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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 ..................................................................................... 7
Setting Up the S9 VPAP Tx .................................................................... 8
Filling the H5i Water Tub ...................................................................... 8
Navigating the Menus ........................................................................... 9
Mask Type and Tube Settings ............................................................... 9
Mask Fit ............................................................................................... 10
Viewing the Treatment Screens .......................................................... 10
In the Control Room ......................................................................... 11
Starting a Session ............................................................................... 12
Manual Connection to a Tx Link .......................................................... 12
EasyCare Tx Toolbar Overview ............................................................ 13
Configuring Mask and Humidifier Settings ......................................... 14
Adjusting Therapy Settings ................................................................. 14
Detailed Settings Report ..................................................................... 15
Running and Printing a Prescription Report ........................................ 16
Technologies 17
CPAP and AutoSet Technology ............................................................. 19
VPAP Technology .................................................................................. 21 iVAPS Technology ................................................................................. 25
ASV Technology .................................................................................... 27
Titration Protocols 31
CPAP and AutoSet Titration ................................................................ 33
VPAP Auto and VPAP S Titration ......................................................... 35
VPAP ST Titration ................................................................................ 37 iVAPS Titration .................................................................................... 39
ResMed’s VPAP Adapt Titration .......................................................... 41
Reimbursement 43
VPAP Adapt Reimbursement Coding .................................................... 45
Medicare Policy for Treatment of OSA ...........................................46-47
Respiratory Assist Device (RAD) Qualifying Guidelines .................48-49
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.
The S9 VPAP Tx is a component of the S9 VPAP Tx Lab System. The S9 VPAP Tx Lab System provides remote PC control of a positive airway pressure therapy device (therapy device) capable of delivering multiple therapy modes. The system comprises:
EasyCare Tx software
• On-screen remote control of the therapy device
• Highly customized for the clinical environment to help manage a wide range of patients from one system
• Creates summary reports and prescriptions
Tx Link
• Provides connectivity between the software and therapy device
• Seamlessly integrates with all existing major PSG systems, relaying real-time signals measured by the therapy device directly to the polysomnography (PSG) equipment
S9 VPAP Tx therapy device
• Built on the award-winning S9 ™ small, sleek, silent
platform —
• Makes treating a wide range of patients possible with adult and pediatric therapy titration applications
• Uses Climate Control, ResMed’s most advanced humidifcation technology, to maximize patient comfort and minimize overall titration pressure
EasyCare Tx
Software
ResMed.com
Tx Link
S9 VPAP Tx
Therapy Device
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Delivering Efficient, Consistent Results
Patient comfort features
Climate Control humidification technology intelligently adapts to environmental conditions and delivers optimal temperature and humidity right to the mask via ClimateLine ™ tubing. Our Climate
Control technology simplifies titration while significantly reducing rainout and dryness issues, which can lead to an average increase in usage of 30 minutes.
1
Sleep lab efficiency features
ResMed’s award-winning S9 platform makes patient therapy acceptance simple with all of ResMed’s essential and advanced modes, now on the award-winning S9 platform.
Working together with the whisper-quiet motor, Easy-Breathe waveform and user-friendly design, the S9 VPAP Tx enables technicians to provide patients a comfortable, easy-going experience for their first night on therapy.
Whisper-quiet operation minimizes therapy disruptions — as one of the quietest home therapy devices on the market
— now available in our all-in-one lab titration device (26dBA).
Intuitive and easily customizable software reduces training time and allows navigation and control of all settings at the bedside and control room, enabling technicians to manage multiple patients across a spectrum of disorders in the same night for increased efficiency.
Mask Fit feature displays real-time leak when fitting the mask at the bedside and ensures the selected mask has a proper seal before starting titration.
Color LCD provides quick access to therapy settings for easy device navigation at the patient’s bedside.
Detailed Settings Report
General Information
Report generated on :
From Date/Time :
To Date/Time :
Location :
Tx Link Serial No :
PAP Device :
PAP Device Serial No :
File Name :
19 March, 2013
18 March, 2013
19 March, 2013
Bedroom 1
20111372537
S9 VPAP TX
22111308216
Patient 01 19Mar13.rdf
9:13:10 am
9:13:25 am
7:14:54 am
Guided mode transitions eliminate sudden changes in pressure and enable a smooth transition from one mode or pressure to another.
Customizable default settings enable customization of therapy settings according to your lab protocols.
ResMed Sleep Lab
Therapy Information
Therapy: ResMed CPAP
From: 9:13:25 am To: 12:15:40 am
Settings Data
Time Pressure
9:13:25 am
10:46:32 pm
4.0
50
0
3
Therapy : ResMed ASV
From : 12:15:44 am
Settings Data
To : 7:14:54 am
Time EPAP Max PS
12:15:44 am 5.0
3.0
1:16:10 am 6.0
3.0
1:47:21 am 7.0
3.0
Therapy :
EPAP :
Max PS :
Min PS :
Patient John Smith Date :
Address : 9001 Spectrum Blvd.
City :
Equipment Provider :
EPR™ Inhale
Phone#
Licence#
03/19/2013
San Diego
AP5836727
Diagnosis :
Medium
Mask :
Setting : Nasal
Other
Min PS
PSG Date : 03/18/2013
Nasal Masks
Mirage™ FX
Mirage™ FX for Her
Mirage™ SoftGel
Activa™ LT
Mirage Micro™
Nasal Pillows
Swift™ FX
Swift™ FX for Her
Swift™ LT
Swift™ LT for Her
Phone# (858) 836-5000
Zip : 92123
Fax#:
UPIN/NPI : 1234567890
AHI : 24 (CAI = 18 OAI=6)
Full Face Masks
Mirage Quattro™
Ultra Mirage™
Mirage Liberty™
Quattro™ FX
Quattro™ FX for Her
15 cmH2O
15.0
Mask Setting
Time
9:13:25 am
Mask Name
Nasal
Global leaders in sleep and respiratory medicine
Detailed Settings Report
PAP Device :
S9 VPAP Adapt
Humidification :
Additional Supplies : www.resmed.com
Compliance Reporting :
General Comments :
Heated ClimateLine™
Chin Strap
Headgear
Page 1 of 7
After
30
Tubing
Filter days, for
12 months
Unable to resolve persistent apnea events (CAI=18) with CPAP
Physician Signature
Dr. Steven Goodnight
Date
03/19/2013
Dispense as Written - No Substitutions
Statement of Medical Necessity :
The above patient has undergone diagnostic evaluation. This evaluation has confirmed a positive diagnosis of sleep apnea. Positive airway pressure therapy is medically necessary and provides effective treatment of this disorder.
Prescription and Detailed Settings
reports capture all changes made to therapy pressures and settings during the night and can be easily generated and edited, minimizing study turnaround times by incorporating final mask and device settings into a script.
True Leak reporting automatically displays accurate mask leak data, eliminating the need to reference charts to calculate appropriate leak values.
EasyCare Tx software has a user-friendly toolbar that allows remote control of a therapy device while displaying current therapy settings.
Page 1 of 1 Global leaders in sleep and respiratory medicine www.resmed.com
Prescription Report
1 Wimms AJ, Richards GN, Benjafield et al. Adherence comparison of a new CPAP system in sleep disordered breathing. Sleep 2011
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 achieve comfortable, quality patient care.
™ to make it easy and efficient
Adult and pediatric therapy titration applications like CPAP, VPAP S, ST, T and
PAC therapy modes are FDA cleared to treat patients weighing 30 lb (>13 kg) and above regardless of age, allowing sleep labs to provide titration for a wider range of patients — including pediatrics.
• CPAP – Fixed pressure delivered with optional expiratory pressure relief (EPR ™ )
• AutoSet ™ – Automatically adjusts pressure in response to snore, flow limitation and obstructive sleep apneas with no pressure support
• VPAP (Bilevel) – Delivers two treatment pressures — one for inspiration (IPAP) and one for expiration (EPAP) — and provides control over the following bilevel therapy modes:
» S (Spontaneous) – Follows the natural breathing pattern, allowing patients to breathe at their regular respiratory rate and rhythm
» S/T (Spontaneous/Timed) – Augments any breaths initiated by the patient, but will also supply additional breaths if the breath rate falls below the clinician’s set “backup” respiratory rate
» PAC (Pressure Assist Control) – The inspiration time is preset in the PAC mode.
There is no spontaneous/flow cycling. The inspiration can be triggered by the patient when respiratory rate is above a preset value, or time-triggered breath will be delivered at the backup breath rate.
» T (Timed) – The fixed respiratory rate and the fixed inspiration/expiration time set by the clinician are supplied regardless of patient effort
» VAuto – Automatically adjusts pressure in response to flow limitation, snore and apneas; pressure support (PS) is fixed throughout the night and can be set by the clinician
» Adaptive Servo-Ventilation (ASV and ASVAuto) – Treats the spectrum of central breathing disorders, including mixed sleep apnea, complex sleep apnea (CompSA) and periodic breathing such as Cheyne–Stokes respiration (CSR)
» iVAPS – Treats hypercapnic respiratory insufficiency, including obesity hypoventilation, chronic obstructive pulmonary disease, neuromuscular disease and restrictive conditions
Technical Specifications
Pressure Ranges
CPAP
4–20 cm H
2
O (EPR 0-3)
AutoSet ™
APAP 4–20 cm H
2
O (EPR 0-3)
Bilevel (S, S/T, T, PAC)
EPAP 3–25 cm H
2
O, IPAP 4–30 cm H
2
O
VAuto
EPAP 4–25 cm H
2
O, IPAP 4–25 cm H
2
O
ASV and ASVAuto
EPAP 4–15 cm H
2
O,
Pressure Support 0–20 cm H
2
O
IVAPS
EPAP 3–25 cm H
2
O,
Pressure Support 0–27 cm H
2
O
Filter
Two-layered, powder-bonded, polyester non-woven fiber
Altitude Compensation
Automatic
Electrical Requirements
100–240 V
DC Power
Direct connect cord
EasyCare Tx Software
Minimum Hardware and
Software Requirements
PC (Mac not supported)
Pentium 1 GHz CPU
1 GB RAM
1024 x 768 display resolution
10/100 Mbps Ethernet Port
Microsoft Windows Vista,
Windows XP ≥ SP2 or Windows 2007
Microsoft .NET Framework 2.0
Cat5 cable or available network port between patient room and control room
S9 VPAP Tx Accessories
H5i ™ Cleanable Tub
H5i Standard Tub
36800
36803
ClimateLine ™ 36995
ClimateLine MAX Oxy
Filter (1 Pack)
Filter (2 Pack)
Filter (12 pack)
Filter (50 pack)
36996
36850
36851
36852
36853
1 EPR available in CPAP and AutoSet modes
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Getting Started
6 S9 VPAP Tx Lab System | Sleep Lab Titration Guide
S9 VPAP
™
Tx Control Panel
Info menu button
LCD screen
Start/Stop button
Setup menu button
Push dial
Alarm mute button
Alarm and therapy LEDs
ResMed.com
Key
Start/Stop button
Info menu button
Function
Starts or stops treatment. Power Save mode — hold for three seconds.
Allows you to view the device service information or to exit from the menu.
Setup menu button
Push dial
Alarm mute button
Allows you to make changes to settings or to exit from the menu.
Turning the dial allows you to scroll through the menu and change settings.
Pushing the dial allows you to enter into a menu and confirm your choice.
Press once to mute alarms. Press a second time to un-mute. If the problem is still present, the alarm will sound again after two minutes.
LCD screen Displays the menus, treatment screens and reminders.
LCD screen backlight
When treatment is being delivered, the backlight (including the Start/Stop button) automatically turns off after 30 seconds, otherwise it turns off after three minutes.
Alarm LED Yellow LED — flashes during an alarm.
Therapy LED Blue LED — always on during therapy (if enabled in the Options menu).
At the Bedside
8 S9 VPAP Tx Lab System | Sleep Lab Titration Guide
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
Plug the USB Module into the Module/
Adaptor port at the rear of the S9 VPAP Tx.
5
Connect the S9 VPAP Tx to the Tx Link via the USB serial cable.
6
Plug the other end of the power cord into the power outlet.
7
Connect one end of the air tubing firmly onto the air outlet.
8
Connect the assembled mask system to the free end of air tubing.
8
Module/Adaptor Port
4
7
1
2
5
To Tx Link
6
3
Align the ClimateLine ™ connector with the outlet port so that the lock symbol is facing up. Push the ClimateLine firmly onto the air outlet. Rotate the ClimateLine clockwise until it clicks into place.
1
Filling the H5i Water Tub
The S9 VPAP Tx is compatible with the integrated H5i heated humidifier.
For further information on using this humidifier refer to the H5i user guide.
2 3 4
Slide the silver latch on the front of the device and lift open the flip lid. Remove the water tub.
Through the center hole, fill the water tub with room temperature
(do not use hot or cold) distilled water up to the max water level mark (380 mL).
Filling water tub while still in humidifier may damage unit.
Overfilling the water tub may result in water splashing through the tubing.
Return the water tub to the H5i. Close the flip lid, ensuring that it clicks into place.
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Navigating the Menus
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1
Turn until the parameter you require is displayed in blue.
2
Press . The selection is highlighted in orange.
3
Turn until you see the setting that you require.
4
Press to confirm your choice.
The screen returns to blue.
Mask Type and Tube Type Settings
Use the following settings below for each mask type:
Mask type Settings
Full Face
Pillows
Nasal
Pediatric
Full Face
Pillows
Nasal (for Ultra Mirage mask, use ‘Nasal Ultra’)
Pediatric
Notes:
• For more information on assembling the mask, see the mask user guide.
• For a complete list of recommended masks and their settings go to www.resmed.com on the Products page under Service & Support.
If you do not have Internet access, please contact your ResMed representative.
The S9 VPAP Tx is compatible with the following air tubing:
Air tubing
ClimateLine
Specifications
Heated
Length: 6’6” (2 m)
Inner diameter: 0.6” (15 mm)
ClimateLine MAX Oxy Heated
Length: 6’3” (1.9 m)
Inner diameter: 0.75” (19 mm)
ClimateLine MAX Heated
Length: 6’3” (1.9 m)
Inner diameter: 0.75” (19 mm)
SlimLine
Standard
3 m
Length: 6’ (1.8 m)
Inner diameter: 0.6” (15 mm)
Length: 6’6” (2 m)
Inner diameter: 0.75” (19 mm)
Length: 9’10” (3 m)
Inner diameter: 0.75” (19 mm)
Settings
Automatically detected
Automatically detected
Automatically detected
If using the SlimLine,
Standard or 3 m air tubing, adjust the tube setting via the Setup menu.
Note:
The ClimateLine, ClimateLine MAX and ClimateLine MAX Oxy are designed only for use with the H5i.
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).
• If necessary, adjust the mask, mask cushion and headgear until there is a secure and comfortable fit. After three minutes, the pressure reverts to the set pressure and treatment will begin. You can end Mask Fit at any time by pressing .
Viewing the Treatment Screens
Depending on how the system has been configured and what mode has been selected, you will see one of the following example screens (shown in iVAPS mode below) when the device is running:
9 H5i humidifier 9 H5i humidifier
9 ClimateLine/ClimateLine MAX
9 Climate Control – Auto
9 H5i humidifier
9 ClimateLine/ClimateLine MAX
9 Climate Control – Manual
9 Therapy data
To toggle between the treatment screens, press from your HOME screen.
Pressure bar:
In bilevel modes, the pressure bar is marked with fixed vertical lines indicating the expiratory and inspiratory pressures.
In CPAP and AutoSet modes, only a set pressure is shown.
9 Treatment with device trigger (Timed) and cycle
(Timed, Ti Max or Ti Min) breath indicators
9 Treatment with spontaneous trigger and cycled breaths
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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. Titration begins and the therapy indicator turns green.
Note:
The Therapy ON/OFF indicator turns green during therapy and gray when therapy is off.
ResMed
EasyCare Tx
Manual Connection to a Tx Link
Connecting to a Tx Link
If you do not specify a default Tx Link in User Preferences, the following window is displayed every time you launch EasyCare Tx. From this window you can connect to any Tx Link on the network.
To connect to Tx Link:
1. From the Menu drop-down, click Connect. The Select Device window is displayed.
2. Select the required Tx Link from the Connect To drop-down list.
3. Click OK. A window indicating that EasyCare Tx is establishing a connection with Tx Link is displayed.
Within a few seconds, EasyCare Tx will connect to the Tx Link.
Connectivity issues
You may experience connectivity issues in the following circumstances:
• EasyCare Tx is unable to connect to the Tx Link;
• EasyCare Tx loses connectivity with the Tx Link;
• Tx Link is unable to connect to the therapy device; or
• Tx Link loses connectivity with the therapy device.
In such instances, a window indicating the connectivity status is displayed and this helps you to take the appropriate action to restore connectivity. For instructions on resolving these issues, refer to troubleshooting in the S9 VPAP Tx Clinical Manual.
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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.
Name of the connected Tx Link
Therapy controls
Therapy controls drop-down
Real-time data
Real-time data items drop-down
Therapy ON/OFF indicator
Start/Stop Therapy button
Humidifier ON/OFF indicator 1
Ramp time indicator
EasyCare Tx real-time graphs
Therapy mode drop-down
Menu drop-down
Therapy device connected
Study recording indicator
Locked/unlocked status
Toolbar shown without callouts for clarity.
1 The Humidifier icon is only displayed if the connected therapy device has a humidifier that can be remotely controlled.
14 S9 VPAP Tx Lab System | Sleep Lab Titration Guide
Configuring Mask and
Humidifier Settings
Configuring circuit settings
Before starting therapy, select the mask type used by the patient and review the humidifier settings.
• Mask Settings
Mask Settings can be specified either at the bedside from the therapy device, or remotely using EasyCare Tx.
• Humidifier Settings
EasyCare Tx automatically provides humidifier controls relevant to the therapy device and H5i humidifier connected. Refer to the clinical guides provided with the therapy device and humidifier.
To configure circuit settings:
1. From the Menu drop-down, click Mask and Humidifier Settings.
The Mask and Humidifier Settings window is displayed.
Adjusting
Therapy Settings
Therapy settings
Therapy settings can be controlled in two ways:
• By adjusting individual parameters displayed on the toolbar
• Using the Therapy Settings window
When adjusting individual parameters displayed on the toolbar, the changes are applied instantly. If a confirmation is not sent from the therapy device within two seconds, the parameter will revert to the original value. Alternatively, using the Therapy Settings window, changes are made to one or more parameters related to a therapy and on clicking OK.
To adjust therapy settings from the Therapy Settings window:
1. From the Menu drop-down, select Therapy Settings.
The current therapy settings window is displayed.
2. Select the required mask type from the Mask drop-down list.
3. Select the desired humidifier option from the Humidifier drop-down list, or the desired temperature setting from the Temperature drop-down list.
4. Click OK. The mask and humidifier settings are applied to EasyCare Tx.
2. Change the appropriate therapy settings as required.
3. Click OK. The updated therapy settings are applied to EasyCare Tx.
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Detailed Settings Report
An easy and efficient way to capture and display all pressure, mode and settings changes made during a session.
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Note: The session must be recorded to generate a Detailed Settings Report.
1 Record the session prior to starting therapy a. From the Menu drop-down, select Session > Record
2 Run and print the Detailed Settings Report a. From the Menu drop-down, select
Reports > Detailed Settings Report b. Populate the patient details in the pop-up window and click Browse to pull up the
“Save Session Data” dialog box b. Click Browse and select the saved patient file c. Click Open, and click OK to display the report c. Choose a location to save the file, enter the file name and click Save
Note: EasyCare Tx will remember and load the previous location selected by the user as default.
d. Click OK to begin recording. To stop the recording, select Session > Stop from the Menu drop-down d. Click the Print icon to print the report
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.
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Technologies
18 S9 VPAP Tx Lab System | Sleep Lab Titration Guide
Notes
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CPAP and AutoSet
™
Technology
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.
CSA detection
ResMed’s S9 AutoSet uses the forced oscillation technique (FOT) to determine the state of the airway during an apnea. When an apnea is detected, small oscillations are added to the pressure to measure airway patency. The CSA algorithm uses the resulting flow and pressure to measure airway patency and differentiate central and obstructive events.
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. Each comfort setting correlates to an exact drop in pressure relief:
• EPR Level 1: Mild reduction (1 cm H
2
O)
• EPR Level 2: Medium reduction (2 cm H
2
O)
• EPR Level 3: Maximum reduction (3 cm H
2
O)
EPR Level 1
Mild pressure
EPR Level 2
Medium pressure
EPR Level 3
Maximum pressure
Device
Pressure
Patient
Flow
Notes:
The numeric value (1, 2 or 3 cm H
2
O) for each EPR setting represents the maximum pressure drop during CPAP therapy expiration. Therapy pressure will never drop below 4 cm H example, if therapy pressure during Ramp Time is 5 cm H
2 pressure will only reduce to 4 cm H
2
O.
2
O. So, for
O and EPR is set at level 3, then the
For this reason, EPR is a unique comfort feature that ensures therapy effectiveness at all times.
EPR allows patient comfort without compromise because the selected setting offers a defined pressure drop value that never exceeds the set value.
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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.
TiControl
™
A number of sophisticated features provide easy access to quality therapy
• Accommodate patients’ unique needs with TiControl. Ti Max enables you to set a maximum inspiratory time to reduce the risk of intrinsic
PEEP and missed patient effort. Ti Min ensures adequate time for gas exchange without having to increase the pressure setting.
• Better synchrony. Setting a rapid rise time and high cycle sensitivity can help decrease the inspiratory time and extend the expiratory time, resulting in improved patient–ventilator synchrony for patients who are prone to intrinsic
PEEP. A slower rise time and lower cycle sensitivity, along with an adequate
Ti Min, ensure that patients with weak inspiratory effort have adequate time for gas exchange.
• Adjustable trigger and cycle.
• Adjustable trigger sensitivity supports patients with a weak inspiratory effort, increasing the sensitivity to every patient effort. Adjustable cycle sensitivity is crucial for those at risk for instrinsic PEEP or premature breath cycling.
• Vsync leak compensation. Vsync constantly monitors the flow so that if an unintentional mask leak occurs, the device can quickly compensate for the leak and maintain breathing synchrony.
Therapy pressure
Patient effort
Total flow
Estimated patient respiratory flow
Unintentional leak
Ti Max
Ti Min
Ti Min
Ti Max
Therapy pressure
Estimated patient respiratory flow
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.
Obstructive lung disease
Recommended Settings
IPAP [cm H
2
O]
EPAP [cm H
2
O]
Ti Max [sec] 1
Ti Min [sec] 1
Rise time [ms] 2
Trigger sensitivity
Cycle sensitivity
PS [cm H
2
O]
Obstructive
Lung Disease
13
5
1.0
0.3
150
Medium
High
8
Patients with obstructive lung disease have chronic airflow limitation. These patients have particular difficulty exhaling air, which leads to air trapping and hyperinflation. These patients require a longer exhalation, which often leads to asynchrony with standard bilevel settings.
The recommended settings use a faster rise time to ensure that the lungs are filled quickly, and a high cycle sensitivity to provide an earlier cycle to exhalation. The rapid inhalation and prolonged exhalation will help to prevent auto-PEEP and preserve synchrony.
Restrictive lung disease
Recommended Settings
IPAP [cm H
2
O]
EPAP [cm H
2
O]
Ti Max [sec] 1
Ti Min [sec] 1
Rise time [ms] 2
Trigger sensitivity
Cycle sensitivity
PS [cm H
2
O]
Restrictive
Lung Disease
300
High
Low
6
11
5
1.5
0.8
Patients with restrictive lung disease have a difficult time maintaining the inhalation phase long enough to ensure adequate tidal volume and gas exchange. This can be caused by a physical restriction of the lungs or by neuromuscular weakness.
The recommended settings use a low cycle sensitivity and a longer Ti Min time to provide a longer inhalation time to help increase tidal volume and gas exchange.
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Obesity hypoventilation syndrome (OHS)
Recommended Settings
IPAP [cm H
2
O]
EPAP [cm H
2
O]
Ti Max [sec] 1
Ti Min [sec] 1
Rise time [ms] 2
Trigger sensitivity
Cycle sensitivity
PS [cm H
2
O]
Obesity
Hypoventilation
Syndrome
15
7
1.5
0.8
300
Medium
Medium
8
Obesity hypoventilation patients often have reduced tidal volumes due to the additional weight pressing down on the chest and abdomen. Additionally, these patients may also have obstructive sleep apnea (OSA) caused by excess tissue in the upper airway and a high body mass index (BMI).
The recommended settings use a higher EPAP pressure to keep the airway open and a higher IPAP to provide additional pressure support and ventilatory assistance.
Normal lungs
Recommended Settings
IPAP [cm H
2
O]
EPAP [cm H
2
O]
Ti Max [sec] 1
Ti Min [sec] 1
Rise time [ms] 2
Trigger sensitivity
Cycle sensitivity
PS [cm H
2
O]
Normal Lung
Mechanics
11
5
2.0
0.3
300
Medium
Medium
6
Patients with normal lungs may use NIV in an institutional environment post surgery or to treat sleep apnea.
The recommended settings provide basic settings for patients with normal lung mechanics.
1 Ti settings based on an observed respiratory rate of 20 bpm.
2 The rise time milliseconds scale is approximate.
24 S9 VPAP Tx Lab System | Sleep Lab Titration Guide
Setting TiControl
Respiratory
Frequency (bpm)
19
18
17
16
22
21
20
15
14
13
12
26
25
24
23
30
29
28
27
ResMed TiControl: Ti Min and Ti Max Calculation Guide
Restrictive
Ti Max Ti Min
1.6
1.7
1.8
1.9
1.4
1.4
1.5
2.0
2.1
2.3
2.5
1.2
1.2
1.3
1.3
1.0
1.0
1.1
1.1
0.8
0.8
0.9
0.9
0.7
0.7
0.8
1.0
1.1
1.2
1.3
0.6
0.6
0.6
0.7
0.5
0.5
0.5
0.6
COPD
Ti Max
1.0
1.1
1.2
1.2
0.9
0.9
1.0
1.3
1.4
1.5
1.7
0.8
0.8
0.8
0.9
0.7
0.7
0.7
0.7
Normal
Ti Max
1.6
1.7
1.8
1.9
1.4
1.4
1.5
2.0
2.1
2.3
2.5
1.2
1.2
1.3
1.3
1.0
1.0
1.1
1.1
Setting Ti Max and Ti Min using the respiratory rate table:
1. Instruct the patient to breathe normally while comfortably sitting or lying down.
2. Count the patient’s respiratory rate (breaths/minute).
3. Considering the patient’s respiratory disease, refer to the appropriate range of settings in the table below (restrictive, COPD or normal) to set Ti Max and Ti Min.
4. In the case of COPD or normal lungs, use the Ti Min default setting.
VPAP Technology Q&A
What does the trigger threshold do?
The trigger threshold is the flow in liters/min used by the
Vsync ™ algorithm to determine the patient’s readiness to receive a breath from VPAP (change from EPAP to IPAP).
In essence, as you change from Low to High, you’re increasing the sensitivity of VPAP to the patient’s effort as detected by measuring flow in the breathing circuit.
When should I adjust the trigger sensitivity threshold?
The Medium (default) setting will be ideal for most patients.
Recommend the Low (or Very Low) trigger sensitivity setting for the following conditions:
• Abnormally strong heartbeat, may cause cardiac oscillation and subsequent auto-triggering (triggers before the patient inhales)
• Any time the patient complains that breaths are starting before inhaling
Recommend the High (or Very High) trigger sensitivity setting for the following conditions:
• Patients with very weak respiratory effort
(eg, neuromuscular diseases)
• Any time the patient complains or there is evidence that the device doesn’t seem to respond to inspiratory effort
Note: COPD patients may benefit, but they may benefit from an increase in EPAP to compensate for auto PEEP or intrinsic PEEP. This should be evaluated first before considering the High trigger sensitivity setting.
What does the cycle threshold do?
The cycle threshold is used by the Vsync algorithm to determine the patient’s readiness to begin exhaling (change from
IPAP to EPAP). VPAP targets a percent of the peak flow used in each breath. For instance, the Medium setting targets 25% of the peak flow as the point where the patient is ready to begin exhalation. The High setting targets 35% and the Low setting targets 15%. As you adjust this setting, the patient may notice a change in the time spent at IPAP.
When should I adjust the cycle sensitivity threshold?
The Medium (default) setting will be ideal for most patients.
Recommend the High (or Very High) cycle sensitivity setting for the following conditions:
• In situations where a shorter inspiratory time is desirable (eg, COPD), whereby a shorter inspiratory time is essential in order to preserve an adequate expiratory time. Ti Max can also be used to shorten inspiratory time
• Any time the patient complains that breaths are too long
Recommend the Low (or Very Low) cycle sensitivity setting for the following conditions:
• In situations where a longer inspiratory time is desirable (eg, neuromuscular diseases or patients with a very weak respiratory effort). Ti Min can also be used to lengthen inspiratory time
• Any time the patient complains that the device seems to switch from IPAP to EPAP too quickly
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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.
Unlike other ventilation modes that only target tidal volume, iVAPS targets alveolar ventilation, accounting for anatomical dead space to ventilate the patient more effectively. iVAPS provides an intelligent Backup Rate (iBR) when necessary while maximizing the patient’s opportunity to spontaneously trigger the device.
Personalized.
The Learn Targets feature learns the patient’s alveolar ventilation and then sets targets accordingly, giving you a simpler, time-saving option to set up NIV patients.
Whether you choose this feature or prefer to set targets directly, iVAPS makes it easy to customize therapy for each patient (Learn Targets not available on S9 VPAP Tx).
Automatic. iVAPS automatically adjusts the level of pressure support to achieve and maintain the target alveolar ventilation while minimizing sleep disruption. iVAPS is suitable for adults with respiratory insufficiency conditions, including:
Neuromuscular disease and restrictive conditions iVAPS can maintain stable ventilation when respiratory effort fluctuates, especially during sleep.
Chronic obstructive pulmonary disease (COPD) iVAPS may reduce the risk of hyperinflation associated with increased respiratory rate, as compared to therapy targeting tidal volume.
Obesity hypoventilation
When compared to standard pressure support therapy, iVAPS can compensate for changes in respiratory mechanics, such as during nocturnal position changes.
iVAPS Settings
Patient height [inches]
Target patient rate [bpm]
Target Va
Restrictive lung disease
EPAP
Obstructive lung disease
Obesity hypoventilation syndrome
Normal
Min PS [cm H
2
O]
Max PS [cm H
2
O]
Ramp time
Recommended
Settings
Set appropriate patient height
Set target patient rate equivalent to patient’s spontaneous respiratory rate
6ml/kg IBW
5 cm H
2
O
5 cm H
2
O
7 cm H
2
O
5 cm H
2
O
4
20
OFF
Notes:
Ensure Ti Max, Ti Min, Rise Time, Trigger and Cycle are set appropriately to maintain patient–device synchrony.
Please reference the attached TiControl ™ adjust based on patient’s respiratory rate.
guide for correlating
Ti Max/Ti Min settings appropriate for each disease state and
26 S9 VPAP Tx Lab System | Sleep Lab Titration Guide iBR maximizes the patient’s opportunity to breathe spontaneously before bringing the patient back to target if backup breaths are required
Patient effort
No patient effort
Patient effort
15
10 iBR stays out of the way when not required
Target patient rate
Patient spontaneous rate iVAPS intelligent backup rate (iBR)
Time
Automatically changing pressure support and iBR to maintain alveolar ventilation
Time
Pressure
Target alveolar ventilation
Actual alveolar ventilation
Time lapse
Pressure increases to meet target alveolar ventilation
Pressure decreases to meet target alveolar ventilation
iVAPS Technology Q&A
Which patients is iVAPS suitable for?
iVAPS is suitable for adults with respiratory insufficiency. It is ideal for patients whose condition is likely to change and is characterized by hypoventilation (day/night hypercapnia).
Patient conditions may include:
• Neuromuscular disease and restrictive conditions — iVAPS can maintain stable ventilation when respiratory effort fluctuates
• Obesity hypoventilation — When compared to standard
Pressure Support therapy, iVAPS can compensate for changes in respiratory mechanics, such as during nocturnal changes in the patient’s body position
• Chronic obstructive pulmonary disease — iVAPS may reduce the risk of hyperinflation associated with increased respiratory rate, as compared to therapy targeting tidal volume
What does iVAPS target?
iVAPS targets alveolar ventilation to deliver required ventilation at the alveoli, where gas exchange occurs.
Unlike other volume-assurance modes, iVAPS maintains the alveolar target even when respiratory rate changes.
Why is alveolar ventilation important?
Setting alveolar ventilation targets the patient’s true ventilation requirements and represents a more accurate approach.
It’s able to deliver the required ventilation at the alveoli, where gas exchange occurs, by taking into account and compensating for the portion of air that travels through the conducting airways.
What are the goals of therapy with iVAPS?
• Optimizing therapy by delivering a set alveolar ventilation with the right pressure at the right time
• Enhancing patient-ventilator synchrony with an intelligent Backup
Rate (iBR) to enhance patient comfort
• Minimizing sleep disruption with its rapid, yet gentle response that is quick enough to maintain stable alveolar ventilation, yet smooth enough to maintain sleep quality during nocturnal therapy
• Increased adherence to therapy with iVAPS 1
1 Jaye J, Kelly J et al. Eur Respir J 2012; 40: Suppl. 56, 51
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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. Users have the choice of auto-adjusting EPAP in ASVAuto mode or fixed EPAP in ASV mode.
ASVAuto mode adapts to a patient’s ventilatory and upper airway stability needs on a breath-by-breath basis. By treating central breathing disorders with auto-adjusting Pressure Support and upper airway obstruction with auto-adjusting EPAP, it rapidly stabilizes breathing to improve blood gases faster and reduce stress on the heart.
1 Simplified patient care is provided through therapy that learns, responds, predicts and optimizes pressures to suit each patient’s own unique breathing pattern.
The following summarizes the therapy provided by the ASV mode:
• Learning continuously for personalized therapy:
The only ASV technology to target the patient’s own recent minute ventilation,
ResMed’s ASV continuously learns the patient’s own breathing and sets ventilation targets accordingly.
• Responding rapidly for effective therapy:
ResMed’s ASV responds within the breath, adjusting Pressure Support to stabilize breathing. In ASVAuto mode, it also stabilizes the upper airway by adjusting EPAP when needed.
• Predicting each patient’s unique needs for ease-of-care:
Treating challenging patients has never been easier. ResMed’s ASV predictive algorithm learns the patient’s unique respiratory rate and delivers pressure matched to the patient’s breathing, adapting dynamically to his or her changing needs.
• Optimizing comfort and synchrony for compliance:
Patient comfort is the underlying goal of ResMed’s ASV. Proven comfort features such as “ramping” pressure that eases the patient gently into therapy, advanced leak management and ResMed’s unique Easy-Breathe pressure waveform provide natural breathing comfort — boosting patient compliance.
1 Hastings et al. Int J Cardiol 2010
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. In ASVAuto mode, the EPAP also responds to flow limitation, snore and obstructive apneas on the next breath, in proportion to the severity of the event.
Treating periodic breathing
VPAP Adapt turned ON
Patient
Flow
APNEA APNEA
VPAP Adapt
Pressure
VPAP Adapt rapidly stabilizes breathing by increasing
Pressure Support in response to hypoventilation
A decrease in ventilation is rapidly treated by increasing Pressure Support
The minimal Pressure Support during normal breathing or hyperventilation prevents over ventilation and hypocapnia
Pressure Support decreases when normal breathing (or hyperventilation) resumes
VPAP Adapt turned OFF
HYPOPNEA APNEA APNEA
EPAP response based on AutoSet
™
algorithm
• In ASVAuto mode, the auto-adjusting Pressure Support functionality works hand-in-hand with auto-adjusting EPAP, continuously monitoring minute ventilation and respiratory flow to protect breathing.
• If ventilation decreases away from target, the algorithm increases
Pressure Support and monitors how that affects minute ventilation.
• The algorithm predicts the onset of airway collapse, assessing the flow shape of each breath. The technology responds to flow limitation and snore, automatically adjusting EPAP in proportion to the severity of the event, to maintain an open upper airway.
• If there is little or no flow during this period, the advanced technology can deduce that the airway is obstructed. Once breathing resumes, it then increases EPAP to prevent further apneas from occurring.
• Once breathing is stabilized, the EPAP gradually decreases towards the minimum EPAP setting for comfort, over a 20–40 minute period, depending on the type of event that occurred.
ASVAuto mode
Pressure Support increases as minute ventilation drops below the dynamic target during flow limitation
Pressure Support increases as minute ventilation drops below the dynamic target during the obstructive apnea
Pressure
Min Pressure Support
Max EPAP
Min EPAP
Increase in EPAP in response to flow limitation
Increase in EPAP in response to obstructive apnea
Flow
Normal effort Flow limitation
Obstructive apnea
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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.
The algorithm achieves this by detecting such apneic events and quickly changing the Pressure Support to control events and normalize tidal volume, thereby normalizing breathing.
Normal breath
Peak flow
Tidal volume
Peak flow
Flow
MV = Vt x RR
Time
Flow
Flow measured with split-second resolution
Time
Other ASV devices estimate the tidal volume based solely on the peak flow. This can work if every breath is shaped the same, but many breaths have a different flow profile.
As seen in the figures below, ventilation can change substantially without any change to the peak flow of each breath. For this reason, measuring minute ventilation directly enables the most timely and effective pressure changes and, therefore, the best therapy.
Flow-limited breath
Peak flow
Flow
MV = Vt x RR
Time
Patient comfort through synchrony
Advanced, predictive technology maximizes comfort and synchrony over a wide range of breath rates
The ASV algorithm continuously learns the patient’s own respiratory rate through high-resolution breath phase mapping, maintaining accuracy even at lower breath rates.
The algorithm maintains synchrony with the patient’s respiratory pattern by learning the rate at which the patient progresses through each breath and dynamically predicting inspiratory and expiratory durations. This enables the VPAP
Adapt to deliver pressure that reaches its therapy peak at end-inspiration and its nadir by end-expiration, continuously and smoothly. Additionally, the ResMed leak management feature ensures greater synchrony by offsetting variations and inconsistency due to leak.
Flow
Pressure
Tracking changes in patient’s respiratory rate and airflow
+
Late mid-inspiration
Early end-inspiration
Flow
Easy-Breathe for the most natural breathing comfort
Unique to ResMed, the patented Easy-Breathe waveform delivers a smoother, more comfortable breathing experience by replicating the natural wave shape of normal breathing.
–
Time
Ease of titration
Market-leading simplicity
Minimal settings with empirically selected default parameters are designed to cover the broadest range of patient setups.
Unlike competing devices that require setting extra parameters such as Rise Time, ResMed’s ASV reduces the need for complicated customization during titration.
30 S9 VPAP Tx Lab System | Sleep Lab Titration Guide
ASV Technology Q&A
Which patients is ASV suitable for?
This extensively studied therapy provides demonstrated results across the spectrum of central breathing disorders including:
• Periodic breathing such as Cheyne–Stokes respiration (CSR), both normocapnic and hypocapnic
• Other forms of central and concomitant obstructive events 1
(mixed sleep apnea)
• Complex sleep apnea (CompSA) 2
ResMed’s ASV should also be considered for central sleep apnea (CSA) and ataxic breathing, which is sometimes seen in opioid, 3 neurological and heart failure patients.
What are the goals of therapy with ASV?
• Rapidly stabilizing breathing to stabilize blood gases
PaCO
2
levels to encourage stable breathing
4 : The primary goal of ASV therapy is to stabilize ventilation, resulting in normalized
• Improving sleep quality and minimizing daytime sleepiness by reducing respiratory-related events
• Improving quality of life 5 through treatment outcomes, ASV helps improve physical performance 4 , increase energy and vitality 6
• Treating complex sleep apnea by adapting automatically to treat both obstructive and central events (in ASVAuto mode)
What does ASV target?
ResMed’s ASV therapy continuously learns and adapts targets to reduce short-term oscillations in breathing, keeping ventilation stable. It is the only ASV therapy to target the patient’s own recent minute ventilation
(MV) and respiratory rate (RR), adapting to changing needs through various sleep stages.
1 Allam et al. Efficacy of adaptive servo-ventilation in treatment of complex and central sleep apnea syndromes. Chest 2007; 132(6): p. 1839-46
2 Morgenthaler et al. Adaptive servo-ventilation versus noninvasive positive pressure ventilation for central, mixed, and complex sleep apnea syndromes. Sleep 2007; 30(4): p. 468-75
3 Javaheri et al. Adaptive pressure support servo-ventilation: a novel treatment for sleep apnea associated with use of opioids. J Clin Sleep Med 2008; 15;4(4): p. 305-10
4 Oldenburg et al. Adaptive servoventilation improves cardiac function and respiratory stability. Clin Res Cardiol 2011; 100(2): p. 107-15
5 Topfer et al. Adaptive servo-ventialtion: effect on Cheyne-Stokes-Respiration and on quality of life. Pneumologie 2004; 58(1): p. 28-32
6 Hastings et al. Adaptive servo-ventilation in heart failure patients with sleep apnea. Int J Cardiol 2010; 139:17-24
ResMed.com
Titration Protocols
32 S9 VPAP Tx Lab System | Sleep Lab Titration Guide
CPAP and AutoSet Therapy Sample Prescription
CPAP Therapy
S9 Elite ™
Pressure:______ cm H
2
O (4–20 cm H
2
O)
Ramp Time:______ min(s) (OFF–45 min.)
EPR ™ : 1 2 3
APAP Therapy
X S9 AutoSet ™
AutoSet Mode
Default Mode Settings
Min. Pressure:______ cm H
2
O (4 cm H
2
O)
Max. Pressure:______ cm H
2
O (20 cm H
2
O)
Ramp Time:______ min(s) (OFF–45 min.)
EPR: 1 2 3
X CPAP Mode
12 cm H
2
O (4–20 cm H
2
O)
Off min(s) (OFF–45 min.)
DEFAULTS
4
20
Bilevel Therapy
S9 VPAP ™ Auto
VAuto Mode
Default Mode Settings
Max. IPAP:______ cm H
2
O (4–25 cm H
2
O)
Min. EPAP:______ cm H
2
O (4 cm H
2
O–IPAP)
PS:______ cm H
2
O (0–10 cm H
2
O)
Ramp Time:______ min(s) (OFF–45 min.)
DEFAULTS
25
4
4
Spont Mode
IPAP:______ cm H
2
O (4–25 cm H
2
O)
EPAP:______ cm H
2
O (3 cm H
2
O–IPAP)
Ramp Time:______ min(s) (OFF–45 min.)
EasyBreathe ON
S9 VPAP S
Spont Mode
IPAP:_______ cm H
2
O (4–25 cm H
2
O)
EPAP:_______ cm H
2
O (3–25 cm H
2
O–IPAP)
Ramp Time:______ min(s) (OFF–45 min.)
EasyBreathe ON
Bilevel with Backup Rate Therapy
S9 VPAP Adapt
DEFAULTS
ASV Mode
Default Mode Settings
EPAP:______ cm H
2
O (4–15 cm H
2
O)
Min. PS:______ cm H
2
O (0–6 cm H
2
O)
Max. PS:______ cm H
2
O (5–20 cm H
2
O)
Ramp Time:______ min(s) (OFF–45 min.)
Backup Rate: automatic (15 BPM)
5
3
15
ASV Auto Mode
Default Mode Settings
Min. EPAP:_______ cm H
2
O (4–15 cm H
2
O)
Max. EPAP:_______ cm H
2
O (4–15 cm H
2
O)
Min. PS:_______ cm H
2
O (0–6 cm H
2
O)
Max. PS:_______ cm H
2
O (5–20 cm H
2
O)
Ramp Time:______ min(s) (OFF–45 min.)
Backup Rate: automatic (15 BPM)
4
15
3
15
S9 VPAP ST
Spont/Timed Mode
IPAP:_______ cm H
2
O (4–25 cm H
2
O)
EPAP:_______ cm H
2
O (3–25 cm H
2
O)
Rate:_______ BPM (5–30 BPM)
S9 VPAP ST-A
Note: Ensure Ti Max, Ti Min, Rise Time, Trigger and Cycle are set appropriately to maintain patient-device synchrony
Spont/Timed Mode
IPAP:______ cm H
2
O (4–30 cm H
2
O)
EPAP:______ cm H
2
O (3–25 cm H
2
O)
Rate:______ BPM (5–50 BPM)
PAC Mode Timed Mode
IPAP:______ cm H
2
O (4–30 cm H
2
O)
EPAP:______ cm H
2
O (3–25 cm H
2
O)
Rate:______ BPM (5–50 BPM)
Ti:______ sec. (0.1–4 sec.)
iVAPS Mode
Height:______ in. (44–100 in.)
Target Patient Rate:______ BPM (8–30 BPM)
Target Va:______ L/min. (1–30 L/min.)
Vt (Tidal Volume)______(mL)
Vt/kg______(mL/kg)
EPAP:______ cm H
2
O (3–25 cm H
2
O)
Min. PS:______ cm H
2
O (0–20 cm H
2
O)
Max. PS:______ cm H
2
O (0–27 cm H
2
O)
Settings to be determined via Learn Targets
©2013 ResMed. 1015938/2 2013-03
1015938r2 Script Note Pad.indd 2
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Lab Support 24/ 7 (888) 288-6738 | Sleep Lab Titration Guide 33
CPAP and AutoSet Therapy Titration Protocol
EPR comfort setting –
Set to patient comfort (1, 2 or 3)
Indications for CPAP therapy
• Obstructive Sleep Apnea
• Upper Airway Resistance Syndrome
Monitor patient
Is the patient having obstructive events?
YES NO
Set mode to CPAP
Initial pressure: 4–5 cm H
2
O
A higher pressure may be required for re-titrations, patients with a higher BMI or patients complaining of air hunger or suffocating sensations.
For re-titrations, it is recommended that the pressure be started 2–3 cm H
2
O below the patient’s current pressure.
Increase CPAP ≥1 cm H
2
O every ≥5 mins for obstructive apneas, hypopneas,
RERAs and at least 3 min of loud or unambiguous snoring
Continue monitoring patient
Consider trial of bilevel if obstructive events persist at a pressure of 15 cm H
2
O
Are events central?
YES NO
Decrease CPAP by 1 cm H
2
O and wait 20 mins. Consider
ResMed’s ASV if centrals persist and patient meets criteria
Observe patient and document final settings; be sure to document the final CPAP pressure, EPR setting (if any) and ramp time
34 S9 VPAP Tx Lab System | Sleep Lab Titration Guide
VPAP Auto and VPAP S Sample Prescription
CPAP Therapy
S9 Elite ™
Pressure:______ cm H
2
O (4–20 cm H
2
O)
Ramp Time:______ min(s) (OFF–45 min.)
EPR ™ : 1 2 3
APAP Therapy
S9 AutoSet ™
AutoSet Mode
Default Mode Settings
Min. Pressure:______ cm H
2
O (4 cm H
2
O)
Max. Pressure:______ cm H
2
O (20 cm H
2
O)
Ramp Time:______ min(s) (OFF–45 min.)
EPR: 1 2 3
CPAP Mode
Pressure:______ cm H
2
O (4–20 cm H
2
O)
Ramp Time:______ min(s) (OFF–45 min.)
EPR: 1 2 3
DEFAULTS
4
20
Bilevel Therapy
X S9 VPAP ™ Auto
X VAuto Mode
Default Mode Settings
25
4 cm H
2
O (4–25 cm H
2
PS:______ cm H
2
O (0–10 cm H
2
O)
15 cm H
2
O (4 cm H
2
O–IPAP)
6
Ramp Time:______ min(s) (OFF–45 min.)
O)
DEFAULTS
25
4
4
Spont Mode
IPAP:______ cm H
2
O (4–25 cm H
2
O)
EPAP:______ cm H
2
O (3 cm H
2
O–IPAP)
Ramp Time:______ min(s) (OFF–45 min.)
EasyBreathe ON
S9 VPAP S
Spont Mode
IPAP:_______ cm H
2
O (4–25 cm H
2
O)
EPAP:_______ cm H
2
O (3–25 cm H
2
O–IPAP)
Ramp Time:______ min(s) (OFF–45 min.)
EasyBreathe ON
Bilevel with Backup Rate Therapy
S9 VPAP Adapt
DEFAULTS
ASV Mode
Default Mode Settings
EPAP:______ cm H
2
O (4–15 cm H
2
O)
Min. PS:______ cm H
2
O (0–6 cm H
2
O)
Max. PS:______ cm H
2
O (5–20 cm H
2
O)
Ramp Time:______ min(s) (OFF–45 min.)
Backup Rate: automatic (15 BPM)
5
3
15
ASV Auto Mode
Default Mode Settings
Min. EPAP:_______ cm H
2
O (4–15 cm H
2
O)
Max. EPAP:_______ cm H
2
O (4–15 cm H
2
O)
Min. PS:_______ cm H
2
O (0–6 cm H
2
O)
Max. PS:_______ cm H
2
O (5–20 cm H
2
O)
Ramp Time:______ min(s) (OFF–45 min.)
Backup Rate: automatic (15 BPM)
4
15
3
15
S9 VPAP ST
Spont/Timed Mode
IPAP:_______ cm H
2
O (4–25 cm H
2
O)
EPAP:_______ cm H
2
O (3–25 cm H
2
O)
Rate:_______ BPM (5–30 BPM)
S9 VPAP ST-A
Note: Ensure Ti Max, Ti Min, Rise Time, Trigger and Cycle are set appropriately to maintain patient-device synchrony
Spont/Timed Mode
IPAP:______ cm H
2
O (4–30 cm H
2
O)
EPAP:______ cm H
2
O (3–25 cm H
2
O)
Rate:______ BPM (5–50 BPM)
PAC Mode Timed Mode
IPAP:______ cm H
2
O (4–30 cm H
2
O)
EPAP:______ cm H
2
O (3–25 cm H
2
O)
Rate:______ BPM (5–50 BPM)
Ti:______ sec. (0.1–4 sec.)
iVAPS Mode
Height:______ in. (44–100 in.)
Target Patient Rate:______ BPM (8–30 BPM)
Target Va:______ L/min. (1–30 L/min.)
Vt (Tidal Volume)______(mL)
Vt/kg______(mL/kg)
EPAP:______ cm H
2
O (3–25 cm H
2
O)
Min. PS:______ cm H
2
O (0–20 cm H
2
O)
Max. PS:______ cm H
2
O (0–27 cm H
2
O)
Settings to be determined via Learn Targets
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Lab Support 24/ 7 (888) 288-6738 | Sleep Lab Titration Guide 35
VPAP S Therapy Titration Protocol
(bilevel spontaneous)
Has patient been on CPAP therapy?
YES NO
Indications for S therapy
• CPAP intolerance
• Continued obstructive events at higher pressures
• Hypoventilation with SpO
2
< 90%
• COPD
Initial settings:
• IPAP = CPAP settings
• EPAP = 4 cm H
2
O below IPAP setting
Initial settings:
• IPAP = 8 cm H
2
O
• EPAP = 4 cm H
2
O
For obstructive apneas:
• Increase EPAP by ≥1 cm H
2
O every ≥ 5 min
• Increase IPAP to maintain 4 cm H
2
O difference between IPAP/EPAP
For obstructive hypopneas and snoring:
• Increase IPAP ≥ 1 cm H
2
O every ≥ 5 min until resolved
YES
Are events central?
NO
Decrease pressure to previous setting, observe for 20 min
For SpO
2
< 90% with all respiratory events eliminated:
• Increase IPAP by ≥ 1 cm H
2
≥ 15 min until ≥ 90% SpO
2
0 every
is reached
• Follow sleep lab protocols for adding O
2
If centrals persist, consider adaptive servo-ventilation
Observe patient and document final settings, including IPAP/EPAP pressures and TiControl settings if altered from default
36 S9 VPAP Tx Lab System | Sleep Lab Titration Guide
VPAP ST Sample Prescription
CPAP Therapy
S9 Elite ™
Pressure:______ cm H
2
O (4–20 cm H
2
O)
Ramp Time:______ min(s) (OFF–45 min.)
EPR ™ : 1 2 3
APAP Therapy
S9 AutoSet ™
AutoSet Mode
Default Mode Settings
Min. Pressure:______ cm H
2
O (4 cm H
2
O)
Max. Pressure:______ cm H
2
O (20 cm H
2
O)
Ramp Time:______ min(s) (OFF–45 min.)
EPR: 1 2 3
CPAP Mode
Pressure:______ cm H
2
O (4–20 cm H
2
O)
Ramp Time:______ min(s) (OFF–45 min.)
EPR: 1 2 3
DEFAULTS
4
20
Bilevel Therapy
S9 VPAP ™ Auto
VAuto Mode
Default Mode Settings
Max. IPAP:______ cm H
2
O (4–25 cm H
2
O)
Min. EPAP:______ cm H
2
O (4 cm H
2
O–IPAP)
PS:______ cm H
2
O (0–10 cm H
2
O)
Ramp Time:______ min(s) (OFF–45 min.)
DEFAULTS
25
4
4
Spont Mode
IPAP:______ cm H
2
O (4–25 cm H
2
O)
EPAP:______ cm H
2
O (3 cm H
2
O–IPAP)
Ramp Time:______ min(s) (OFF–45 min.)
EasyBreathe ON
S9 VPAP S
Spont Mode
IPAP:_______ cm H
2
O (4–25 cm H
2
O)
EPAP:_______ cm H
2
O (3–25 cm H
2
O–IPAP)
Ramp Time:______ min(s) (OFF–45 min.)
EasyBreathe ON
Bilevel with Backup Rate Therapy
S9 VPAP Adapt
DEFAULTS
ASV Mode
Default Mode Settings
EPAP:______ cm H
2
O (4–15 cm H
2
O)
Min. PS:______ cm H
2
O (0–6 cm H
2
O)
Max. PS:______ cm H
2
O (5–20 cm H
2
O)
Ramp Time:______ min(s) (OFF–45 min.)
Backup Rate: automatic (15 BPM)
5
3
15
ASV Auto Mode
Default Mode Settings
Min. EPAP:_______ cm H
2
O (4–15 cm H
2
O)
Max. EPAP:_______ cm H
2
O (4–15 cm H
2
O)
Min. PS:_______ cm H
2
O (0–6 cm H
2
O)
Max. PS:_______ cm H
2
O (5–20 cm H
2
O)
Ramp Time:______ min(s) (OFF–45 min.)
Backup Rate: automatic (15 BPM)
4
15
3
15
S9 VPAP ST
Spont/Timed Mode
IPAP:_______ cm H
2
O (4–25 cm H
2
O)
EPAP:_______ cm H
2
O (3–25 cm H
2
O)
Rate:_______ BPM (5–30 BPM)
X S9 VPAP ST-A
Note: Ensure Ti Max, Ti Min, Rise Time, Trigger and Cycle are set appropriately to maintain patient-device synchrony
X Spont/Timed Mode
15
7 cm H
2
O (4–30 cm H
2
O)
EPAP:______ cm H
2
O (3–25 cm H
2
O)
15
BPM (5–50 BPM)
PAC Mode Timed Mode
IPAP:______ cm H
2
O (4–30 cm H
2
O)
EPAP:______ cm H
2
O (3–25 cm H
2
O)
Rate:______ BPM (5–50 BPM)
Ti:______ sec. (0.1–4 sec.)
iVAPS Mode
Height:______ in. (44–100 in.)
Target Patient Rate:______ BPM (8–30 BPM)
Target Va:______ L/min. (1–30 L/min.)
Vt (Tidal Volume)______(mL)
Vt/kg______(mL/kg)
EPAP:______ cm H
2
O (3–25 cm H
2
O)
Min. PS:______ cm H
2
O (0–20 cm H
2
O)
Max. PS:______ cm H
2
O (0–27 cm H
2
O)
Settings to be determined via Learn Targets
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Lab Support 24/ 7 (888) 288-6738 | Sleep Lab Titration Guide 37
VPAP ST Therapy Titration Protocol
(bilevel spontaneous, timed)
Initial settings:
• IPAP = 8 cm H
2
O settings
• EPAP = 4 cm H
2
O
• Set backup rate at 2–4 below resting respiratory rate
Indications for ST therapy
• Neuromuscular/restrictive disorders
• COPD
• Obesity hypoventilation
Evaluate and titrate:
• Based on VT, rate, SpO
2
and CO
2
compared to baseline
Continuously monitor sleep and blood gas parameters (including CO
2
).
Ensure patient’s ventilation levels stay consistent with initial levels, including tidal volume (IPAP–EPAP) and patient respiratory rate versus device backup rate.
For obstructive apneas:
• Increase EPAP by ≥1 cm H
2
O every ≥5 min
• Increase IPAP to maintain 4 cm H
2
O difference between IPAP/EPAP
For residual snoring, hypopneas and/or O
2
desats:
• Increase IPAP ≥1 cm H
2
O every ≥ 5 min until resolved
For SpO
2
< 90% with all respiratory events eliminated:
• Increase IPAP by > 1 cm H
2
O every ≥15 min until SpO
2
> 90% is reached
• Follow sleep lab protocol for adding O
2
Note:
SpO
2
, VT and backup rate should be reviewed/monitored throughout the night.
Evaluate VT (tidal volume) if too small:
• Maintain EPAP raise IPAP by 1 cm H
2
O every ≥15 min until SpO
2
≥ 90%
”Exploratory” pressure increase should not exceed 5 cm H
2
O
Evaluate if backup rate is adequate:
• Increase backup rate by 1-2 BPM every 20 min as needed
Observe patient and document final pressure settings (IPAP/EPAP pressures, respiratory rate and
TiControl settings) if altered from default
38 S9 VPAP Tx Lab System | Sleep Lab Titration Guide
iVAPS Sample Prescription
CPAP Therapy
S9 Elite ™
Pressure:______ cm H
2
O (4–20 cm H
2
O)
Ramp Time:______ min(s) (OFF–45 min.)
EPR ™ : 1 2 3
APAP Therapy
S9 AutoSet ™
AutoSet Mode
Default Mode Settings
Min. Pressure:______ cm H
2
O (4 cm H
2
O)
Max. Pressure:______ cm H
2
O (20 cm H
2
O)
Ramp Time:______ min(s) (OFF–45 min.)
EPR: 1 2 3
CPAP Mode
Pressure:______ cm H
2
O (4–20 cm H
2
O)
Ramp Time:______ min(s) (OFF–45 min.)
EPR: 1 2 3
DEFAULTS
4
20
Bilevel Therapy
S9 VPAP ™ Auto
VAuto Mode
Default Mode Settings
Max. IPAP:______ cm H
2
O (4–25 cm H
2
O)
Min. EPAP:______ cm H
2
O (4 cm H
2
O–IPAP)
PS:______ cm H
2
O (0–10 cm H
2
O)
Ramp Time:______ min(s) (OFF–45 min.)
DEFAULTS
25
4
4
Spont Mode
IPAP:______ cm H
2
O (4–25 cm H
2
O)
EPAP:______ cm H
2
O (3 cm H
2
O–IPAP)
Ramp Time:______ min(s) (OFF–45 min.)
EasyBreathe ON
S9 VPAP S
Spont Mode
IPAP:_______ cm H
2
O (4–25 cm H
2
O)
EPAP:_______ cm H
2
O (3–25 cm H
2
O–IPAP)
Ramp Time:______ min(s) (OFF–45 min.)
EasyBreathe ON
Bilevel with Backup Rate Therapy
S9 VPAP Adapt
DEFAULTS
ASV Mode
Default Mode Settings
EPAP:______ cm H
2
O (4–15 cm H
2
O)
Min. PS:______ cm H
2
O (0–6 cm H
2
O)
Max. PS:______ cm H
2
O (5–20 cm H
2
O)
Ramp Time:______ min(s) (OFF–45 min.)
Backup Rate: automatic (15 BPM)
5
3
15
ASV Auto Mode
Default Mode Settings
Min. EPAP:_______ cm H
2
O (4–15 cm H
2
O)
Max. EPAP:_______ cm H
2
O (4–15 cm H
2
O)
Min. PS:_______ cm H
2
O (0–6 cm H
2
O)
Max. PS:_______ cm H
2
O (5–20 cm H
2
O)
Ramp Time:______ min(s) (OFF–45 min.)
Backup Rate: automatic (15 BPM)
4
15
3
15
S9 VPAP ST
Spont/Timed Mode
IPAP:_______ cm H
2
O (4–25 cm H
2
O)
EPAP:_______ cm H
2
O (3–25 cm H
2
O)
Rate:_______ BPM (5–30 BPM)
X S9 VPAP ST-A
Note: Ensure Ti Max, Ti Min, Rise Time, Trigger and Cycle are set appropriately to maintain patient-device synchrony
Spont/Timed Mode
IPAP:______ cm H
2
O (4–30 cm H
2
O)
EPAP:______ cm H
2
O (3–25 cm H
2
O)
Rate:______ BPM (5–50 BPM)
PAC Mode Timed Mode
IPAP:______ cm H
2
O (4–30 cm H
2
O)
EPAP:______ cm H
2
O (3–25 cm H
2
O)
Rate:______ BPM (5–50 BPM)
Ti:______ sec. (0.1–4 sec.)
X iVAPS Mode
70 in. (44–100 in.)
18
BPM (8–30 BPM)
4.8
L/min. (1–30 L/min.)
Vt (Tidal Volume)______(mL)
Vt/kg______(mL/kg)
8 cm H
2
O (3–25 cm H
2
O)
4
20 cm H cm H
2
O (0–20 cm H
2
O)
2
O (0–27 cm H
2
O)
Settings to be determined via Learn Targets
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iVAPS Therapy Titration Protocol
Initial iVAPS settings:
• Set Patient Height (eg, 70 inches for 5’10”)
• Set Target Pt Rate equivalent to patient’s spontaneous respiratory rate (eg, 18 bpm)
• Set Target Va such that Vt is equal to 6ml/kg IBW
• EPAP = 5 cm H
2
O
• Min PS = 4 cm H
2
O
• Max PS = 20 cm H
2
O
Indications for iVAPS therapy
• Neuromuscular/restrictive disorders
• COPD
• Obesity hypoventilation
Once a patient is fitted with an appropriate mask, select the appropriate mask setting.
Evaluate and titrate:
• Based on Target Pt Rate, Target Va, Vt, SpO
2 compared to baseline
and CO
2
For obstructive apneas:
• Increase EPAP by ≥ 1 cm H and flow limitation
2
O every ≥ 5 min to eliminate obstructive apneas, hypopneas, snoring
For SpO
2
< 90% with all respiratory events eliminated:
• Increase Target Va by 0.3 every ≥ 5 min until desaturations are resolved
Evaluate if Target Pt Rate is adequate:
• If central events persist, increase Target Pt Rate by
1–2 BPM every 20 min as needed
40 S9 VPAP Tx Lab System | Sleep Lab Titration Guide
VPAP Adapt Sample Prescription
CPAP Therapy
S9 Elite ™
Pressure:______ cm H
2
O (4–20 cm H
2
O)
Ramp Time:______ min(s) (OFF–45 min.)
EPR ™ : 1 2 3
APAP Therapy
S9 AutoSet ™
AutoSet Mode
Default Mode Settings
Min. Pressure:______ cm H
2
O (4 cm H
2
O)
Max. Pressure:______ cm H
2
O (20 cm H
2
O)
Ramp Time:______ min(s) (OFF–45 min.)
EPR: 1 2 3
CPAP Mode
Pressure:______ cm H
2
O (4–20 cm H
2
O)
Ramp Time:______ min(s) (OFF–45 min.)
EPR: 1 2 3
DEFAULTS
4
20
Bilevel Therapy
S9 VPAP ™ Auto
VAuto Mode
Default Mode Settings
Max. IPAP:______ cm H
2
O (4–25 cm H
2
O)
Min. EPAP:______ cm H
2
O (4 cm H
2
O–IPAP)
PS:______ cm H
2
O (0–10 cm H
2
O)
Ramp Time:______ min(s) (OFF–45 min.)
DEFAULTS
25
4
4
Spont Mode
IPAP:______ cm H
2
O (4–25 cm H
2
O)
EPAP:______ cm H
2
O (3 cm H
2
O–IPAP)
Ramp Time:______ min(s) (OFF–45 min.)
EasyBreathe ON
S9 VPAP S
Spont Mode
IPAP:_______ cm H
2
O (4–25 cm H
2
O)
EPAP:_______ cm H
2
O (3–25 cm H
2
O–IPAP)
Ramp Time:______ min(s) (OFF–45 min.)
EasyBreathe ON
Bilevel with Backup Rate Therapy
X S9 VPAP Adapt
ASV Mode
Default Mode Settings
EPAP:______ cm H
2
O (4–15 cm H
2
O)
Min. PS:______ cm H
2
O (0–6 cm H
2
O)
Max. PS:______ cm H
2
O (5–20 cm H
2
O)
Ramp Time:______ min(s) (OFF–45 min.)
Backup Rate: automatic (15 BPM)
DEFAULTS
5
3
15
X ASV Auto Mode
X Default Mode Settings
4
15 cm H cm H
2
O (4–15 cm H
2
2
O (4–15 cm H
2
Min. PS:_______ cm H
2
O (0–6 cm H
2
O)
O)
O)
3
15
OFF cm H
2
O (5–20 cm H
2
O)
Ramp Time:______ min(s) (OFF–45 min.)
Backup Rate: automatic (15 BPM)
4
15
3
15
S9 VPAP ST
Spont/Timed Mode
IPAP:_______ cm H
2
O (4–25 cm H
2
O)
EPAP:_______ cm H
2
O (3–25 cm H
2
O)
Rate:_______ BPM (5–30 BPM)
S9 VPAP ST-A
Note: Ensure Ti Max, Ti Min, Rise Time, Trigger and Cycle are set appropriately to maintain patient-device synchrony
Spont/Timed Mode
IPAP:______ cm H
2
O (4–30 cm H
2
O)
EPAP:______ cm H
2
O (3–25 cm H
2
O)
Rate:______ BPM (5–50 BPM)
PAC Mode Timed Mode
IPAP:______ cm H
2
O (4–30 cm H
2
O)
EPAP:______ cm H
2
O (3–25 cm H
2
O)
Rate:______ BPM (5–50 BPM)
Ti:______ sec. (0.1–4 sec.)
iVAPS Mode
Height:______ in. (44–100 in.)
Target Patient Rate:______ BPM (8–30 BPM)
Target Va:______ L/min. (1–30 L/min.)
Vt (Tidal Volume)______(mL)
Vt/kg______(mL/kg)
EPAP:______ cm H
2
O (3–25 cm H
2
O)
Min. PS:______ cm H
2
O (0–20 cm H
2
O)
Max. PS:______ cm H
2
O (0–27 cm H
2
O)
Settings to be determined via Learn Targets
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Lab Support 24/ 7 (888) 288-6738 | Sleep Lab Titration Guide 41
VPAP Adapt Therapy Titration Protocol
Begin therapy with default settings
Indications for ASV therapy
• Periodic breathing, both normocapnic and hypocapnic
• Other forms of central and concomitant obstructive events 1 (mixed sleep apnea)
• Complex sleep apnea (CompSA) 2
Excessive leak
Leak is greater than 24 L/min
Adjust or change mask until leak fixed
Obstructive events eliminated?
Any obstructive apneas, hypopneas or RERAs?
Increase EPAP by 1 cm H
2
O every
20 minutes until obstructive events are eliminated
The guidelines below can help to set up and treat patients with central breathing disorders using the standard ASV mode in ResMed’s adaptive servo-ventilation
(ASV) devices. This guidance is intended for in-lab titration and should not supercede direction by a physician.
For more details on therapy settings and adjustments, please refer to the Clinical Guide for the specific therapy device.
ASV default settings
Only three therapy parameters to set
EPAP
Min PS
Max PS
5 cm H
2
O
3 cm H
2
O
15 cm H
2
O
Ramp OFF
ASVAuto default settings
Only four therapy parameters to set
Min EPAP 4 cm H
2
O
Max EPAP 15 cm H
2
O
Min PS 3 cm H
2
O
Max PS 15 cm H
2
O
Ramp OFF
1 Allam JS et al. Efficacy of adaptive servo-ventilation in treatment of complex and central sleep apnea syndromes. Chest 2007; 132(6): p. 1839-46
2 Morgenthaler T I et al. Adaptive servo-ventilation versus noninvasive positive pressure ventilation for central, mixed, and complex sleep apnea syndromes. Sleep 2007; 30(4): p. 468-75
42 S9 VPAP Tx Lab System | Sleep Lab Titration Guide
Notes
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Reimbursement
44 S9 VPAP Tx Lab System | Sleep Lab Titration Guide
Notes
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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: 780.54 Hypersomnia, unspecified
* It is important to note that Medicare will not recognize all codes as medically necessary for sleep disorder testing. Medicare most commonly accepts diagnoses of sleep-related breathing disorders, narcolepsy, parasomnias and impotence.
MD – sleep specialist
ICD-9 Codes
327.21 Primary CSA*
327.22 CSA due to high altitude periodic breathing
327.26 Sleep-related hypoventilation/hypoxemia in conditions classifiable elsewhere
(requires underlying diagnosis code)
327.27 CSA in conditions classified elsewhere
(requires underlying diagnosis code)
786.04 CSA due to CSR
* Most commonly used for complex sleep apnea patients. These are examples of diagnoses that may be associated with the above mentioned technology. Physicians must determine the appropriate ICD-9 diagnosis based on individual patient needs during the initial exam or through a history and physical.
95810 PSG; sleep staging with four or more additional parameters of sleep, attended by a technologist
95811 PSG; sleep staging with four or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist (94770 carbon dioxide, expired gas determination by infrared analyzer)
CPT ® is a trademark of the American Medical Association
Definitions
Respiratory Insufficiency – Impairment in respiratory function severe enough to prohibit certain activities that the patient might normally pursue, and to interfere with daily living; occurring in association with measurements of respiratory mechanics and/or gas exchange that are markedly abnormal.
Complex sleep apnea (CompSA) is a form of CSA specifically identified by the persistence or emergence of central apneas or hypopneas upon exposure to CPAP or an E0470 device when obstructive events have disappeared. These patients have predominantly obstructive or mixed apneas during the diagnostic sleep study occurring at greater than or equal to five times per hour. With use of a CPAP or E0470, they show a pattern of apneas and hypopneas that meets the definition of CSA.
CSA is defined as:
(1) An apnea–hypopnea index greater than five; and
(2) Central apneas/hypopneas greater than 50% of the total apneas/hypopneas; and
(3) Central apneas or hypopneas greater than or equal to five times per hour; and
(4) Symptoms of either excessive sleepiness or disrupted sleep.
1
Prescription for S9 VPAP Adapt
HCPCS Code
E0471 Bilevel w/ backup rate
References
1 Centers for Medicare & Medicaid Services, “LCD for Respiratory Assist Devices (L11493)”
U.S. Department of Health and Human Services, http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_
id=11493&lcd_version=22&show=all (revision effective date 4/01/2006) Current Procedural Terminology
©2005 American Medical Association. All Rights Reserved. Current Procedural Terminology (CPT) is copyright 2005 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein Applicable FARS/DFARS restrictions apply to government use.
46 S9 VPAP Tx Lab System | Sleep Lab Titration Guide
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Clinical re-evaluation and documentation of adherence on the bilevel by 120 documentation of adherence on the bilevel between 31
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documentation of adherence on the bilevel between 31
48 S9 VPAP Tx Lab System | Sleep Lab Titration Guide
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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. Adapt SV, AutoSet, EPR, Escape, HumidAire, Mirage, Quattro, S9 and VPAP are trademarks of ResMed Ltd and are registered in the U.S. Patent and Trademark Office.
©2013 ResMed. Specifications may change without notice. 1013904/3 2013-04
Global leaders in sleep and respiratory medicine www.resmed.com
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