Sleep Lab Titration Guide
Sleep Lab Titration Guide Table of Contents Introduction 1 S9 VPAP Tx Lab System.......................................................................2-3 ResMed Therapy Modes and Algorithms, Specifications...................... 4 S9 VPAP Tx Accessories.......................................................................... 4 Getting Started 5 VPAP Tx Control Panel ............................................................................ 6 At the Bedside.................................................
Introduction Introduction
Introduction 2 S9 VPAP Tx Lab System | Sleep Lab Titration Guide S9 VPAP™ Tx Lab System ResMed’s award-winning sleep lab titration system is designed with the patient’s comfort in mind. A truly all-in-one lab system, the S9 VPAP™ Tx delivers comfortable therapy and caters to all patient types, allowing them to fall asleep and stay asleep, so your titrations are an overnight success. The S9 VPAP Tx provides continuous positive airway pressure (CPAP) and bilevel therapy.
Lab Support 24 / 7 (888) 288-6738 | Sleep Lab Titration Guide 3 Delivering Efficient, Consistent Results Patient comfort features Sleep lab efficiency features Climate Control humidification technology intelligently adapts to environmental conditions and delivers optimal temperature and humidity right to the mask via ClimateLine™ tubing.
4 S9 VPAP Tx Lab System | Sleep Lab Titration Guide ResMed Therapy Modes and Clinically Superior Algorithms The S9 VPAP Tx puts access to all of our advanced titration modes at your fingertips to provide complete care across the full range of sleep disorders. ResMed technologies like iVAPS and ASVAuto — our unique bilevel modes — combine with innovative features like TiControl™ to make it easy and efficient to achieve comfortable, quality patient care.
Getting Started Getting Started
6 S9 VPAP Tx Lab System | Sleep Lab Titration Guide S9 VPAP™ Tx Control Panel Info menu button Setup menu button LCD screen Push dial Alarm mute button Getting Started Start/Stop button Alarm and therapy LEDs ResMed.com Key Function Start/Stop button Starts or stops treatment. Power Save mode — hold for three seconds. Info menu button Allows you to view the device service information or to exit from the menu. Setup menu button Allows you to make changes to settings or to exit from the menu.
At the Bedside At the Bedside
8 S9 VPAP Tx Lab System | Sleep Lab Titration Guide At the Bedside Setting Up the S9 VPAP Tx 1 Align the H5i with the S9 VPAP Tx and push them together until they click into place. 2 Connect the DC plug of the power supply unit to the rear of the S9 VPAP Tx. 3 Connect the power cord to the power supply unit. 4 P lug the USB Module into the Module/ Adaptor port at the rear of the S9 VPAP Tx. 5 C onnect the S9 VPAP Tx to the Tx Link via the USB serial cable.
Lab Support 24 / 7 (888) 288-6738 | Sleep Lab Titration Guide 9 Navigating the Menus 1 Turn until the parameter you require is displayed in blue. 2 3 4 Press . The selection is highlighted in orange. Turn until you see the setting that you require. Press to confirm your choice. The screen returns to blue.
10 S9 VPAP Tx Lab System | Sleep Lab Titration Guide Mask Fit Mask Fit is designed to help fit the mask properly to the patient. The Mask Fit feature delivers CPAP pressure for a three-minute period, prior to starting treatment. During this time, the mask can be adjusted to minimize leaks. To use Mask Fit: • Fit the mask as described in the mask user guide. • Press for at least three seconds. One of the MASK FIT screens is displayed (as shown on the right).
In the Control Room In the Control Room
12 S9 VPAP Tx Lab System | Sleep Lab Titration Guide Starting a Session Before you start titrating a patient, you need to start EasyCare Tx and then start a titration session. To start a titration session: 1. Double-click the EasyCare Tx icon on the Desktop. The EasyCare Tx toolbar is displayed and the default Tx Link is automatically connected. (If the Tx Link is not automatically connected, connect to a Tx Link.) 2. Configure Mask and Humidifier Settings. 3. Click the Therapy Start/Stop icon.
Lab Support 24 / 7 (888) 288-6738 | Sleep Lab Titration Guide 13 EasyCare Tx Toolbar Overview EasyCare Tx is designed as a user-friendly toolbar and allows remote control of a therapy device while displaying current therapy settings.
14 S9 VPAP Tx Lab System | Sleep Lab Titration Guide Configuring Mask and Humidifier Settings Adjusting Therapy Settings Configuring circuit settings Therapy settings Before starting therapy, select the mask type used by the patient and review the humidifier settings. Therapy settings can be controlled in two ways: • Mask Settings Mask Settings can be specified either at the bedside from the therapy device, or remotely using EasyCare Tx.
Lab Support 24 / 7 (888) 288-6738 | Sleep Lab Titration Guide 15 Detailed Settings Report Note: The session must be recorded to generate a Detailed Settings Report. An easy and efficient way to capture and display all pressure, mode and settings changes made during a session. 1 Record the session prior to starting therapy a. From the Menu drop-down, select Session > Record b.
16 S9 VPAP Tx Lab System | Sleep Lab Titration Guide Running and Printing a Prescription Report 1 From the Menu drop-down, select Reports > Prescription Report.This will open a separate window for the report. 2 Use the print, or save, report button at the top of the screen. Follow standard procedures for your computer. ResMed.
Technologies Technologies
18 S9 VPAP Tx Lab System | Sleep Lab Titration Guide Technologies Notes ResMed.
Lab Support 24 / 7 (888) 288-6738 | Sleep Lab Titration Guide 19 ResMed’s AutoSet technology Using a multiple-breath moving average, the AutoSet algorithm continuously monitors breathing and responds immediately to any airway changes, such as flow limitation, snoring and apneas. Event detection and response ResMed’s AutoSet assesses the severity of the event — whether it is limited flow, snoring or an apnea — determines the best pressure solution, and applies it without delay.
CPAP and AutoSet Technology 20 S9 VPAP Tx Lab System | Sleep Lab Titration Guide EPR™and Easy-Breathe EPR is designed to maintain optimal treatment for the patient during inhalation and reduce the delivered mask pressure during exhalation in the CPAP or AutoSet mode. The desired result of EPR is to decrease the pressure the patient must breathe out against, making the overall therapy more comfortable. Comfort levels EPR provides three comfort settings.
Lab Support 24 / 7 (888) 288-6738 | Sleep Lab Titration Guide 21 VPAP™ Technology Proven technology, effective treatment ResMed’s VPAP technologies ensure comfortable therapy and enable the clinician to fine-tune settings to a degree not possible in competing products. Backup rate, all ResMed Bilevel modes (not available on VPAP S) All bilevel modes on S9 VPAP Tx provide a programmable backup rate. The backup rate is manually set in ST, T, PAC and iVAPS modes. It is automatically set in ASV mode.
22 S9 VPAP Tx Lab System | Sleep Lab Titration Guide Patient Setups These settings are provided as a guideline for initial settings. Individual patients may require further adjustments based on their own conditions. Existing protocols within your facility should always supersede these baseline recommendations. Please reference the TiControl guide on page 24 for correlating Ti Max/Ti Min settings appropriate for each disease state and adjust based on patient’s resting respiratory rate.
Lab Support 24 / 7 (888) 288-6738 | Sleep Lab Titration Guide 23 Obesity hypoventilation syndrome (OHS) Recommended Settings Obesity Hypoventilation Syndrome IPAP [cm H2O] 15 EPAP [cm H2O] 7 Ti Max [sec] 1.5 1 0.8 Ti Min [sec]1 Rise time [ms] 300 Trigger sensitivity Medium Cycle sensitivity Medium PS [cm H2O] 8 2 Obesity hypoventilation patients often have reduced tidal volumes due to the additional weight pressing down on the chest and abdomen.
24 S9 VPAP Tx Lab System | Sleep Lab Titration Guide Setting TiControl ResMed TiControl: Ti Min and Ti Max Calculation Guide Restrictive Respiratory Frequency (bpm) Ti Min COPD Ti Max Normal Ti Max Ti Max 30 1.0 0.5 0.7 1.0 29 1.0 0.5 0.7 1.0 28 1.1 0.5 0.7 1.1 27 1.1 0.6 0.7 1.1 26 1.2 0.6 0.8 1.2 25 1.2 0.6 0.8 1.2 24 1.3 0.6 0.8 1.3 23 1.3 0.7 0.9 1.3 22 1.4 0.7 0.9 1.4 21 1.4 0.7 0.9 1.4 20 1.5 0.8 1.0 1.5 19 1.6 0.8 1.0 1.6 18 1.7 0.
Lab Support 24 / 7 (888) 288-6738 | Sleep Lab Titration Guide 25 iVAPS Technology (intelligent Volume-Assured Pressure Support) For hypercapnic, hypoventilating patients iVAPS is intelligent air iVAPS is ResMed’s intelligent Volume-Assured Pressure Support, a unique technology that simplifies the process of ensuring appropriate ventilation for the patient and reduces the need for frequent adjustments to therapy over time. The iVAPS advantage Intelligent.
26 S9 VPAP Tx Lab System | Sleep Lab Titration Guide iVAPS Technology Q&A iBR maximizes the patient’s opportunity to breathe spontaneously before bringing the patient back to target if backup breaths are required Which patients is iVAPS suitable for? Patient effort No patient effort Patient effort Breaths per minute 15 iVAPS is suitable for adults with respiratory insufficiency.
Lab Support 24 / 7 (888) 288-6738 | Sleep Lab Titration Guide 27 ASV Technology For normo/hypocapnic, hyperventilating patients ResMed’s ASV is the most clinically studied adaptive servo-ventilation therapy and has been shown to provide effective and comfortable treatment for a range of breathing disorders including obstructive, central and mixed apnea, periodic breathing such as CSR, and CompSA. ResMed’s ASV therapies are available on the VPAP Adapt.
28 S9 VPAP Tx Lab System | Sleep Lab Titration Guide The Most Responsive Algorithm ResMed’s ASV targets minute ventilation for optimal therapy outcomes ResMed’s unique ASV algorithm continuously monitors and learns the patient’s recent minute ventilation (tidal volume × breathing rate) and sets a target at 90% of this calculation. The Pressure Support then continuously adjusts to reflect the patient’s changing needs, reliably and steadily keeping patients on target all through the night.
Lab Support 24 / 7 (888) 288-6738 | Sleep Lab Titration Guide 29 Pressure Support response based on minute ventilation To successfully treat central and mixed apneas, minute ventilation should be stabilized. This is best achieved by constant monitoring of the patient’s breathing pattern, minute ventilation and nimble adjustment of Pressure Support to break the cycle of hyperventilation and central apneas that occur during CSA. Other ASV devices estimate the tidal volume based solely on the peak flow.
30 S9 VPAP Tx Lab System | Sleep Lab Titration Guide ASV Technology Q&A Which patients is ASV suitable for? What are the goals of therapy with ASV? This extensively studied therapy provides demonstrated results across the spectrum of central breathing disorders including: • Rapidly stabilizing breathing to stabilize blood gases4: The primary goal of ASV therapy is to stabilize ventilation, resulting in normalized PaCO2 levels to encourage stable breathing • Periodic breathing such as Cheyne–Stokes resp
Titration Protocols Titration Protocols
32 S9 VPAP Tx Lab System | Sleep Lab Titration Guide CPAP and AutoSet Therapy Sample Prescription CPAP Therapy Bilevel with Backup Rate Therapy S9 Elite S9 VPAP Adapt Pressure:______cm H2O (4–20 cm H2O) Ramp Time:______min(s) (OFF–45 min.) EPR™: 1 2 3 ASV Mode Default Mode Settings EPAP:______cm H2O (4–15 cm H2O) Min. PS:______cm H2O (0–6 cm H2O) Max. PS:______cm H2O (5–20 cm H2O) Ramp Time:______min(s) (OFF–45 min.) Backup Rate: automatic (15 BPM) 5 3 15 ASV Auto Mode Default Mode Settings Min.
Lab Support 24 / 7 (888) 288-6738 | Sleep Lab Titration Guide 33 Indications for CPAP therapy • Obstructive Sleep Apnea EPR comfort setting – Set to patient comfort (1, 2 or 3) • Upper Airway Resistance Syndrome Set mode to CPAP Initial pressure: 4–5 cm H2O A higher pressure may be required for re-titrations, patients with a higher BMI or patients complaining of air hunger or suffocating sensations.
VPAP Auto & VPAP S Script 34 S9 VPAP Tx Lab System | Sleep Lab Titration Guide VPAP Auto and VPAP S Sample Prescription CPAP Therapy Bilevel with Backup Rate Therapy S9 Elite S9 VPAP Adapt Pressure:______cm H2O (4–20 cm H2O) Ramp Time:______min(s) (OFF–45 min.) EPR™: 1 2 3 ASV Mode Default Mode Settings EPAP:______cm H2O (4–15 cm H2O) Min. PS:______cm H2O (0–6 cm H2O) Max. PS:______cm H2O (5–20 cm H2O) Ramp Time:______min(s) (OFF–45 min.
Lab Support 24 / 7 (888) 288-6738 | Sleep Lab Titration Guide 35 VPAP S Therapy Titration Protocol (bilevel spontaneous) Indications for S therapy • CPAP intolerance Has patient been on CPAP therapy? YES • Continued obstructive events at higher pressures NO • Hypoventilation with SpO2 < 90% Initial settings: Initial settings: • IPAP = CPAP settings • IPAP = 8 cm H2O • EPAP = 4 cm H2O below IPAP setting • EPAP = 4 cm H2O For obstructive apneas: • Increase EPAP by ≥1 cm H2O every ≥ 5 min • Increas
36 S9 VPAP Tx Lab System | Sleep Lab Titration Guide VPAP ST Sample Prescription CPAP Therapy Bilevel with Backup Rate Therapy S9 Elite S9 VPAP Adapt Pressure:______cm H2O (4–20 cm H2O) Ramp Time:______min(s) (OFF–45 min.) EPR™: 1 2 3 ASV Mode Default Mode Settings EPAP:______cm H2O (4–15 cm H2O) Min. PS:______cm H2O (0–6 cm H2O) Max. PS:______cm H2O (5–20 cm H2O) Ramp Time:______min(s) (OFF–45 min.) Backup Rate: automatic (15 BPM) 5 3 15 ASV Auto Mode Default Mode Settings Min.
Lab Support 24 / 7 (888) 288-6738 | Sleep Lab Titration Guide 37 VPAP ST Therapy Titration Protocol (bilevel spontaneous, timed) Indications for ST therapy Initial settings: • Neuromuscular/restrictive disorders • IPAP = 8 cm H2O settings • COPD • EPAP = 4 cm H2O • Obesity hypoventilation • Set backup rate at 2–4 below resting respiratory rate Continuously monitor sleep and blood gas parameters (including CO2).
38 S9 VPAP Tx Lab System | Sleep Lab Titration Guide iVAPS Sample Prescription CPAP Therapy Bilevel with Backup Rate Therapy S9 Elite S9 VPAP Adapt Pressure:______cm H2O (4–20 cm H2O) Ramp Time:______min(s) (OFF–45 min.) EPR™: 1 2 3 ASV Mode Default Mode Settings EPAP:______cm H2O (4–15 cm H2O) Min. PS:______cm H2O (0–6 cm H2O) Max. PS:______cm H2O (5–20 cm H2O) Ramp Time:______min(s) (OFF–45 min.) Backup Rate: automatic (15 BPM) 5 3 15 ASV Auto Mode Default Mode Settings Min.
Lab Support 24 / 7 (888) 288-6738 | Sleep Lab Titration Guide 39 iVAPS Therapy Titration Protocol Indications for iVAPS therapy Initial iVAPS settings: • Neuromuscular/restrictive disorders • Set Patient Height (eg, 70 inches for 5’10”) • COPD • Set Target Pt Rate equivalent to patient’s spontaneous respiratory rate (eg, 18 bpm) • Obesity hypoventilation • Set Target Va such that Vt is equal to 6ml/kg IBW • EPAP = 5 cm H2O • Min PS = 4 cm H2O Once a patient is fitted with an appropriate mask, select
40 S9 VPAP Tx Lab System | Sleep Lab Titration Guide VPAP Adapt Sample Prescription CPAP Therapy Bilevel with Backup Rate Therapy X S9 VPAP Adapt S9 Elite ™ Pressure:______cm H2O (4–20 cm H2O) Ramp Time:______min(s) (OFF–45 min.) EPR™: 1 2 3 ASV Mode Default Mode Settings EPAP:______cm H2O (4–15 cm H2O) Min. PS:______cm H2O (0–6 cm H2O) Max. PS:______cm H2O (5–20 cm H2O) Ramp Time:______min(s) (OFF–45 min.
Lab Support 24 / 7 (888) 288-6738 | Sleep Lab Titration Guide 41 VPAP Adapt Therapy Titration Protocol Indications for ASV therapy Begin therapy with default settings • Periodic breathing, both normocapnic and hypocapnic • Other forms of central and concomitant obstructive events1 (mixed sleep apnea) • Complex sleep apnea (CompSA)2 Excessive leak Leak is greater than 24 L/min Adjust or change mask until leak fixed The guidelines below can help to set up and treat patients with central breathing disorde
42 S9 VPAP Tx Lab System | Sleep Lab Titration Guide Titration Notes Notes ResMed.
Reimbursement Reimbursement
44 S9 VPAP Tx Lab System | Sleep Lab Titration Guide Reimbursement Notes ResMed.
Lab Support 24 / 7 (888) 288-6738 | Sleep Lab Titration Guide 45 S9 VPAP Adapt Reimbursement Coding MD – Primary care physician ICD-9 Codes Sleep-related breathing disorders, hypersomnias, circadian rhythm sleep disorders, parasomnias, sleep-related movement disorders (a listing of ICD-9 codes related to sleep disorders can be found in the ResMed Reimbursement Manual) EXAMPLE: 780.
ResMed.com Patient has had a Medicare-covered sleep test2 that meets either of the following criteria: ❑ Patient and/or caregiver has received instruction from the supplier of the CPAP device and accessories in the proper use and care of the equipment. ❑ Yes No Has CPAP been used < 3 months? (ie, CPAP is tried and found ineffective during the initial 3-month home trial) If “No,” a new initial face-to-face clinical evaluation is required but not a new sleep test.
Clinical re-evaluation and documentation of adherence on the bilevel by 120th day from CPAP initiation Clinical re-evaluation and documentation of adherence on the bilevel between 31st – 91st day from CPAP initiation 2. Repeat sleep test in a facility-based setting (Type 1 study). 1.
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4. Symptoms of either excessive sleepiness or disrupted sleep 3. Central apneas or hypopneas ≥ 5 times per hour 2. Central apneas/hypopneas > 50% of the total apneas/hypopneas 1.
Sleep Lab Titration Guide Swift™ FX Pair S9 VPAP Tx with ResMed’s premium masks for successful overnight titrations. Mirage™ FX Quattro™ FX ResMed Corp San Diego, CA, USA +1 858 836 5000 or 1 800 424 0737 (toll free). ResMed Ltd Bella Vista, NSW, Australia +61 (2) 8884 1000 or 1 800 658 189 (toll free). See ResMed.com for other ResMed locations worldwide. S9 Elite, S9 Escape, TiControl and VPAP Adapt SV are trademarks of ResMed Ltd.
