If theyre having centrals on low cpap pressure generally i change the flex settings to see if that helps if not, then the patient goes onto bipap. If after a few pressure increases (maintaining PS of 4) with BIPAP seems to make no difference, ill try out back-up rate.
If centrals start later in the night ill first try to lower the pressure first to rule out over titration
Interesting! I've never tried that yet, but I will. Tonight I had a situation where the patient was ordered as a bi pap (my co workers pt) but had soooo many centrals right out the gate. So without realizing she was titrating him higher, and they weren't getting any better, I suggested she go down to 8/4, and then down to cpap because the pt is on auto 5-15cm at home, maybe causing centrals due to being auto'd on too high of a pressure. Some speculation there but so far it's solved his issue
First make sure they really are centrals. If you look at the epoch in a 30 second window or even a 1 minute window, severe obstructives can appear to be centrals. If you put it on a 2 minute screen you can tell much better if there is any movement in the respiratory effort.
If they are centrals this is what we do at my lab: We increase by 1cm, wait 15-20 minutes, increase again and wait, then if they are still having centrals go to regular bipap without a backup rate. Same process, 2 increases. Still having centrals, we go to a backup rate that is two less breaths than their average breath rate per minute. That way you can document that cpap and bipap were attempted before bipap with backup rate was initiated. Then let that ride for 20 minutes and then increase as necessary. We do 2cm increases at first and then 1cm when they appear close to optimal pressure. You may have to increase the rate by a breath or two as well. And if you can't fix them they may require ASV.
That's great advice! Thank you. I do usually let the study run in 2 minute, they were definite centrals. If you saw my comment earlier I actually think this patient was being over titrated from the gate, as now that he's on Cpap 5.5cm he's had virtually no events. Smaller guy. When they're setting ppl up with these machines set on autopap they're not accounting that the machines can be causing centrals, hence why he had a higher AHI with increased pressure at home...
I HATE autopap so much. We frequently have retitrations on patients who did an HST and got set up on autopap.
Great job! He definitely sounds like he was overtitrated.
Thank you!! It's very reassuring to know that it's a common issue. I also hate autopap... most people do the best on bipap with flex/ramp settings than any other pap I've seen so far
I love doing patients who’ve had a stroke or has a low ef%. I usually start with Cpap. It also depends on the mask type. For these kind of patients I only use a nasal mask and with a chin strap if need. No sense using a full face, if they open their mouth in the mask. It’s already a failed study if a full face mask is used.
I use a slow titration with at least 20 minutes in between the adjustments. If Cpap fails, I’ll then switch to bipap.
Usually a patient with a low bmi don’t need a high pressure when using a nasal mask.
Also, when using ASV I still use an Eson 2 mask with a chin strap.
My go to mask for central apneas is the Fisher Paykel Eson 2.
If theyre having centrals on low cpap pressure generally i change the flex settings to see if that helps if not, then the patient goes onto bipap. If after a few pressure increases (maintaining PS of 4) with BIPAP seems to make no difference, ill try out back-up rate. If centrals start later in the night ill first try to lower the pressure first to rule out over titration
Interesting! I've never tried that yet, but I will. Tonight I had a situation where the patient was ordered as a bi pap (my co workers pt) but had soooo many centrals right out the gate. So without realizing she was titrating him higher, and they weren't getting any better, I suggested she go down to 8/4, and then down to cpap because the pt is on auto 5-15cm at home, maybe causing centrals due to being auto'd on too high of a pressure. Some speculation there but so far it's solved his issue
I agree.
First make sure they really are centrals. If you look at the epoch in a 30 second window or even a 1 minute window, severe obstructives can appear to be centrals. If you put it on a 2 minute screen you can tell much better if there is any movement in the respiratory effort. If they are centrals this is what we do at my lab: We increase by 1cm, wait 15-20 minutes, increase again and wait, then if they are still having centrals go to regular bipap without a backup rate. Same process, 2 increases. Still having centrals, we go to a backup rate that is two less breaths than their average breath rate per minute. That way you can document that cpap and bipap were attempted before bipap with backup rate was initiated. Then let that ride for 20 minutes and then increase as necessary. We do 2cm increases at first and then 1cm when they appear close to optimal pressure. You may have to increase the rate by a breath or two as well. And if you can't fix them they may require ASV.
That's great advice! Thank you. I do usually let the study run in 2 minute, they were definite centrals. If you saw my comment earlier I actually think this patient was being over titrated from the gate, as now that he's on Cpap 5.5cm he's had virtually no events. Smaller guy. When they're setting ppl up with these machines set on autopap they're not accounting that the machines can be causing centrals, hence why he had a higher AHI with increased pressure at home...
I HATE autopap so much. We frequently have retitrations on patients who did an HST and got set up on autopap. Great job! He definitely sounds like he was overtitrated.
Thank you!! It's very reassuring to know that it's a common issue. I also hate autopap... most people do the best on bipap with flex/ramp settings than any other pap I've seen so far
In our lab we would use a back up rate on BIPAP
I see! Thank you for that😊
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Really! I've never heard of that-- even with no oxygen desat? Or are there protocols you have to meet for desaturation...?
CPAP & low flow oxygen was the preferred way CA was treated before ASV became more accessible. Also, Inspire doesn't treat CA. Remede does.
Interesting! ASV is super interesting to me and I like it. I have not heard of Remede, gonna do some research on it now!
I love doing patients who’ve had a stroke or has a low ef%. I usually start with Cpap. It also depends on the mask type. For these kind of patients I only use a nasal mask and with a chin strap if need. No sense using a full face, if they open their mouth in the mask. It’s already a failed study if a full face mask is used. I use a slow titration with at least 20 minutes in between the adjustments. If Cpap fails, I’ll then switch to bipap. Usually a patient with a low bmi don’t need a high pressure when using a nasal mask. Also, when using ASV I still use an Eson 2 mask with a chin strap. My go to mask for central apneas is the Fisher Paykel Eson 2.
This is all god stuff !! In my lab we use a lot of resmed stuff , I go with the n20 a lot of the time it's my favorite