Deciding on treatment modalities based on TcCO2

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Deciding on treatment modalities based on TcCO2

Postby SlowWaveSiren » Mon Mar 11, 2013 7:33 pm

My lab is having constant discussions about the appropriateness of utilizing ASV on all patients with central apneas. As far as I have been told, ASV is for patients that are hyperventilating (exhibit low CO2). We have people who want to use ASV for patients with a higher CO2, which I believe is contraindicated. I realize that the MD has to order it, but at times, the CO2 level is not even discussed during this communication. In my mind, patients who hypoventilate should be using bilevel. Anyone care to weigh in?
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Postby somnonaut » Mon Mar 11, 2013 8:18 pm

I followed a policy this weekend on a titration of a 360# 46yo M,with AHI of 69 on Split. The policy called for titrating Central events as obstructive events IF they have 4% desaturations accompanying them. I got up to 14cm, all things clear, then some hypops and centrals, banged up to 16, then treatment specific Centrals right away so I backed off, then waited, then Centrals came back, so instead of 2cm, I only went up 1 cm, and then the Centrals re-ppeared a little while later, with desats, so I went up to 17 (fooled ya) and voila, the Centrals were abolished and the guy ended up with a 40+ minute REM period supine. BooYa!

Ahhh fun times.

I was discussing with my fellow tech about how would AutoPAP titrate this guy.
VPAP can affect both guranteeing that a person takes a breath (backup rae) as well as how fast a fast breather can breath (Inspiration time.) So, in effect you could control both through VPAP.
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Postby linuxgeek » Mon Mar 11, 2013 8:28 pm

somnonaut wrote:VPAP can affect both guranteeing that a person takes a breath (backup rae) as well as how fast a fast breather can breath (Inspiration time.) So, in effect you could control both through VPAP.


IMO bi-level only guarantees when the machine switches to IPAP and how long it stays on IPAP (to follow your example). That is a huge difference from saying that it guarantees the patient doing anything.

BTW, they added a Trigger signal in the latest EasyCare upgrade. Finally! I've been asking for this for about 7 years.
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Postby SlowWaveSiren » Mon Mar 11, 2013 8:29 pm

Awesome job! That sounds like quite a night! Did you monitor CO2 at all?
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Postby bduce » Mon Mar 11, 2013 8:30 pm

Well it depends on the patient disorder. The clinical guide for the ResMed VPAP Adapt used to have sleep hypoventilation as a contraindication but that has been removed from the latest version. It is not however in the list of indications - so an MD can utilise it for off label use.

However it does have severe bulbous lung disease as a contraindication which would make sleep hypoventilation due to COPD contraindicated.

In our lab our physicians use bilevel for sleep hypoventilation as you state. The reason is that there is no published data at the moment to suggest it has efficacy.

Good luck but remember physicians do have the discretion to use therapies for other disorders but also take the legal liability if it all goes down like a lead balloon.
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Postby SlowWaveSiren » Mon Mar 11, 2013 8:42 pm

Thanks bduce-

It just seems to me that with bilevel, you can ensure higher volumes and control the RR through the back up rate... Do you know of any specific studies that examined the efficacy of ASV with COPD/hypoventilation patients?
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Postby stars » Mon Mar 11, 2013 11:06 pm

our policy BMI 45 and up mandatory tco2 from start
patient with COPD /CHF / heavy smooker ,as well
Also for all patient with BIPAP ST mode and back up rate and ASV
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Postby stars » Mon Mar 11, 2013 11:09 pm

well for now we have IVAPS its work ok with COPD
Bduce in same case ASV work very well with MIXT COPD and CHF
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Postby SlowWaveSiren » Mon Mar 11, 2013 11:20 pm

Thanks Stars!

Those parameters are pretty sound. I'm curious if decisions to use bilevel vs. ASV are influenced by the CO2 trending...
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Postby somnonaut » Mon Mar 11, 2013 11:58 pm

LG, as usual you are correct, there is no gurantee, my bad wording.

Slowwavesiren, no this lab has no TcCO2 available.
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Postby SlowWaveSiren » Tue Mar 12, 2013 12:10 am

Somnonaut-

Thanks so much!
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Postby bduce » Tue Mar 12, 2013 5:55 am

LG - you were not the only one asking for that signal.

Slowwavesiren - no there aren't any at the moment. interested in a research project?

Stars - there is COPD and then there is severe bullous disease. People can have COPD but not have severe bulli in there lungs. Usually looking at an FEV1 below 50% with FEV1/FEV of less than 70% (of predicted).
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Postby RPSGT88athome » Tue Mar 12, 2013 10:31 am

Thanks guys last weekend I loaded version 6.1 and have not used it with a backup rate yet. I've been wanting that backup rate signal as well. Glad they finally put it in there!

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Postby bduce » Tue Mar 12, 2013 11:43 am

88
For compumedics you will create the channel in psg config with a stepped calibration like your position sensor. So I have three steps with trigger, spontaneous, then cycle as my steps. Trigger is 1V , spontaneous 0V and Cycle -1V.

They also put in the ramp finally. Makes it easier for staff to get a patient back up to pressure slowly after being disconnected eg voiding
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Postby RPSGT88athome » Tue Mar 12, 2013 11:46 am

can you post a pic on how you have it set up? I'd just like to see it. Does it have to be a seperate channel from Mask Pressure?

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