The Ups and Downs of Bi-level Pressure Therapy in Sleep

The Ups and Downs of
Bi-level Pressure Therapy in
Sleep disordered breathing
Shahid M. Ahsan, M.D.
Pulmonary Medicine
Critical Care Medicine
Sleep Disorder Medicine
Sigma Medical Group
Sleep Apnea
„
Sleep Apnea refers to the temporary absence or
cessation of breathing (airflow) during sleep.
Traditionally defined as 10 seconds for adults and eight
seconds (or more than two times the normal respiratory
cycle time) in infants.
„
„
„
„
Obstructive apnea: ventilatory effort but no airflow
Central apnea: no effort to breathing
Mixed apnea: no ventilatory effort, but an obstructive apnea
pattern is evident when effort resumes
Complex Sleep Apnea have a mixture of both OSA and CSA
Apnea Patterns
Obstructive
Airflow
Respiratory
effort
Mixed
Central
Sleep Apnea
„
„
Hypopnea: arbitrary decrease in airflow signal in
conjunction with arbitrary reduction in
oxygenation saturation measured by pulse
oximetry
Apnea-Hypopnea index (also called respiratory
disturbance index or disordered breathing event
index), which is number of apneas plus
hypopnea per hour of sleep
Upper Airway resistance
Syndrome:
„ A mild variant of obstructive sleep
disordered breathing
„ Patients present with complaints of
excessive daytime sleepiness,
polysomnography reveals loud snoring
associated with respiratory effort related
arousals
Guilleminault C, Sleep 1994;17:242-7
Medicare CPAP rules
• A single level continuous positive airway pressure (CPAP)
device is covered if the patient has a diagnosis of obstructive
sleep apnea (OSA) documented by an attended, facility-based
polysomnogram and meets either of the following criteria (1 or
2):
1) The AHI is greater than or equal to 15 events per hour
(Moderate OSA) ; or
• 2) The AHI is from 5 to 14 events per hour (Mild OSA) with
documented symptoms of:
a) Excessive daytime sleepiness, impaired cognition,
mood disorders, or insomnia; or,
b) Hypertension, ischemic heart disease, or history of
stroke.
OSA vs. Central vs. Complex
OSA starts with airway collapse
CSR : Pulmonary congestion/chemoreceptors/
circulation
Obstructive Sleep Apnea
Symptoms
¾
¾
¾
¾
¾
¾
¾
¾
Snoring
Excessive daytime sleepiness or Insomnia
Fatigue
Morning headaches
History of witnessed apneas
Complaints of impotence
History of High Blood Pressure
History of Depression
Pathophysiology of Apnea
Exam: Oropharynx
Exam: Tonsillar Hypertrophy
Shepard JW Jr et al. Mayo Clin Proc 1990;65.
Obstructive Sleep apnea
Mechanisms
Negative
Negative oropharyngeal
oropharyngeal
Pressure
Pressure
Primary events
Sleep Apnea
Decreased
DecreasedUpper
UpperAirway
Airway
Muscle
Activity
Muscle Activity
Small
SmallPharyngeal
PharyngealCavity
Cavity
High
Pharyngeal
Compliance
High Pharyngeal Compliance
High
HighUpstream
UpstreamResistance
Resistance
Apnea
Baseline arterial PO2
Degree of Diffuse Airways
Obstruction
Lung Volume
O2, CO2
pH
Chemoreceptor Sensitivity
CNS Arousability
Arousal From
Sleep
Resumption of
Airflow
Return to Sleep
Sleep Apnea
Apnea
↓O2, ↑CO2,
↓ pH
Arousal from
Sleep
Resumption of
Airflow
Decreased Pleural Pressure
Increased Cardiac Afterload
Left Heart Failure
Vagal Bradycardia
Ectopic Cardiac Beats
Unexplained Nocturnal
Death, Stroke
Pulmonary Vasoconstriction
Pulmonary Hypertension
Right heart failure
Systemic Vasoconstriction
Systemic Hypertension
Acute CO2
Retention
Chronic Hypoventilation
Cerebral Dysfunction
Loss Of Deep Sleep
Sleep Fragmentation
Return to Sleep
Excessive Motor
Activity
Excessive Daytime
Sleepiness
Intellectual Deterioration
Personality Changes
Behavioral Disorders
Restless Sleep
OSA and splinting of airway by
CPAP
Obstructed Airway
Patent Airway
CPAP Masks
Positive Airway Pressure: Problems
Positive Airway Pressure Mask:
Complications
Mean percentage days
CPAP used
CPAP Compliance
Time CPAP used
Kribbs NB et al. Am Rev Respir Dis 1993;147.
CPAP Compliance
• Patient report: 75%
• Objectively measured use
> 4 hrs for > 5 nights / week: 46%
• Asthma-medicine compliance: 30%
Mask fit is critical
•
•
•
•
Patients won’t use it unless it’s comfortable
Most manufacturers have a fitting guide – make a
point of using it
Many patients will need a chin strap to prevent air
leakage from the mouth
Poor fit can result in:
1. Air leaks, leading to increased flow rates as the CPAP
machine tries to compensate
2. Damage to skin because straps are too tight
Positive Airway Pressure Machines
Positive Airway Pressure Devices
• Continuous positive airway pressure (CPAP)
1.Positive end expiratory pressure (PEEP) or Continuous
end expiratory pressure (CPAP), acts as a pneumatic splint
to prevent collapse of the pharyngeal airway
2. Maintains a constant level of pressure throughout the
patient’s respiratory cycle during spontaneous breathing
3. Pressure range 4 to 25 cm water
4. Effective both in obstructive apneas and mixed apnea
5. Some central apneas are associated upper airway
resistance, so may help
Continuous Positive Airway Pressure (CPAP)
6. Simple apnea prevention is not the endpoint of CPAP
titration
7. Residual upper airway obstruction may present as
arousal only, so objective should be try eliminate
arousals
8. When correct CPAP pressure is reached the sleep
should no longer be fragmented by repetitive arousals
and in fact rebound slow wave sleep and rapid eye
movements REM sleep
9. Continued snoring is another sign of inadequate CPAP
pressure, so objective should be to eliminate snoring
during CPAP titration
Bilevel Positive Airway Pressure
(BiPAP)
1. Provides air at suitable pressures and flow rates for
patient ventilation assistance
2. Assistance is provided by administration of two levels
of positive pressure
3. During exhalation, pressure is variably positive or near
ambient, Expiratory Positive Airway pressure (EPAP),
range 4-25 cm water
4. Inspiratory level is variably positive and is always
higher than expiratory level, Inspiratory Positive
Airway pressure (IPAP), range 4-30 cm of water
Bilevel Positive Airway Pressure (BiPAP)
5. Responds precisely to changes in patient flow rates
which indicates movement to inhalation and exhalation
6. Reliably sense the patient’s breathing efforts to trigger
the change inspiratory effort
7. BiPAP spontaneous/timed (S/T) senses air flow in
patients circuit by using flow transducer, If the patient
fails to initiate an inspiration, the unit will cycle to
Inspiratory PAP (IPAP) preset interval determined by
synchronized rate breaths per minute (BPM)
Bilevel Positive Airway Pressure
(BiPAP)
Respironics® BiPAP® M Series with Bi-Flex®
Sleep Systems
¾BiPAP Auto combines auto adjusting bi-level pressure delivery with
the breath-by-breath pressure relief of Bi-Flex
¾Bi-Flex technology “softens” the airflow in inhalation and exhalation to
provide increased pressure relief, making breathing more comfortable
for the patient. Digital Auto-Trak™ Sensitivity works with Bi-Flex and
the auto algorithm to track each breath so that the device can cycle
between inspiratory and expiratory pressure based on the patient’s
breathing. The result is more natural and comfortable therapy.
Auto-titrating Continuous positive airway
pressure (Auto CPAP)
¾ Auto-PAP is the machine that has a system with
diagnostic capability of recognizing obstructive
respiratory events
¾ Parameters monitored by various systems include those
derived from airflow, pressure or snoring and other airway
sounds (e.g: airway vibration)
¾ Data suggest that severe OSAS can be accurately
identified by this machine
Auto-titrating Continuous positive airway
pressure (Auto CPAP)
It has not been established that unattended automatic
CPAP titration is safe without previous diagnostic
polysomnogram to establish the diagnosis of OSA
™ Other nocturnal breathing disorders like central sleep
apnea, chronic hypoventilation due to emphysema or other
diseases cannot be recognized with automatic CPAP
™ Patients are at risk for mask leak which may lead to
increased variability of CPAP pressures and associated
arousals
™
The amount of pressure required for effective CPAP therapy varies
according to sleep stage, sleep position, and other factors. Insufficient
pressure results in ineffective therapy while too much pressure can lead to
discomfort, non-compliance, and pressure-related side effects.
ResMed’s AutoSet SpiritTM is an automatic titration system for the
treatment of obstructive sleep apnea (OSA). AutoSet devices adjust
pressure on a breath-by-breath basis to suit patient needs as they vary
throughout the night. As a result, the patient receives the minimum
pressure required for effective therapy. The lower pressures may improve
patient comfort, reduce pressure-related side effects, and lead to increased
patient compliance.
The AutoSet algorithm responds to three key respiratory parameters:
Inspiratory flow limitation
Snore
Apnea
REMstar|pro 2 by
Respironics
¾The REMstar|pro 2 with C-Flex is an advanced, patient
friendly CPAP system. It is Encore Smart Card stores all
the data for exceptionally quiet and easy for patients to
use. It is packed with features that help accommodate the
needs of all types of patients. The downloading by your
physician. Now you don't have to take your machine with
you.
¾The REMstar|pro 2 delivers a wide pressure range to fill
the need of most patients. It is also tolerant for most
mask leaks. It provides an effective, comfortable form of
therapy.
REM Star C-flex CPAP machine
by Respironics
C-Flex positive airway pressure
• A complaint by those using conventional CPAP is that
it is difficult to breath out against the pressure
• C-Flex is designed to provide pressure relief during
exhalation
• C-Flex technology reduces expiratory pressure in
response to airflow, the relief pressure varies on a breath
to breath basis - depending on the actual patient flow
• 90% of a study participants believed that C-Flex was a
very comfortable
¾VPAP™ Adapt SV is an adaptive-servo ventilator designed
specifically to treat central sleep apnea (CSA) in all its forms,
including complex and mixed sleep apnea.
¾Unlike conventional SDB therapies such as CPAP, adaptiveservo ventilation:
¾Treats complex sleep apnea syndrome and central sleep
apnea
¾Normalizes breathing, completely suppressing CSA and/or
Cheyne-Stokes respiration (CSR)
¾Improves sleep architecture (the amount of time the patient
spends in slow-wave and REM sleep increases).
ResMed S8
Escape
¾Small, lightweight 2.9 pounds, robust, and travelfriendly.
¾* 12VDC and 24VDC power input via ResMed's 12
VDC converter and automatic international power
switching.
¾* Flexibile user management capabilities incluing the
ResScan Data Card that interacts with ResMed's PCbased user management system.
The adaptive-servo ventilation algorithm:
Adapts to the patient’s ventilatory needs on a breath-by-breath basis
automatically calculates a target ventilation (90% of the patient's
recent average ventilation) adjusts the pressure support to achieve
it.
Maximizing patient comfort and compliance
VPAP Adapt SV:
Ensures pressure support is synchronized to the patient's own
recent breathing rate and flow pattern provides a constant, low level
of pressure support.
Strategies to Improve Compliance
• Machine-patient interfaces
– Masks
– Nasal pillows
– Chin straps
•
•
•
•
Humidifiers
Ramp
Desensitization
Bi-level pressure
Comfort Series Nasal Mask by
Respironics
RESPIRONICS Comfort Lite 2
ComfortLite 2 uses its new "Halo" headgear and forehead
mechanism for stability. This allows the cushion to provide a
comfortable, reliable seal with no pressure points -- and that's why
we put special focus on the cushion
The ComfortLite 2 reaches an all new level of personalized comfort
with three cushion styles available: Pillows Cushion, Simple
Cushion and Direct Seal Cushion
Nasal Aire II nasal CPAP prong
The Mirage Swift nasal pillows system
provides Mirage comfort and quality in a
nasal pillows system. It's ideal for people
who want a light, flexible system that
provides a clear field of vision.
ComforGel mask by
Respironics
ResMed Mirage Activa
Mirage Activa -- the first nasal mask with ActiveCell Technology
Active Seal---dynamic seal and leak control during active sleep, all
night long.
Auto-stabilizing --- air-filled suspension keeps the cushion in place,
even when various forces pull or push the mask frame in different
directions.
ResMed Mirage Activa
Improved comfort --- due to reduced headgear strap
tension.
Easier fitting --- due to less dependence on headgear trap
tension.
ActiveCell Technology maintains an active seal and a
dynamic defense against leaks.
Fisher and Paykel Flexifit
405 mask
¾The Hybrid is a unique fusion of technologies, designed to be
a universal interface for patients, clinicians, providers and users.
This one product serves as a nasal interface, an oral interface,
and a combination of the two.
¾The Hybrid is a dual airway interface for use with positive
pressure ventilation devices for the treatment of respiratory
insufficiencies and obstructive sleep apnea. The unique design
of the Hybrid promotes patient comfort by eliminating pressure
points on the forehead and across the bridge of the nose.
The Mirage Kidsta™ Nasal Mask
by ResMed
Fisher and Paykel
The FlexiFit 431 Full Face Mask with Under Chin Design builds on
the foundation of the unique features common to the FlexiFit Series of
nasal masks.
The FlexiFit Technology has been incorporated into the contoured
Silicone Seal to allow a large range of nasal bridge movement and simple
one step auto adjustment fitting. The unique Glider Strap provides
freedom of movement while maintaining a seal.
Complex Sleep Apnea Characteristics
„
Characteristics of Complex Sleep Apnea
„
„
„
„
„
Complex Sleep Apnea is a mixture of OSA which converts
over to central apnea upon CPAP application and opening of
the airway 1
Minimal data available
„
1
Typically emerges during titration not during diagnostic PSG
Emerges with the implementation of CPAP to alleviate OSA events1
Occurs at ~ 30 second intervals vs. 60-90 second intervals with CSR
Estimated prevalence 1/7 or ~15% of the SDB population
Morganthaler, et. al. Sleep 2006; 29 (9):1203-1209
CompSAS: OSAHS and CSA
„
Complex Sleep Apnea Syndrome:
„ The 3 main forms of Central Sleep Apnea are: Idiopathic
Central Sleep Apnea, Complex Sleep Apnea or CheyneStokes Respiration, or Periodic Breathing.
„
Patients considered to have complex sleep apnea syndrome if
CPAP titration eliminated events defining obstructive sleep
apnea-hypopnea syndrome, but residual central sleep apnea
index was more than 5 or more per hour or Cheyne-Stokes
respiratory pattern became prominent and disruptive
Morgenthaler TI, et al, Sleep 2006; 29: 1099-1248
RAD policy requirements for Central or
Complex Sleep Apnea
Defines when a BiPAP® S/T (E0471) can be prescribed for a specific
patient population
Definition of Complex Sleep Apnea (form of central sleep apnea)
„ Persistence or emergence of central events upon exposure to
CPAP/BiPAP S when obstructive events have disappeared
„ Complex patients have predominately obstructive or mixed apneas
during the diagnostic sleep study occurring at > 5 events / hour
„ With the application of CPAP / BiPAP S, patterns of apnea and
hypopnea that meet the definition of CSA
What is Complex Sleep Apnea?
It is central apnea that emerges after the application of CPAP for OSA
Idiopathic Central Sleep Apnea –
Under PSG
•No output
from
respiratory
center of the
brain causing
lack of
movement of
the thorax.
•No movement
of thorax &
abdomen
causes apnea
„
Treatment Recommendations for
Idiopathic Central Apnea
Oxygen Therapy **
„
„
Oxygen Therapy and CPAP Therapy
„
„
Must have desaturation below 88% for 5 minutes or longer to qualify for oxygen
therapy (CMS guidelines) OR 89% for 5 minutes with history of either CHF, Pulm.
HTN, Cor Pulmonale or Increased RBC count
Must have desaturation + AHI >5 with EDS or AHI>15 without EDS (CMS
guidelines)
Medications:
„
„
„
Theophylline 1, 3
Acetazolamide 2, 3
Gradual reduction of opioid medications may improve
narcotic-induced CSA3
1 Orth, et al. Resp. Med. 2005;99:471-476
2 Javahari, S. AJRCCM: 2006:173(2) 234-237
3 Eckert, et al. Chest. 2007; 131:595-607
Remember:
<2% of SDB
Diagnosis of Central Sleep Apnea
Defines when a BiPAP® S/T (E0471) can be prescribed for a specific
patient population
CANNOT BE STRAIGHT OSA, MUST HAVE FORM OF CSA
Central Sleep Apnea
„ Apnea index > 5
„ Central apneas / hypopneas >50% of the total apneas / hypopneas
„ Central apneas or hypopneas > 5 times per hour
Recommendations for Implementation of S/T Titration
„
Titration done in the sleep lab
setting or home environment for
COPD, neuromuscular
abnormality, or restrictive disease.
„
Recommended starting points:
„ Start on S/T Mode
„ EPAP 4 cmH20
„ IPAP 8 cmH20
„ Rate of 8-10 bpm or 2 less
than patients’ set RR
„ I-Time: 1.2 seconds
„ Rise time: 2-3
„
Careful monitoring of sleep
parameters and blood gas
parameters should occur
(including CO2 if available)
„ Titration should occur
based on events
„
Monitoring of ventilation should
continuously occur to maintain
the patients original ventilation
levels:
„ Tidal volume (IPAP – EPAP)
„ Patient respiratory rate vs.
device rate
Assess & titrate
ventilation based on
Vt, Rate, SaO2 and CO2
compared
to baseline
Assess Vt:
Adequate?
Too
Small
Maintain EPAP
↑ IPAP
by 2
Return
Yes
Titration Protocol for S/T
Evaluate for Apnea –
OSA
Yes
↑ EPAP
&
IPAP by 1
Maintain ∆
Return
No
Assess Rate
and SaO2
Titration Protocol for S/T
Assess and titrate
ventilation based on
Vt, Rate, SaO2 and CO2
compared
to baseline
Evaluate back up rate:
Is it adequate?
No
Yes
With sleep-related events:
raise EPAP and IPAP by 1
SaO2 <90%?
With pulmonaryrelated issues:
add supplemental O2 1Lpm
Raise rate by 2 BPM
as needed
Assess I-Time
for comfort
Return
Return
Titration Protocol for NIV – Prescription Zone
„ Prescription for BiPAP®
S/T
„ Mode
„ Breath
Per Minute (if in S/T): 0 to 30 breaths/min
„ IPAP setting: 4 to 30 cm of water
„ EPAP setting: 4 to 25 cm of water
„ I-Time : 0.5 to 3.0 seconds
„ Ramp Time: 0 to 45 minutes
„ Humidification : Heated
Implementation of autoSV® Titration:
Complex Breathing
„
„
BiPAP® AutoSV® designed for patients who have mixed
apneas, complex apnea, periodic breathing or central apnea
Recommended starting points:
„
„
„
„
„
„
„
Switch mode to BiPAP® autoSV®
EPAP: last pressure that relieved obstructive apnea
IPAPmin: same as EPAP
IPAPmax: 25-30 cm H20
Rate: 8-10 BPM or 2 below spontaneous RR
Rise time: 2-3
I-Time: 1.2 sec
Treatment Recommendations
„
„
„
„
NO to CPAP for patients with Central Sleep Apnea and Heart Failure
due to CANPAP Results
Medical management of heart failure is KEY in treatment for resolving
CSR 1
„ This includes alterations in medications used to treat heart failure
If the patient has predominately OSA (<50% CSA)
„ CPAP can help with improvement of EDS or Sleep Apnea
If the patient has predominately Central Apnea (>50%)
„ Oxygen therapy 1
„ Bi-Level therapy with back up rate 2
„ Adaptive Servo Ventilation3
1 Javaheri, et. al. Curr Treatment Option in CV Med: 2005:7:295-306
2 Kasi, et. al. Circ. J.; 200569:913-921
3 Teschler et al, AJRCCM, 164:614-419, 2001
Implementation of autoSV® Titration:
Periodic Breathing
„
BiPAP® autoSV® is designed for patients who have mixed apneas,
complex apnea, periodic breathing or central apnea
„
Recommended starting points:
„ Switch mode to BiPAP® autoSV®
„ EPAP: 4 cm H20
„ IPAPmin: same as EPAP
„ IPAPmax: 10 cm H20 above IPAPmin
„ Rate: Auto
„ Rise time: 2 or 3
Titration Protocol autoSV®: Periodic Breathing
Assess Patient
Observe for
obstructive apneas
Yes
Raise EPAP, IPAPmin
and IPAPmax by 1
Return
No
Observe for partial
airway obstruction
Yes
If no leaks and obstructive,
raise EPAP by 1
Return
No
Observe for continued
periodic breathing and
central apneas not
corrected by auto-rate
Titration Protocol autoSV®: Periodic Breathing
Assess Patient
Central apneas not
corrected by auto-rate
Yes
Set fixed rate to minimum of
10 BPM or 2 below starting RR;
set I-Time for 1 – 2 sec
Return
No
Observe for
periodic breathing
Yes
Raise IPAPmax by 2 cm H20
Return
No
Summary of Treatment Strategies for SDB Patients
~5% have CSA or CSR
Treatment includes:
Medication mgmt.
Oxygen therapy
Bi-Level therapy
ASV therapy
OSA
CSA
~85% - 90% of patients
have OSA
Treatment includes:
CPAP or BiPAP S
Complex
~10% have Complex SDB
Treatment includes:
CPAP therapy
CPAP + Oxygen
Bi-Level Therapy
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¾The HC604 comprises ThermoSmart Technology, a
unique Fisher & Paykel Healthcare technology that
allows for optimum levels of humidity independent of
room temperature.
¾The levels of heated humidification being provided are
up to 50% higher than conventinal humidifiers are able to
deliver (up to 30 mg/l. Furthurmore, the technology
prevents condensation from forming and thus ensures
optimal pressure being delivered at the mask.
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Humidifiers
„
„
Heated humidifiers are intended to resolve the
symptoms caused by the effects of dry air, cool air
temperatures, and pressure, created by CPAP, on the
tissue in the nasal passage and upper airway.
Those symptoms are usually one or more, but not
always, of the following: Nasal congestion, sinus
congestion, nasal tissue bleeding, dry throat, dry
mouth, excessive dried mucus, and the numerous
arousals caused by the foregoing symptoms.
Humidifiers
„
„
Heated humidifiers are effective in resolving the
symptoms listed. However, environmental
conditions within the sleeping area can severely
effect the entire system.
Conditions such as placement of the CPAP flow
generator, room temperature, the breathing
circuit (tubing, mask or nasal pillows/seal) and
the length of the air tubing are key factors.
Humidifiers
„
„
„
„
Temperature at the ceiling is higher than at the floor. For
every foot of height there is about 1 degree temperature
increase.
If your CPAP is on the floor it will be drawing intake air
that is about 3 degrees cooler than the air at your nose level
and about 5 degrees cooler than the temperature at the
thermostat level.
If you sleep in a 65 degree (at thermostat level) bedroom,
the temperature on the floor is closer to 60 degrees; nose
level about 63 degrees. Remember, air entering your lungs
is 98.6 degrees and 100% relative humidity.
It is the job of the nasal tissue and the tissue in your upper
airway to warm and humidify the ambient air to body
conditions. If the air flow is to dry and/or to cool it can
cause the symptoms listed previously.
Humidifiers
„
We've learned that warm air can hold more
water vapor than cool air. We also learned
that a lower atmospheric pressure allows
more water vapor to form than higher
pressure.
CPAP and heated humidifiers
„
„
„
„
Applying these two principles to CPAP and heated
humidifiers we can reason that the lower the pressure and
warmer the water in the heated humidifier chamber, the
higher the relative humidity in the air flow.
Increasing the pressure increases the air flow rate and has a
squeezing effect on water vapor, lowering the relative
humidity.
In simple terms, if you are on high CPAP pressures you
need to run higher temperatures in your heated humidifier.
This can lead to rain-out and gurgling in the air tubbing.
To increase the relative humidity the temperature of the
water in the humidifier must be increased so there is more
water vapor available for absorption into the air stream.
Humidifiers
„
Secondly, your breathing circuit dissipates
heat rapidly. Every part of the mask or nasal
pillows, and tubing is made as light weight
as possible. When a sufficient amount
collects, the air flowing through the tubing,
reacting on the collected water, causes a
gurgling sound that will wake you.
Fisher & Paykel vinyl sleeve
Fisher & Paykel vinyl sleeve
„
„
In order to eliminate condensation in the tubing
and to deliver a warm humid air flow to alleviate
the symptoms caused by CPAP, the simple
solution is to insulate the tubing.
Fisher & Paykel offers a vinyl sleeve that goes
over the outside of the tubing and is held in
place by wide, heavy rubber bands. It forms a
dead air space around the tube.
Ramp Time
„
„
Pressure Ramp allows initiation of CPAP at a
very low positive pressure (2-4 cm H2O) to
higher preset pressure
Pressure can build on the preset time period that
range from 5 to 45 minutes, allowing the patient
to fall asleep before reaching higher levels o
prescribed pressure
Chin Restraint/Chin Strap:
Separate strap to help hold mouth closed
during CPAP treatment and reduce air
leaking from mouth.