subnani will be first speaking about bi-level S devices, ST devices, and VAPS technology in general. And then my name is Sri Nayak. I'll be speaking about the first few home vent devices, and Dr. Lussier will be speaking about the last three sets. Thank you very much. All right. Let's get going. So I'm a pediatric pulmonologist within the pulmonary and sleep section at Cincinnati Children's, and I'm primarily embedded within the neuromuscular center at our institute. So I've been doing this for almost 15 to 17 years. It's been a fun journey to see a lot of development in the field. I have no disclosures, and my objectives today are for you to just get an understanding on the implications of respiratory muscle weakness. Clinically, we'll kind of just touch upon some of the PAP therapy, the most commonly used PAP therapies, non-vasively in bi-levels. And something that I think is really important that often gets missed or swept under the rug because people don't stop to think a minute about it is synchronization between the ventilator and the patient. So, you know, we have a wonderful integration in our human, in the human body of a variety of sensors in the peripheral system, including upper airway, carotid bodies, stretch lung receptors, and in the CNS as well. And all of these inform respiratory drive. Now, there's also the cortical component, but the outputs from all of this govern very important functions. The activation of the upper airway muscle, activation of diaphragm, and the activation of the intercostals. So, what you have is functional respiratory drive and a reasonably well-balanced respiratory muscle power. All of this is important for normal respiratory effort. So, what happens with respiratory muscle weakness? We know that this leads to respiratory insufficiency. On one side are the pulmonary changes that take place with chronic respiratory muscle weakness. Patients are predisposed to low lung volumes, and hence changes in lung compliance. They're subject to risks of recurrent pneumonia and aspirations. And on the other side, particularly in the pediatric world that you may not be seeing as much as adults, is evolving thoracic dystrophy, particularly when the insult is very early on. You don't see the same chest wall changes in adults that we see in, let's say, a spinal cord injury occurring at 10 months or two years of age. So, as children grow, even though the insult may be static, the consequences are progressive, unlike in the adult world. In addition, we also see patients with a variety of cardiomyopathies in the background, and let's say you've got traumatic brain injury, you also, as a part of a spinal cord injury, you also will have abnormal changes in ventilatory drive. And last but not the least, all of these begin to play into each other as well, particularly as the child or the individual grows. So, when we think about a respiratory equipoise, it's balanced with respiratory drive and power on one side, and then the resistive respiratory loads on the other side. And these are informed by chest wall and airway compliance and resistance changes. So, when the balance tips in the favor of respiratory failure, it is often in the form of infections or secretion burden in patients with respiratory muscle weakness. And then you may have patients who also come following a procedure. Let's say you have a young adult who comes following spinal cord surgery and spine stabilization with a background of SMA or Duchenne muscular dystrophy. Then you do a couple of things. One is you do apply sedation, but on the other side, the respiratory drive and power also diminishes out of proportion. So, it will tip these patients to respiratory muscle failure, and that's why we say that even if you have patients electively admitted following a procedure, depending on their baseline state and pulmonary function status and baseline ventilator needs, it's never a bad idea to consider a guarded extubation in the ICUs. So, you're used to, you know, when you think about, I find it easier to deliver a message sometimes by using cartoons. So, let's say you have normal tidal breathing, which is, you know, slower and deeper. A lot of the times, patients with respiratory muscle weakness will compensate and have a candid conversation with you, breathing shallower and faster. There'll be wheelchair-bound individuals who can lose 70 to 80 percent of lung function and sit there comfortably having a conversation with you. So, respiratory muscle weakness needs to be listened for even and assessed even as you enter the room. Now, when you think about using conventional PAP therapy, remember these patients also tend to have myopathic airway. I like to use that term because it's really not just straight plain-gain OSA from adenotoxin enlargement in children versus, you know, soft tissue encroachment from adults. It's truly myopathic airways. The use of just continuous positive airway pressure is going to be inadequate in these patients because it does nothing to augment the tidal volume. As a result, you need differential pressures. So, bi-level pressures are what you will always need in order to optimize not only the patency of the upper airway, but also to deliver an optimal driving volume so that your patient can ventilate. Now, very often, as soon as the body gets this nice deep breath, there's a result in central apnea that can occur, and that's why you need a backup rate. The other reason for the backup rate is that you will provide this patient with respiratory muscle rest. We should talk about that maybe later. Some of the other features that also are important in optimizing your patient's comfort are features like the ramp. Now, the ramp occurs in different varieties of equipments. It's termed differently, and sometimes it's called the ramp, and sometimes it's the rise profile. So, understand your equipment, understand the terminology that the company uses, and go with that. Understand that if you have a very long ramp, you're going to spend less time at peak pressure, and as a result, the tidal volume may actually be lower. So, the area under the curve informs what your average tidal volume is going to be. So, when you think about pap therapy, you've got a compressor, which has a turbine that has a persistent bias flow through a circuit, and it ends with a nasal interface or a face mask, whichever interface on your patient, and it has an intentional leak built into that so that there is no CO2 retention. Now, this turbine, the flow of the turbine, is governed by constant input from pressure and flow sensors during each respiratory cycle, as well as between cycles. So, the flow sensors constantly monitor for flow limitation, and if there is significant reduction in flow, then force oscillations are sometimes used in corporate to assess whether there's an area of obstruction or simply a decrease in effort, because that determines the next intervention that the machine will deliver, is whether to go up on just the peak on the end-expiratory pressure or to increase your peak-expiratory pressure, which would be, therefore, increasing your pressure support. So, if your patient's having an obstructive apnea versus just a central hypopnea, if I may, the machine is going to respond differently. So, the conventional machines of age have been used, now, I'd say for, these were, you know, the S and ST modes came out first when considering bi-level machines as iterations of ventilators for use in the clinic, and most commonly, I see people use even S modes in neuromuscular patients, and so, that's the other message I want for you to understand here, is why we shouldn't be using that. When you think about spontaneous breaths, these are initiated by the patient, versus time breaths, which are going to be initiated by the machine itself. So, whenever you have an assisted breath, that's the one where the patient can deliver, but the ventilator or the machine delivers an optimal eye time with that. So, what is important to understand is that, although you may set parameters of a lower and a higher pressure, meaning the pressure support, as well as a rate, it's also important to set an optimal eye time. Very often, patients with muscle weakness, when they may start non-invasive support, may be strong enough to optimize their, or hold their own eye time, but what will happen, and I'll show you a couple of screenshots later, is that as patients progress in their muscle weakness, they're not able to hold their own eye time, and so, it's really important that you consider delivering that, and at least optimizing it, setting it appropriately. Sorry, the other thing I wanted to bring up here is, on the far end, you see this flow time curve, and on the descending loop, you see that trajectory change from a descent to an oblique descent to a vertical. Now, that's the termination of inspiratory flow, what we would call cycling of the ventilator, and you can set that process at what flow rate that should occur. If you set it too high, meaning at a higher percentage of peak flow, that drop-off into exhalation is going to occur closer to the peak of your inspiratory flow. What that means is the tidal volume is going to be constricted, but if you allow for the patient to take his own inspiratory breath, and support that through the process of his spontaneous breath, to a lower percentage, that means that peak inspiratory flow will drop much lower to maybe 10 or 15 or 20 percent before it cycles into exhalation. That will allow the patient a greater sense of completeness, of a spontaneous breath. So when you think graphically about the ST mode, there are spontaneous breaths, which patients can take in any frequency they desire. However, if the, so in this example, and I took this from the Respironics manual, I do feel that whatever a piece of equipment you desire to use, it is important that you read the manual and you understand the language of it. This has been set at a peak pressure of 26 with an EPAP of 6 and a rate of 10, so you have a respiratory cycle time of six seconds. So as long as patients are taking breaths within six seconds, it's less of an issue. But as long as the gap increases past six seconds, then a mandatory breath kicks in. Now, the other reason I wanted to show you this is that mandatory breath there just so happens to be a tad bit longer than that spontaneous breath, which goes back to the point that I wanted to emphasize. This graph is purely just to show you a difference, but I'm going to show you some epochs with that. In the time mode, this machine is going to just march on and ignore all of the patient's efforts. So regardless of what the patient is trying to do in terms of trying to trigger the machine, it's going to land up with no breath. So triggering is an important aspect as well. If you want to make the machine easier for your patient to initiate a breath with, you have to optimize the trigger. One of the more favorite modes that have now, I think, begun to, that has begun to take traction in the neuromuscular space is the pressure control mode. And the idea here is that it offers you the ability to do kind of spontaneous breaths, but each breath gets a fully designated eye time, okay? So you will not be able to separate out the assisted breath from the mandatory breath. And I find this a little tricky when you are doing titrations. We just had a patient the other day in the sleep lab, and I had to tell the tech, could you please let the patient fall asleep on ST mode, get an idea what the patient's spontaneous eye time is, and then we can find the right eye time and switch to T mode, I mean to PC mode, so that we make sure that we meet the patient's need. So there are, this is a paper that actually talks about some suggested settings, and I just want you to focus on the restrictive or the neuromuscular portion of that. Find a finite, a reasonable TI min and max range, if possible, because you do have the ability to sometimes set a range. Some machines are much more definitive, and set an optimal rise time. Now the trigger and the cycle are important words for you to understand, and it changes from machine to machine. So essentially, when we say the trigger is set high, it means it's set highly sensitive. If the machine is set with a low cycle sensitivity, it means we are allowing the peak inspiratory flow to drop low enough before it cycles into exhalation. So this is a 14-year-old boy with Duchenne muscular dystrophy who came for titration. This is back in the day where someone had to fail CPAP before they went on to bi-level, and what the arrows point to is one in capnometry. So think about this, this is a 14-year-old who's breathing, 32 minutes asleep. So that's tachypneic, and that's another point to think about, that these are patients who may not manifest hyperventilation, because this is relative hyperventilation to me. The CO2 is at 49, he's breathing at 32 a minute. If you were to slow him down, he'd definitely be hyperventilating. So you have a poor signal on your end tidal capnometry, your saturations are low, okay, and your transcutaneous CO2 is higher than your end tidal CO2. So this is a patient with congenital muscular dystrophy, and what the red arrows are pointing to are the capnometry channel, where you see a little deflection of the patient's effort. When you look at the C flow channel and the abdominal belts, so the blue arrows will show you that there's no effective ventilator breath being delivered, despite the black arrows that show you a patient's effort, right. So the things that you need to think about is, am I leaking too much, because my patient is not able to synchronize with my ventilator, or is my patient so weak that they cannot trigger the ventilator at that particular sensitivity. Okay, so these are the things that need to run through your mind when you see something like this. If someone is breathing like this, even though you have a rate of 10, the patient's rate is about 20 total, you're not getting effective ventilation. This is where I say it's important to take a look at your in-spirit time. In the red circle, there is the first breath on the left, is actually the mechanical breath, and you can see the duration of that is much shorter than the spontaneous breath which follows, because that initial negative deflection is missing on that spontaneous breath. So this was a relatively stronger patient with Duchenne muscular dystrophy, and it caught him just after he fell asleep, but things changed in REM sleep. So pay attention to what's happening when your patients are being set up on ventilation. Just a slide on volume assured therapy. This is something that allows, is a feature on bi-level modes, that really helps you either set the stage for optimal tidal volumes or minute ventilation. The pressure support is then varied based on what the tidal volume appears like to the ventilator. So the lower image on the left is a snapshot, is a scan from the Respironics trilogy manual, and that shows you that as the pressure remains constant for the first half of that 60 second sequence of breaths, but you see a progressive drop in tidal volume, but the tidal volume picks up as the pressures begin to rise. So in the Respironics system, you will tend to set, you will have to set up both a target volume as well as a rate, so it aims for minute ventilation. Now this has its own limitations which we can talk about later. In the ResMed section, you would consider setting a target volume and the height of the patient, so that would calculate what your minute ventilation, target alveolar ventilation would be. So I'm going to end with a question over here. This is an 18-month, 18-year-old Duchenne patient who comes for a titration study. He's got 25% lung function about a year ago and we're not repeating PFTs. He falls asleep with a nasal mask and this is what you're going to see. So ignore the part in the box. In the interest of time, I'm just going to walk you through this. What you're seeing is mechanical breaths being delivered in your C-flow channel and complete asynchrony of your patient when you look at the thoracic and abdominal channels. So my next question, and as you can see, your capnometry and your saturations are kind of bleh. So what are the next missteps? And the reason I framed it this way is because there are no easy, straightforward, single answers, so this is definitely not a board question. Do you increase your IPAP and EPAP? Can I get a show of hands for people who would say this? Okay, good. Would you increase your backup rate? Okay, two. Increase your eye time? Okay, a few over there. Control the leak? Good. Change the mode? Okay. Add oxygen? Good. Or switch to a volume-assured mode? All right, so let's go through this, right? So what you're seeing here is asynchronous breaths with the ventilator and the ventilator is not being triggered by the patient. So the rule I always have and I tell that techs in the lab is always check your leak first. If your patient is leaking, a weaker patient is not going to be able a weaker patient is not going to be able to produce enough of a trigger signal to the machine. Okay, there is no benefit right now at this stage of increasing your pressure if your patient is not synchronous. In fact, if your leak is the issue and increase your pressures, you could blow your leak even further and cause more asynchrony. Your patient is going to wake up. Increasing the backup rate may help, but in a case where the patient is already breathing so fast, it makes more sense to try and optimize the synchronization of the ventilator and the patient. Increasing the eye time at this point is not going to help you either. So definitely control the leak. You can consider switching to pressure control mode, but I think the first thing is, again, making sure your sensitivity and your leak is controlled. You can also switch to an altered volume control mode to assure optimal ventilator delivery, but again, the first thing you want to do is control your leak and optimize your sensitivity. And adding oxygen would not improve your patient's sensitivity. This is typically what will happen as you get a download and your patient falls asleep. The patient was sitting in bed watching TV for a couple of hours and fell asleep and pretty much rode his machine for the rest of the night. Okay, so that's how you deliver respiratory muscle rest. So when you think about patients triggered breaths, spontaneous breaths in a neuromuscular patient, the goal is to keep it low for overnight stuff. Those are my references, and thank you very much. Thank you. Awesome. So please pardon any kind of formatting changes which occur from Mac to PC transition, but hopefully the pictures and animation still came out OK. And so these are the devices that we're going to be talking about in this component. My name is Sri Nayak. I am primarily an adult pulmonary critical care and sleep physician, and I work for a system called Geisinger out in Pennsylvania. And I also am the program director for a sleep fellowship. And I love Pokemon Go still, even though it's been eight years since its inception. So I hope you guys do too, as we'll be alluding to some of that. So the goal of today is to really talk about the Trilogy and Astral devices, and how do you choose those versus the other bi-level devices and VAPs that Dr. Subnani spoke about. And also, what are the clinical applications? How do you choose between these two versus the devices Dr. Lussier is going to speak about? Whoops. OK, yeah, it wants you to navigate this here. And so there are many devices out there, and by no means is this slide comprehensive. Actually, in the left side, we see the bi-level S, or the EO470 and EO471 devices, which are the ACPT codes for those. And so one device brand that's missing there is the ResVent device, which is also a really good device. But yeah, those ones are cheaper. They run on the order of $1,200 to $2,000 for a lifetime for the patient, in addition to then mask supplies. They usually have to be plugged into a power source to run the entire time. The devices on the right are the home ventilator devices, some of them, and the ones that we'll speak about today. And those generally can run even if you don't plug into a power source for a little while. They deliver more pressures, and so they're more expensive. They run anywhere from $1,200 to $2,000 per month for every single month for as long as the patient's using the device. So a lot more expensive. And these two, of course, are the focus of now. So I'll start with a case. This is Shannon. She's a 54-year-old woman with a background history of prior severe OSA with the AHI 4% of 33 per hour. She had a really bad pneumonia one year, ended up in the ICU, and was intubated in this context. She couldn't wean from the ventilator and had tracheostomy. And she was discharged home from LTAC. She didn't wean. And so you're seeing the patient in clinic. And in clinic, you're weaning her, and you're successful getting her off on ambient air during the daytime. She's still using the vent at night. And this is often something we do in our clinic where our respiratory therapist, my partner Dahlia, she'll wean them during the day. And we get to the nighttime, and it's like, how do we now transition back to whether the patient needs NIV for night? So here's the poll. She lost 65 pounds, now weighs 185 pounds. You'd think she still has OSA, right? And based on her anatomy when you see her in clinic. And so she has not tolerated CPAP in the past. And you really want to decannulate her because you want to feel boss. And so you want to get her on NIV and decannulate her. Which of the following devices, if you were to use the vent noninvasively, can be used to see the AHI on the download? I don't know how this comes up. I think you. Oh, OK, look at that. Look at so many people did astral. That's cool when technology works and stuff. So there's so many ventilators out there. And sometimes you're thinking, oh, Luisa, is this this character from Encanto? No, that's really a ventilator. Although every time you see that ventilator, that song, you guys know, that song goes in your head, Luisa. And then sometimes you're like, is this really a ventilator? Or is that a Pokemon? Maybe it's Charjabug because they sneak right in there so you have to be careful, make sure in your talk that you don't have a Charjabug. So speaking first about the Trilogy devices, and also watching my time, Trilogy devices, these older ones on the left are still out there. And these are the devices that are recalled. They have very similar weight. You can get more presets on the Trilogy Evo. And they have very similar, I will say similar, but not the same type of modes. And what's really more cool for me with the Trilogy Evo is that it has a pressure control breath feature, which we'll talk about in the subsequent slides. And it also has the ability, like you have a ramp up button so that the pressures tend to ramp up in Trilogy very slowly, as the higher EPUB takes a really long time to ramp up. But you can push a button so that it ramps up faster. So if we're trying to apply this device to Shannon, I often find it easiest when learning about individual patients. So what we may end up doing is we may end up capping her trach all day. And then when she's ready at night, we might put a mask on her and try AVAP's AE mode. And so when we're doing that, how do we set it? And we'll look at, I don't know, you guys can't see my cursor. You can get the pointer to work. Yeah, it's definitely not on. Well, we'll pivot. We'll look at that picture on the right. We'll be Vanna White today. We'll look at the picture on the right. You can set the title volume, where it says 500 CCs. I'm just kind of guest meeting in this picture for ease of understanding and speaking about this. And a respiratory rate of 15. You will notice there is a sign that says EPUB min and max 5 over 5. I left it fixed here for ease of understanding. But that's essentially like our PEEP or your EPUB for your bi-level patients to stent the upper airway. For Shannon, we don't have to let that be a fixed number. We could set that to be a range if we're trying to figure out what pressures she needs to treat stent the upper airway that Dr. Subnani spoke about to address her obstructive component, and then the pressure support to kind of really address her ventilation if she has concerns with both and not just an obstructive sleep apnea component or just a ventilation component. You can set a range of pressure support, which again, your EPUB plus pressure support would equal your IPUB on your bi-level devices. And I'm trying to understand. So P max of 25, E is 5. Is there even a label for that? Yeah, so I have found that it depends on the device. But often, I feel like it focuses on the ventilation first. So it tries to figure out in a lot of scenarios what the tidal volume is. So what it'll do in this particular scenario is it'll start at a pressure support of 5 over 5, which is essentially bi-level 10 over 5. And it'll say, OK, is my tidal volume 500? And if it's not, it ramps up the pressure support first to a max pressure support of 20. And then it then goes to the EPUB. And you know, your point is really cool because sometimes if you don't set your max pressure high enough, you end up with a high AHI, which I've seen in a couple of patients. And then I'm like, oh my goodness, I need to change my ranges. But yeah, so once it fixes the ventilation, because you're more likely to die if your CO2 builds up. And so it fixes that. And then it ramps the EPUB is what I've seen. But insulation has obstructive risk also. So I think the EPUB minimum and maximum is set that obstructive risk will continue to happen. Absolutely. Absolutely. So I mean, so that way, the AHI could be because we are not treating obstructive risk to begin with. Absolutely, 100%. So the concern, just to reiterate into the recording, is that if we set a minimum fixed pressure of the EPUB, we're not addressing the OSA. We're just addressing the ventilation. 100% correct. So I just listed that there for ease of understanding. But for if you're doing the AE, here it's fixed as in the parentheses. You would, if you're using an AE, you would set a range of EPUB as well. So we can do that also, right? We can also do the EPUB minimum of 5 and EPUB maximum of 10 or so. We can set to do that setting too. Absolutely. And then you would have to adjust your maximum pressure support to make sure that you're giving enough room for ventilation. So you can go to maximum of 55, right? Yeah. Yeah. And so it depends on the patient. Sometimes I do like much higher pressures, 30, even 35. For us to go to 30? Yes. So I believe the trilogy goes to a max of 50 and even 60, actually. And then so I guess the point is that your patient may seem scary, like a Gyarados. And it's about using even a cute little mode like an AVAPS AE, like a P2, you can still get there. And as we had talked about, I feel like we've kind of talked about what the slide depicts. The bottom line is more so the desired volume. The dotted line is the desired volume. And the shark fins going by are the volume the patient's actually getting. If the patient gets adequate volume that we set, the IPAP does not ramp up. But whereas as perhaps physiology changes as you fall into deeper sleep, if your tidal volumes drop off, the IPAP readjusts. And so this is first, and then the EPUB ramps. Oh gosh, I should have gone through. And then pressure increases until you get to your goal tidal volume. And this is really important. That eye time that Dr. Subnani spoke about is really important. Because in the trilogy devices, the eye time on spontaneous breaths is not necessarily controlled. And so let's say in this first picture, your patient's going to have a tidal volume of 195. But Shannon really needs that 500 CCs. But if she's panicking and going that fast way, then even if we ramp up the pressure, she may not get her goal tidal volume. And so you're just ventilating dead space at some point. And so it's really important that we then, let's say Shannon's getting 435 CCs with a better eye time. If you control that eye time from breath to breath, changing that IPAP or the pressure support above may be more impactful in the patient. And so how do we do this in the trilogy devices? Because if it's not regulated from breath to breath, there's two ways. Either you're on the AVAPS AE mode, and you can put on the pressure control breath and save your eye time. And that allows you to still use the AE mode and address her concurrent upper airways, like OSA stuff. And so you can still change that IPAP min and max to where I've just listed as five over five here. Or you could put her in pressure control mode with AVAPS on. And so pressure control will regulate breath to breath again, but now you don't have that ability. You don't have that ability to change your IPAP. And so you then only, you lose the AE mode. And so that's the danger. Like, so if you have a concurrent OSA like in Shannon, you're not gonna be able to do that. Now, I never know what my patients really want. And I do guesstimate sometimes, and I'm like, hmm, your neck, my internal sleep physician's feeling like you'll need an IPAP of eight and I'll set it. But I could be wrong. The patient goes home, they're struggling. And then you don't wanna have a respiratory therapist go out. So you can set multiple modes for the same patient and you teach the patient and family to toggle between them. So really, any electric type Pokemon, in case you guys need education on that, can be used for water type Pokemon. And so you don't necessarily need to use a Pichu, you can use a Jolteon as well. And that's what you can set all at the same time, right? I choose you. And then there are these additional features. You can set a backup rate, or you could do like auto backup rate where the device picks it on its own. You can choose an EVAPs rate. It's usually in respironics, the devices take over two minutes to ramp up the pressure that IPAP to get to your goal tidal volume if you're not there. And how quickly you get there is determined by the EVAP. So going from that 10 over five to, do you go to 12 over five the next couple of breaths is determined by that rate. And so set that optimally. And then you can change the trigger sensitivity and eye time that Dr. Subnani referred to. In terms of downloads, what can you see? You can see the tidal volume and respiratory rate. And so you can see their usage. For anyone that's not used to looking at downloads, each of these horizontal bars with the colors in the bottom are different dates. And it allows you to see what time the patient's putting on their device, what's their patterns of use as well. And you can see things like a leak as well. What you don't see in the Trilogy devices is the AHI. And then there's a more detailed view where you can't, whoops, you can see the pressures that the patient's getting. This particular patient has COPD, and I do like a higher EPAP to kind of accommodate for any auto peep they may be experiencing. I think this patient has an FEV1 of 9%. It's very sick. And so his baseline pressures are like 25 over seven. He's six foot three. So the tidal volume is actually kind of low for him. And so you could see all that data. Now switching gears, that is also a Pokemon, is the Astral devices. And so the great part about the Astral devices is a little bit lighter. They also have multiple modes. And you'll find that most of the modes are very similar as well. And so most of the modes are very similar. The one contrast is the IVAPS mode. And the IVAPS and EVAPS are really just like different EV lutions, but they're really the same EV. And so what I mean by that is that, as Dr. Subnani spoke about, you set an alveolar ventilation. And so it's calculated based on the height. And what I circle on the top is that it allows you to see, based on the respiratory rate you're setting for the patient, which in this example is 15, and the patient's height, it says, okay, their alveolar ventilation, based on their internal algorithm, their minute ventilation should be 8.6 liters. And it divides that by that 15 you set. And it says, okay, that's gonna be your average tidal volume. And it tells you how many cc per kilo that is predicted body weight. And then you can change, you'll notice the cycle sensitivity and trigger sensitivity in the IVAPS mode. And again, what this graph depicts is pressure on the y-axis and time on the x-axis. And the dotted line is your target, and the red is what the patient's doing. So if the red and the dotted line meet, then it doesn't ramp up the pressure, whereas if your tidal volume's below goal or above goal, like on the right, it adjusts the pressures up and down. And so, but the target in IVAPS, once again, is not tidal volume, it's minute ventilation. And so in this cartoon above here, the patient is taking four breaths and 500 cc's each, whereas if you have a panicky patient who's taking 10 breaths a minute that are 200 cc's, you're still meeting the alveolar ventilation goal, but you're really not effectively ventilating. And so while the numbers are the same, you're not achieving the same goal. And so there are two ways to really get around it. There's the pressure control mode, where you can set a safety tidal volume, or there's alternatively, in the IVAPS mode, you can set the minimum PS a little bit higher, so it's your sneaky way of getting around it. But you can set the safety mode. The one limitation of the pressure control mode in the astral is that you then lose the ability to control the cycle sensitivity, which for me, if I have a COPD patient that was not effectively ventilating on IVAPS, and I'm switching to pressure control, it still just becomes harder. They're not gonna be able to exhale as easily, and I can't, if they can't exhale as easily, I don't have that ability to control that. And I like control, you know, just saying. And then these are additional modes available, so that's where you find the pressure AC. And so in the cloud, you're able to see the average pressures the patient is getting. You can see an AHI. And you can see, if you click down on the little arrow that looks like Louis Griffin's nose, you can actually see day-to-day data as well. And you can see total volumes and respiratory rates. When the patient, you know, where I live in northeastern Pennsylvania, sometimes I just don't have internet, even if the DME's giving patients devices with modems. And so what happens is sometimes you just can't get the data on the cloud. So we do make patients bring in their device to clinic. And you can see this level of data on the device screen itself under trends, which this is where you can find it. And so now I should, we should see 100% on this particular question. Which of the following devices allows you to see an AHI on the Download Trilogy or Astral device? The results show, oh, so mostly, mostly Astral. I'm gonna start all over again. All right, I'm just gonna do it again. All right, cool, awesome. And I'm just going to, you know, pass it over to Dr. Lussier, who will wrap it up. All right. Thank you all for coming to this session. I know we have some stiff competition out there for this one. So we appreciate you coming. I'm gonna talk about the rest of the ventilators that weren't covered. So my name is Bethany Lussier. I'm from Dallas, Texas, UT Southwestern. I work in neurocritical care and pulmonary critical care home ventilation. I don't have any real disclosures. I do a little trauma consulting for the NFL and that's not really super relevant to this, hopefully. When I was going to approach this, there's a lot that could be covered because I'm gonna cover all the other ventilators and there's so much that could be covered. I was like, no, let's just give everybody a little taste of what's out there. How many of y'all have used a Trilogy before? How many an Astral? How many a Vivo? Yeah, how many a Voxon? Yeah, it gets lower and lower and lower, right? And so that's what this is. If you've never touched them, you're gonna be less likely to prescribe them, less likely to use them. And when you have it sitting in your office, you're like, crap, what do I do with this? I tell the fellows all the time, touch the vent. Just touch it. You can't break it. You're not gonna break it. They're all locked for the most part, unless your patient's figured out how to permanently unlock it, which they all can figure out. It's on YouTube. But touch the vent, play around with it, because even if I go through this, even if you read the manual and you don't use it for six months, you go and you touch it again, it's gonna be hard to do. But they're all the same. They're all different, but the same. It's just what one feature has, the other one doesn't. I put this up there for a second so that we can do the next poll question, because I'm not sure if it's gonna actually work for you. So this is one of my patients. She's 53 years old. I do a lot of neuromuscular. This is a little different. But 53 years old, she had ASD, VSD repaired at 10 years old. She's got severe pulmonary hypertension. She's on Bosentin. For all of you who are out of your comfort zone, her right heart cath numbers are in the bottom corner. She has very severe scoliosis. Her FEC is .47. She's been progressive for years, hospitalized probably twice a year. She's on eight liters O2. She was really intolerant on prior attempts to use non-invasive ventilation. But of late, she's been tolerating BiPAP ST, 18 over five. But she's hospitalized again, and you're gonna send her home on a home ventilator. The question is, what would you do? I'm not really sure if this is going to work. So we'll see. I would say there's not actually a right answer. This is a what would you do? I'm not going to torture everybody with this, okay. Yeah, so I think most people are going to stick with what they're comfortable with, right? You're guaranteed that you're going to get some oxygen during the day. You use whatever system you use. Use your pendant, whatever it is. Free them up and then use your Trilogy or your Astral because you're comfortable with using that at night. But it's mostly because we don't know the capabilities of these other machines. And so we're going to go through some of what they are. I can't go all inclusive. We just, there's not enough time in the day. But you kind of have the old guard and the new guard at the bottom, right? The new guard is kind of some of these newer ones. They're not actually new. They've been around for 10 plus years. It's just they haven't hit the common market. They haven't been marketed particularly well. You'll notice the one on the bottom, the bottom right for you is going to be the Vivo. And you notice how nice and small that is? Everybody wants that vent. So if they've seen it and they've seen somebody who's had it, they're like, that thing's only four and a half pounds. I want that one. Patients who are on ALS websites will come in and ask you for a box-in because it's gotten a lot of press. So you're going to see these things. What they all deliver is this. They deliver dependable ventilation. It moves air in. It pulls air out. It's positive airflow. You can set multiple programs on all these devices, somewhere between three and five programs on all of these devices. It has an internal battery. The battery life varies by machine and by weight, frankly. They all allow for mouthpiece ventilation or sip and puff, whatever you like to call it. All of these have the capacity to do it. They have different algorithms for trigger. They can all be used for both invasive and non-invasive ventilation. And that's important to remember because the only thing you're going to get for your patient who has a trach is a ventilator, and these are all ventilators. So they can be used for invasive also. And then the cap is different. So I know we mentioned it before. I have a slide at the end that kind of is an overview, and it shows you the different caps on all these RAD devices, the respiratory assist devices, BiPAP, BiPAP-ST, IVAPs that are isolated. They're going to hit a max pressure of about 30. The newer one can hit up to 40, but it's just coming on the market now. But most of them are not going to get above a pressure of 30. Most of them don't get above 25, 26. And after about a year or two, the motor's fried. So if you want something that's going to consistently deliver high pressures, you're going to have to get one of these devices. And that's on any of those devices, old guard, new guard, whatever you want. The cost consideration, I mean, most of our patients are covered, and the cost tends to be similar among ventilatory devices. There are some difference for patients who are pay out of pocket or facilities providing the fee. If you, across the board, they're pretty similar in price. The biggest cost factor is who's going to maintain that device over time. So the patient never owns it. They may pay a monthly rental fee, and it can be up to $2,000 to $2,500. But what you're really paying for is the DMV to come and maintain this device. Familiarity is really what's guiding what patients are getting access to. The best ventilator for your patient is the one they can get hooked up to now. That's the bottom line. We can adapt any of these devices to work exactly the same way. And there's a few capabilities that are, other ones will offer you that you can take advantage of. So again, these are the three devices I'm going to go through in brief. Just an introduction, get your feet a little wet. I wish I had them to put your hands on, because that's always a better way to learn. Although, Dr. Sunani, I'll tell you, read the manual. I do agree with him. Boot. So, the Breas, or Breas, I don't know how they actually pronounce it at the company. I believe it's Breas. It's actually pretty easy. It's a pretty user-friendly machine. I will say that despite its weight, it tends not to be super popular among the elderly because it's a push button. So to navigate, you'll see the buttons at the bottom. That's how you switch between modes, activate, deactivate, say yes or no. And then how you change the settings are gonna be these ones over here. I think I can actually see. Nope, okay. Well, the left and right buttons and the up and down. So you're gonna navigate through your screen by pushing up or down, and then you choose the selection and you go left or right to change that setting. It's pretty straightforward. Unlocking devices. Unlocking devices. So your patient can't make changes unless the device is unlocked. You and your office, if you're gonna change the prescription, unlock the device. For a Breas, you hold down the left and the right. I didn't write it on the slide. I don't know if I'm supposed to be telling you this. You hold down the left and the right buttons at the same time, and it will unlock the device. You can scroll up or down. What is nice on the Breas, you can see here. I do like this a lot, actually. When you come down, you pick your setting. You wanna do a pressure mode, great. You put an eye pop, you put a peep, you do a rise. If you wanna adjust the rise, as you adjust it, it'll actually change that waveform so you can see what you're actually doing for the patient. And the same thing with your eye time, with your rates. So you can make the adjustments. You can set your backup rates. You can go through, it has all the, I'm gonna show you a page where it actually has the same settings for it. When you can go, you can go into your monitor setting, and it can actually give you an event alarm, and it gives you the time, the date it occurred, what the alarm was, what the situation was. And this is fun in the office if you're really nervous about the machine, you don't wanna unlock it, you don't wanna go into the prescriptions, but you wanna see what they're doing, or you just change the trach in the office, and they're struggling a little bit, you got a nice waveform, they give you the graphics right there, or the patient's telling you they're short of breath, you can actually have your patient send you a picture of the graphics, and you can get an idea of what they may be wanting, more air, less air, whatever it is. So those are kinda nice, and then the monitor will give you an actual readout so you can ask the patient, what is your peak pressure been running at home when you're on a volume mode, and they can give you an idea. So pretty nice there, they have good monitoring, they have an interface where you can actually monitor end-tidal CO2 or transcutaneous CO2, it can integrate with those machines. I'm gonna just jump ahead now, so the, Louise says the other one, don't sing the song, don't sing the song, we'll do that later. It's a really friendly machine, it's actually also pretty light, it's about eight pounds, pretty mobile-friendly, but you'll see that they were smart about this, it can be stood up or it can be laid down flat on a countertop, and it's got an angled screen so that people won't put their coffee cup directly on it. I'm not sure that's exactly why they did it, but it was a smart move. Really user-friendly, almost too user-friendly, I will say, because most of the patients have figured out you just hold the lock screen on the top to undo it, and so when they don't like the pressures you set for it, they can really easily change the pressures themselves. It's a touchscreen, so it scrolls really smoothly, and you just plop your finger on it, change the settings as you go. It has about 18 hours of battery life, because they have a six-hour internal, and then you can add in two additional batteries, so it can last a long time on battery-operated. The other nice thing about this is that it's got a high-flow oxygen, and it also has its own adapters if you wanna hook it up in a sleep lab to do titrations, and it has a lot of output monitoring, so it's capacity. This is just an example of what it's capable of doing. They have a high-flow therapy. In this particular one, you can go into the pressure modes and you can actually put in a TTS AVAPS, so it can do AVAPS, and it can do auto-EPAP, so it can do an AVAPS-AE, but there's a bunch of different options. It can do MPV in pressure and in volume control mode, and it can actually do it with the same circuit, which is interesting. Not everything can do that. It's got a bunch of different, I'm gonna skip through some of this, but I'm just trying to get you a little bit familiar if you've seen it. It's actually really easy to navigate through, and when you start going into, well, this doesn't project particularly well with the lights, but you can activate separate programs. You can do several on there. Once you've activated the programs, again, this is your AVAPS-AE. You can pick your range. A lot of us, when we're sending patients from the hospital and we wanna get a vent fast and we don't wanna battle the insurance companies to say, oh, I don't want a RAD device, I want a vent, you're like, oh, I'm just gonna put them on AE because you can't get that on a RAD device, but I can get it on a vent, so insurance companies have to say yes, and so we'll set this with a pretty narrow EPAP range, and then you can figure out where your patient falls. The monitoring is good. The downsides to a Luisa, and this is not supposed to be bias in any way, just to know what they are, things that we've heard a lot of, the power cord is terrible, it's really cheap, and so that has to get replaced, and it's an expense for the DME companies, and they hate it. They have had problems with some of the internal batteries in the add-ins, so it doesn't last as long as some of them do, but it's a rare problem. That's the biggest thing, and then the other thing is that they're still working on their platform for remote downloads on these devices, so there's that. I would say this is probably the one that you can get the least expensively, if you're, and it does integrate well with monitoring, really well with monitoring, and for high flow, so that's the biggest sell for this particular device. The Voxen, this, again, a lot of press in ALS, and it's because it's an all-in-one. That's the big selling feature for the Voxen. You can get different versions from Ventech that don't have the all-in-one. I'm gonna show you the next page here. Voxen is, it is, I don't wanna say it's not user-friendly. It's a little bit more challenging to navigate if you've never used one before as a provider when you're setting it up, but once it's set up, the patients find it incredibly easy to use. So this is the main screen. It's called the Voxen because it does ventilation, oxygenation, cough assist, suction, and nebulizer. It cannot do all of them at the same time, but it can provide all of them on the go, and that's the important thing to remember when you're using this device. If you have a patient who's on oxygen and they're on five liters per minute, and you go to cough assist, you need to pre-oxygenate them because it's not gonna deliver oxygen during the cough assist but you can very smoothly transition from ventilation. You're in the middle of ventilating, and then you just do three cough breaths, and then you go straight back to ventilation. It's all-in-one, great for travel, really long battery life, very heavy. It's like 18 pounds. The other downside to the Voxen, and it just depends on what you consider a downside, but for some patients, usually you can only get one. If you have a patient who's 24-hour dependent on ventilators, oftentimes you can get an insurance company to have one specifically mounted to the chair in another stationary. You usually can't get that with a Voxen. You get one, but it's because it's all-in-one and the battery life can be extended for so long. It is a little challenging in order to, so to unlock this one, it's not just a push button. You actually have to go into the initial settings. You have to go and find the serial number for the vent, and then you enter a code into the clinical settings as the last four numbers of the serial code. You can figure this out because there's YouTube videos where they go over the whole thing, but it is a little bit more challenging to get in to change it, but it also means it's pretty easy to navigate and not screw it up if you're not trying to make any changes to the vent. You can put three presets in it for ventilation. You can, this is so the oxygen mode, so if you click on oxygen, you're on ventilation, you click on the oxygen mode, and you can see, you can actually start, it has its internal concentrator, and you can bleed in oxygen. And you can actually adapt it to have a high-flow component to it, although the high-flow component too is not particularly well-worked out, so it's not typically used for that. And then you also can have a three-minute cycle where you can bleed in, it will do a six liters per minute flow for three minutes prior to a therapy if you want to do a cough therapy, suction, whatever it is. So that's kind of what it looks like. It's just kind of going through, right? So you can pick between your different modes. You start the ventilation, ready to go. When you're going through the settings, this is kind of what it looks like. It's pretty standard. It's all different but the same. You just plug in your settings. It's a nice scroll-through touch screen. You actually have a range. You can adjust manually on the bottom, or you can plug in your number for your target tidal volume, whatever you want to do, and you just accept it, and it's ready to go. The suction is interesting on these because it's great that it has suction in line. I'll tell you, the vast majority of my patients who have the suction set up don't use it when they actually still bring their portable device with them. Part of it's because it actually drains the battery. The other part is questionable if it's super strong. And they just, maybe they just don't trust the integrity. They haven't really told me. They just usually have a separate travel device. The cough is interesting also. You can actually adjust it. You can have three separate cough settings. Weak, strong, you can have hyperinflation therapy if you want to throw one in. And you can adjust it as you go. That you can adjust the settings and the cycle. So you can say, I'm gonna throw in three cough breaths, or I'm gonna throw in five cough breaths is my typical cycle. And the patient can actually pre-oxygenate if they need to, if they're on oxygen. And then you can just go into a smooth cough cycle and pull it through. These are kind of what my standard are. So I put them on the side. But you can set whatever you'd like for the cough assist settings. And you can set more than one. And then it gives you a feed out. So if anybody's ever used the T70 cough devices that are out there, it gives you a read out what the cough expiratory volumes are. And it will give you an estimate of a cough flow. I don't know how reliable the cough flow is, but I'm told it's actually quite good. But it's assisted cough. This is kind of what the transition looks like. Really smooth. And it actually does time it with a patient breath. So this is available on their website. But it will time the exhalation phase and the next portion of the inhalation. They'll do an inhalation breath and then it will cycle through. And it will do a complete three to five breaths, whatever you have it set at. And then it will just resume ventilation. Comparison. I know it's a heavy slide. But there's just like, it's just about wording. It's how they word it and where they apply it. So, and I can make these slides available to you if it's actually helpful. And I apologize at the bottom because I was trying to compile it. And this is, I personally compiled it. So it doesn't say at the bottom what the MPV mode is. To be, in all frankness, I've never used the mouthpiece ventilation mode on the Voxin personally. Most of my patients who are on it are past the point where they're going to need it. So I don't know what the setting is actually called. And that's why I apologize. I didn't put it on there. But they do have one. And they have their own circuit. So the Voxin circuit is unlike any other. You have to buy it from the company. But they have, you can see all of them have some version of a VAPS mode, which is viral volume targeted pressure support. Voxin doesn't have an AE, but the other ones do. They all have CPAP, although some of them you have to be a little creative. You put them on a SIMV and then just take away the pressure support portion of it. There's a way to achieve all of the modes just by tweaking the other modes. There's a capacity to do that. The two with the high flow, they can go up to 60 liters per minute. They do not require oxygen. So you can do high flow nasal cannula without oxygen, which is a really nice feature for some of our myotonic dystrophy patients or some of our upper airway. And you just want CO2 washout without oxygen because of that, for ventilatory support if they're struggling. So we've done that in the past. And then the internal concentrator on the Voxin is really nice too. This is a really comprehensive slide. It tells you all about the capabilities for circuits and the different types of displays and the interfaces that it is. So again, I can make these available to you if anybody needs them. A number of presets on all these devices and the different modes that are available. It's not super comprehensive, but it was an attempt. This is my last one. I'm not gonna open this up. So choosing the vent, right? You're gonna choose the vent that best suits your patient. The first available is the best one. The one that you have maintenance for is the second best one. And the decision on whether you need a vent is gonna depend on, yeah, do you have a tracheostomy? Do you need daytime ventilation? Do you need mouthpiece ventilation? All of these vents can do that. So my patient from earlier, 53-year-old woman, she has scoliosis. She's on a lot of high flow, she's on a lot of oxygen. So we chose something that has a high flow capacity for it. She wanted a somewhat lighter device. We could have gone with the Vivo. We could have gone with the Luisa in order to make sure that during the day she has access to high flow nasal cannula. O2, we ended up going with a Luisa. She really likes it. She flaps it on, she puts it on her counter when she's cooking. And then at night she actually goes on a controlled mode. She does very well with that. So she goes on full vent support at night and then during the day she uses the high flow nasal cannula. It's got a good battery life. That's what she really likes about it. The second patient there is 29. He's got myotonic dystrophy type one. Notoriously difficult to get compliant with non-invasive ventilation in general. And we tried BiPAP on this guy five times over the last 10 plus years and just fail, fail, fail. Horrible, horrible sleep disordered breathing. He's got an FEC that's 54% of predicted. He's a little bit hypercatholic in the mornings. For that guy we actually did a desensitization. So we put that guy on high flow with a Vivo just during the day and at night. We put him on a little bit of high flow as much as he could tolerate. And then over six weeks he actually walked up the high flow nasal cannula rate. So he was desensitized. After he got desensitized we moved into a mouthpiece. We incorporated mouthpiece ventilation during the day. At lower than normal, very much lower. Normally I'll start them at one and a half times their tidal volume. We started him super low. Got him acclimated to incoming pressures with some control and then transitioned him to positive pressure at night. And he's been compliant with his PAP therapy ever since. He still uses high flow nasal cannula when he's traveling. The last guy is a 54 year old guy. Rapidly progressive familial ALS. He has bulbar symptoms. He's wheelchair dependent. He just really enjoys travel. That's his thing. He wants to continue to travel. And so to support that we chose to get him an all in one. He doesn't require oxygen but he likes to have the suction capacity. He likes to have the all in one cough assist. And he's wheelchair dependent so we just mount his box into the back of his chair because of the weight. He just travels with it. So the choice is yours. You just need to know what you're getting. And they're actually really easy to use. Once you touch them you can't break them. And there's lots of references online if you wanna at any point go through and watch the videos. All of these companies have great YouTube videos. They're really five minutes shorts. I think they're actually really well done. And that's it. We're open for questions. I know we probably ran a little over but. Thank you.

ventilator devices

Trilogy

Astral

Voxen

user-friendly interface

monitoring systems integration

preset options

customization of settings

lightweight

portable