AVAPS and Auto SV Advanced

Emerson Kerr RRT, RPSGT

Hospital Readmission Rates

19.6

% Medicare Beneficiaries readmitted within 30 days of discharge

34 22.6

% Medicare Beneficiaries readmitted within 90 days of discharge

% Medicare Beneficiaries readmitted within 30 days of discharge with COPD Billion in expenditures for potentially preventable rehospitalizations reported by Medicare Payment Advisory Commission

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Source: Medicare Payment Advisory Commission, June 2005:83-103.

Hospital Readmission Reduction Program

Financial incentive for hospitals to lower readmission rates
Starting for discharges on October 1, 2012, must establish a program for preventable readmissions for 3 high-volume and/or high-rate conditions. Expanded by four or more conditions in FY2015 Hospitals with excess readmissions will have all payments reduced by an adjustment factor up to 1 percent in FY 2013 2 percent in FY 2014 3 percent in FY 2015 and beyond

Source: 2008 Homecare Provider Survey by Echo Strategies

Hospital Readmission Reduction Program

Initial Diagnosis Impacted in FY2013

Heart Attack Heart Failure Pneumonia

Beginning in FY 2015, expand the list of conditions to include chronic obstructive pulmonary disorder and others

Potential for Savings

NIV NIVSuccess SuccessRate Rate

100% 80% 60% 40% 20% 0% CHF COPD Hypercarbia

80% 89%

63%

80%

1998 2001

Cost Savings between $1,019,520 and $1,699,200 per year based on a decrease of 60 to 100 ventilator days per month in the ICU.

What do AVAPS and Auto SV Advanced have in common?

EASY TO USESIMPLE TO OPERATE EASY TO USESIMPLE TO OPERATE EASY TO USESIMPLE TO OPERATE

Bi-level with Average Volume Assured Pressure Support (AVAPS)

Acts primarily as a bi-level pressure support device but is able to provide a constant tidal volume with the AVAPS feature enabled.
Can be used with S, S/T, PC or T modes.

Automatically adjusts the pressure support level to maintain a consistent tidal volume
IPAP will automatically increase or decrease to maintain set tidal volume

Introducing BiPAP AVAPS/ST Noninvasive

Feature Benefit

Exclusive AVAPS Algorithm (BiPAP The Only Way of Ensuring the AVAPS Only) Delivery of a Target Tidal Volume Digital Auto-Trak Advanced Leak Sensing Technology
Easy Access to Patient Data

Encore Pro and Encore Anywhere

Wired, Wireless Modems, SD Card

Flexible Connectivity

Clinical benefits of AVAPS

Maintains ventilatory support and tidal volume during progressive ventilatory changes of the patient.

Maintains ventilatory support and tidal volume during positional changes during sleep. Provides the assurance of a tidal volume within a bi-level system. Alarms to indicate that tidal volume is not being maintained.

AVAPS Algorithm
Automatically adjusts IPAP to maintain a consistent tidal volume for patients with changing respiratory needs

Improved Patient Care is Now Automatic

AVAPS Feature
Why It Matters: Automatically adapts to disease progression and changing patient needs Improves ventilation efficacy Simplifies the titration process

Volume Assurance with PS is NOT recommended for patients with periodic breathing
Treatment of periodic breathing requires a variable breath by breath response system so the patients PaCO2 stabilizes quickly Prevents overshooting or undershooting the PaCO2 breath by breath Does not augment the patients tidal volume consistently Volume Assurance with PS does not have a quick variable response to changes in tidal volume. It is designed to adjust and maintain a constant tidal volume with each breath over time. This benefit often seen with patients who have slow declines in their ventilatory conditions.

AVAPS Benefits
Adapt to disease progression
Adjusts therapy to meet patients changing needs

Simplify titration process

No trial and error to get the desired tidal volume.

AVAPS Benefits
Improve patients ventilation efficacy
Focus is on tidal volume

Improve patients comfort

Uses the minimum pressure to achieve the target tidal volume

Increase safety by guaranteeing a minimum ventilation

No guessing if the patient is getting their prescribed therapy.

AVAPS Candidates
Patients that require a specific tidal volume throughout the progression of their disease
Neuromuscular Disorders ALS

Patients that require a specific tidal volume throughout the night

Obesity Hypoventilation

Patients that require a comfortable breath delivery with the knowledge that their volumes are being met
COPD

Which Patients Benefit from BiPAP AVAPS? Patients With Hypoventilation

Reduced amount of air enters the lungs, resulting in decreased levels of oxygen and increased levels of carbon dioxide in the blood.

Major Causes of Hypoventilation

Respiratory Muscle Weakness ALS, Muscular Dystrophy Restrictive Disorders Obstructive Lung Disease Scoliosis, Obesity Hypoventilation COPD, Cystic Fibrosis

Chronic Respiratory Insufficiency

Results
Supine body position demonstrated worse sleep efficiency AVAPS has better sleep efficiency in both body positions during REM Ve was greater with AVAPS regardless of body position or sleepwakefulness state

Conclusion
AVAPS was comparable to NIV-PS therapy with regards to sleep Ve was statistically greater with AVAPS
Ambrogio, C. et al., Sleep and non-invasive ventilation in patients with chronic respiratory insufficiency, Intensive Care Medicine, 2008.

Obesity Hypoventilation Syndrome

Results
TcCO2 decreased significantly during nocturnal BiPAP S/T with AVAPS. Sleep quality was comparable with both therapies

Conclusions
BiPAP S/T improved sleep quality in patients with OHS The addition of AVAPS provides beneficial physiological aspects resulting in a more efficient decrease of PtcCO2 as compared to BiPAP S/T alone.

Chest Sept 2006, Storre et all, Average Volume-Assured Pressure Support Ventilation in Obesity Hypoventilation: A Randomized Crossover Trial

Obesity Hypoventilation Syndrome

Results
TcCO2 was reduced from 45.5 to 42.4 mmHg Vt was increased from 670 to 764 ml Ve was increased from 9.5 to 10.8 L

Conclusion
Vt targeting improves correction of nocturnal hypoventilation in stable patients with OHS treated with NPPV Lower target Vt values may improve tolerance and patient comfort

Janssens J-P et al., Impact of volume targeting on efficacy of bi-level non-invasive ventilation and sleep in obesity- hypoventilation, Respiratory Medicine (2008)

COPD
Results
Baseline CO2 was decreased with both PS and PS with AVAPS Sleep Quality Score was decreased in PS with AVAPS

Conclusions
PS with AVAPS has similar efficacy to PS PS with AVAPS produces better effects on sleep quality

Clini, E; A Pilot study on Efficacy of Nocturnal AVAPS Mask Ventilation in Patients with Hypercapnic COPD

 Philips Respironics introduces a complete line of products with the AVAPS algorithm to allow for a continuity of care from the hospital to the home.

Improved Patient Care is Now Automatic

Digital Auto-Trak
What It Does: Automatically adjusts triggering and cycling Provides Advanced Leak detection Why It Matters: Recognizes and compensates for leaks Provides optimum patient/ventilator synchrony

Improved Patient Care is Now Automatic

EncorePro and Encore Anywhere Ventilation Data Management Software
What it does: Access data such as AHI, leak, clear airway apneas, and minute ventilation Connect to patients via wired and wireless modems plus an SD memory card Why it matters: Enables clinicians to monitor patient compliance, evaluate ventilation efficiency and identify trends

Encore Reports
IPAP and EPAP Respiratory rate Tidal volume % patient triggered breaths Peak flow

Total Leak
Minute ventilation Statistics Long term trends (past 12 months) Short term trends (past 8 days) Alarms Apnea Count

Summary of compliance

Encore Reports
Sleep Event Detection
Apneas, hypopneas, clear-airway apneas, exactly as the sleep devices

Wired and Wireless Modems

Same as the sleep therapy platform

Oximetry
Will bring in info from a Masimo Oximetry module and synchronize the data on an Encore report with other ventilator info

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Servo Ventilation Algorithm

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Clinical benefits of servo ventilation

Treatment for complicated breathing patterns such as: Central apnea Complex apnea Periodic breathing such as CSR Provides non-invasive ventilatory support to treat adult patients with OSA and respiratory insufficiency caused by central and/or mixed apneas and periodic breathing.

Confidential

Sector, MMMM dd, yyyy, Reference

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Servo ventilation algorithm

4 Minutes

On a breath by breath basis peak flow is captured Peak flow is monitored over a moving 4 minute window As 1 breath is added, the initial breath falls off

At every point within this 4 minute period an Average Peak Flow is calculated
The Peak flow target is established around that average and is based on the patients needs

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Servo ventilation algorithm normal breathing

IF: Peak flow is at target THEN: autoSV Advanced delivers CPAP pressure

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Servo ventilation algorithm decreased flow

IF: Peak flow falls below target THEN: autoSV Advanced increases pressure support

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BiPAP AutoSV
Sophisticated Three Layered Algorithm:
Safety Net
Primary Function
Leak Tolerance

Proactive Analysis

At the core is the proven REMstar Auto algorithm

#1 Goal: Normalize sleep (AHI, arousals, etc.)
#2 Goal: Minimize pressure

Lets take a look at these terms graphically

Auto EPAP - Looks like Auto CPAP!
Max pressure

EPAPmax
PSmin

PSmax 10 cm H2O PSmin 3 cm H2O

OA

PSmax

Auto EPAP

OA

OA

EPAPmin

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BiPAP autoSV Advanced Auto backup rate

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BiPAP autoSV Advanced Features & Benefits

Features Benefits
Less titration time and expertise needed
Better therapy acceptance Lower mean pressure Optimal pressure (Sleep stage or position dependant OSA) Adapts to changing conditions (allergy, alcohol abuse, weight, altitude, etc..) Guarantees minimum average pressure for all patients

Auto EPAP

More ADAPTIVE to meet Your Patients Changing Needs

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Popt No Improvement

Stable Breathing

10.0 to 11.5 to 10.0

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Obstructed Airway Apnea

Obstructed Airway Apnea

The BiPAP autoSV ADVANCED establishes a patient flow baseline using a moving flow signal window.
P therapy & P optimum 2 Apneas are necessary An obstructed airway to apnea increase pressure P critical AND Only 1 Apnea is necessary limited or no response to increase pressure from

is recorded when there is an 80% reduction in flow lasting at least 10 seconds

the flow signal with the introduction of a backup breath Encore reports each Apnea regardless of number necessary to change Pressure
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Obstructed Airway Apnea Detection

Event classified as an Obstructed Airway Apnea
EPAP Pressure increased (after 2-OAs)

No Flow Response!

Backup Breaths

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Obstructed Airway Apnea

12.5 to 13.5

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Clear Airway Apnea

Clear Airway Apnea

A clear airway apnea is recorded when there is an 80% P therapy & P optimum reduction in flow lasting 2 Apneas are necessary to at least 10 seconds
increase pressure

AND

critical there is aPresponse in the flow signal with the Only 1 Apnea is necessary introduction of a backup breath to increase pressure
Encore reports each Apnea regardless of number necessary to change Pressure

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Clear Airway Apnea Detection

Flow Response!

Event classified as an Clear Airway Apnea

EPAP Pressure NOT increased

Backup Breaths
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Clear Airway Apnea

13.0 to 13.0

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Hypopnea Detection

Hypopnea
A hypopnea is recorded when there is an 40% reduction in flow lasting at least 10 seconds
P therapy &increase P optimum NOTE: EPAP in response to a hypopnea that 2 Hypopneas are necessary shows obstructive characteristics, to increase pressure

ALSO, the Servo Ventilation algorithm (Breath by breath Only 1 Hypopnea is necessary adjustment of pressure Pressure Support), will attempt to fix the to increase hypopnea as the peak flow decreases

P critical

Encore reports each Hypopnea regardless of number necessary to change Pressure

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Hypopnea Response
During the time of decreased peak flow, the Servo Ventilation algorithm, will attempt to fix the hypopnea

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Hypopnea

Attempts to fix hypopnea

10.0 to 11.0

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Vibratory Snore Review

Vibratory Snore

P therapy & P optimum 3 Vibratory Snores are The BiPAP autoSVpressure ADVANCED necessary to increase P critical 2 Vibratory Snores are from Vibratory snores differ necessary to increase pressure

identifies vibratory snores by means of an internal pressure sensor.

audible snores Vibratory snores are airway pressure vibrations.
Encore reports each Snore regardless of number necessary to change Pressure

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Flow Limitation Review

Flow Limitation
Flow Limitations are identified as any change in inspiratory parameters

Shape Roundness Flatness Peak

2 of the four parameters must fall out of trend to be considered Flow Limitation
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BiPAP autoSV Advanced Features & Benefits

Features Benefits

More aggressive and effective treatment for Periodic Breathing (CSR) patients

Enhanced Auto Backup Rate

Complex Apnea patients Pain management patients Designed for clinical effectiveness across all patient classes

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Advanced Auto backup rate

Objectives:
1. 2. Determine clear vs. obstructed airway Find the best back up rate Do not overdrive the patient Spontaneous breathing is encouraged 3. Synchronize each breath to patients breathing patterns Do not deliver timed breaths when patient is still moving air Backup breaths are delivered in sync with patients previous spontaneous breathing pattern and most recent attempts so the rate may vary breath by breath. 4. Work with autoSV algorithms to meet breath by breath peak flow targets. 5. Utilize auto EPAP algorithms to maintain optimal airway patency.

Enhanced Auto Backup Rate

Objectives:
1. Find the best back up rate Do not overdrive the patient Spontaneous breathing is encouraged

2. Synchronize the breath to patient Do not deliver timed breaths when patient is still moving air

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Enhanced Auto Backup Rate

Backup Breaths are delivered proportional to patients spontaneous rate

Old algorithm used time constants Typically delivered between 10-15 BPM

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Multi-Layered Auto Backup Rate

TO PREVENT ANY CONFUSION: MULTI LAYERS are all part of Auto Backup Rate

Algorithm determines how aggressive to be on each breath

NOT different clinician settings CLINICIAN CHOOSES AUTO RATE

Backup Breaths
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BiPAP autoSV Advanced Features & Benefits

Features Benefits
Best patient synchronization
Provides better comfort to the patient

Digital Auto-Trak

Better leak compensation easier for HCP

Enables accurate peak flow targeting for ASV algorithm

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Evaluate your patient type

Complex Patients- Sensitive to pressure increases CHF- may be more likely to have Cheyne Stokes and/or central events, but may have strong obstructive component as well. Opioid users- May be more likely to have Cheyne Stokes or Centrals. COPD, hypoventilation

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What do you see?

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What do you see?

AM060606

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What do you see?

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What do you see?

AM060606

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What do you see?

S
A
Note square wave pattern of OSA recovery breathing. Different from CSR. Note difference in oximetry pattern.
OSA Normal

CSA

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What do you see?

Centrally mediated events tend to improve during REM sleep. Obstructive events get worse.

SDB goes away in REM. Is this pattern more likely OSA or CSR?

AM060606

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Periodic breathing (CSR)

Polysomnography

Oximetry
REM Sleep

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Triangular Paradoxical

Central or obstructive hypopnea? Likely response to CPAP?

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CMS Reimbursement Pathways

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autoSV acclimation zone

PC Direct

Trilogy Lab Titration

Why not use auto servo ventilation for a neuromuscular diseased patient?
Would continually reset its baseline, worsening the hypoventilation Normal target continues to decrease continues to under ventilate patient as the night progresses

Ventilation

Time

Why not use volume assured pressure support for Periodic Breathing such as Cheyne Stokes?
Volume assurance with PS does not respond fast enough event would be over before reaching needed pressure Length of event vs. time of response

BiPAP Auto SV Advanced

Auto SV Advanced
Periodic Breathing (Cheyne-Stokes) Central Apnea Complex Sleep Apnea

AVAPS
AVAPS Average Volume Assured Pressure Support
Trilogy and BiPAP S/T Trilogy Chronic Respiratory Failure

Hypoventilation Disorders
COPD Restrictive Lung Diseases Obesity Hypoventilation

Dont have to worry about the deadspace the device wont account for or an estimated minute ventilation Uses a proven algorithm for ventilation Delivers a Specific VT for the changing needs of both the stable and unstable patients

Just to remind you

Both AVAPS and Auto SV Advanced are..

EASY TO USESIMPLE TO OPERATE

Questions?