Hello everyone, welcome to the PAP Therapy Troubleshooting Webinar. My name is Loretta Colvin. I'm a nurse practitioner in St. Louis, Missouri, and my co-presenter is Ann Cartwright, a physician assistant in Denver, Colorado. We both work in sleep centers within the sleep clinic, and we see a lot of PAP patients in that setting, and we wanted to go through some of our troubleshooting tips to offer to you. For us, what we want to do is take the scary experience of PAP therapy and help patients transition to a more comfortable and successful experience with their PAP. But we know it takes a lot of education and support for patients. Just a quick disclaimer, we'll talk a lot of brand names. We recognize that it would be great if we could talk in generics, but because brands have such specific features within them for the devices and the masks, it's very hard to talk in a generic way. So this is not intended to be a specific endorsement of a product or company, but you will see us mention things by company name. We're going to focus on two PAP machines today, which are the ones we most commonly see in our clinics and in our region. And we list our solutions sort of in order of ease or cost as considerations as part of how we structure some of our troubleshooting tips. If we could have our way, we would see all of our patients within 30 days of starting PAP therapy, because we'd like to see them early, and that first two to three weeks is great because they're not so new. They've sort of figured out the problems they're having, but they're not past the 30-day window for mask replacement, should you need to use that as a resource. And they haven't gotten too frustrated with therapy yet, so you have a chance to intervene and help them on issues. We're going to talk a lot about leak. It's important to remember that leak is reported differently between Philips Respironics and ResMed. It also will vary based on the pressure the machine is at and the mask type, ranging from the pillows to the full. There are nice charts that your reps from the companies can give you showing how each mask, the intentional leak that comes with that mask at certain pressures. It's a nice reference, but in clinic, you might not pull that chart out all the time, so it's helpful to remember a key threshold. For Respironics, you're going to look for a leak less than 50 as acceptable, and for ResMed, you're looking for a leak less than 24. The reason these numbers are different is because Philips Respironics uses a total leak, which is intentional and unintentional leak combined, while ResMed removes the intentional leak and only reports unintentional leak. To do that, they actually have to have the mask dialed into the machine, and if a patient changes their mask and doesn't change that, it could affect that calculation a little bit, so just be aware of that. Also we're starting to get more and more new masks, and so sometimes those three categories you can choose from might not fully reflect what that particular mask they have is, such as a hybrid mask. Both Ann and I really like to look at the detailed report for either Respironics or ResMed. You see ResMed at the top. ResMed gives you the dotted line to remind you where the recommended leak threshold should be below, and then on Respironics, you have to eyeball around that 50, but they do give you the visual for the large leak in light green or the black for essentially no respiration detected or super high leak. In order to get this information, we log in ourselves to our systems, either AirView or Care Orchestrator, which is replacing Encore Anywhere, and we will pull up the detailed report. For me, I look at the last seven days and just sort of get a sense, so anyone with a high leak, I go and look at the details, so I get a sense of the pattern. Is it early in the night? Is it later in the night? Is it quite variable? Are some nights good, some nights not? And that gives you a sense of some of the things you may need to ask about and troubleshoot. So if you have not learned how to get into the systems and you're seeing a lot of PAP patients, I recommend this so that you can pull that, or you can also train your support staff for a leak over a certain amount that maybe they go ahead and pull a seven-day detailed report for you as well to look at. For mask leak, we're going to talk about various types of leak, starting with the mask. And the bigger the mask, often more leak you're going to have. So I tend to try to get patients on smaller masks as much as possible. Sometimes I don't get to them in time. They end up with a bigger mask because they're worried about mouth breathing, and then I'm having to try to figure out how to minimize their leak. When you're looking at the mask itself, you need to think about is the mask fitting well, are they having positional leak, and does it seem to be associated with pressure to help figure out more of your troubleshooting focus. Some of the clues to leaking at the mask would be that they can hear it, they'll see it on the report, and sometimes it doesn't actually bother the patient. They may complain of dry nose or mouth, and they may tell you that it's blowing into the eyes or have redness or irritation. It's important to assess the fit of the mask. Ann and I both like to have patients come in with their equipment. We want to see their mask, we want to see the machine, and we want to see them put the mask on in front of us if they're having problems. Now for those of you who might be newer, you may be thinking I don't want them to do that because then they'll know that I don't know what I'm doing, but it's okay because you know more than they do. So if you haven't put it on in front of you, you can see simple things like is it straight? Is it in the right spot? Does it seem like it's too big or too little? How does it interfere with the creases of the skin or their facial hair? So you can get a sense of just general fit without having to be an expert in this area. It's also important to remind patients they should be taking out their dentures if they also don't wear dentures at night in order to assess for a good mask fit. This is particularly important with a patient with memory loss or a patient with a developmental delay. When you ask them to put on in front of you, you recognize how much they do or don't know about their equipment. Anne has had a patient who put his mask on his ear. I've had a patient put his mask on upside down in front of me, and I've also had a patient who slides the mask from the top of the head all the way down and by the time it gets over his nose and mouth, the seal is so cockeyed that he can't get a good seal from that mask. So it's very helpful in that patient population to get a better sense of what they're doing when they're putting their equipment on. As you're looking at some solutions for mask fit and leaking, we talked about facial hair. Now for some patients it's an easier negotiation than others. They may be willing to trim their facial hair more closely. They may or may not be willing to get rid of it. But you may be able to talk to them about how that is one of the barriers and contributors to their leak, and maybe they need to go to a different style of mask that is not over the facial hair. You need to make sure they're replacing their seals frequently, ideally one to two months for most patients, and they may not be doing that more than once a year when you ask them. So it's good to double check that. They may not realize they can replace it, so it's always helpful to ask them that question. There are memory foam cushions, such as the picture you see here. Also another picture you see here is the mask that has straps. It's a nice low-profile mask, but the straps tend to stretch more easily. So you need to make sure patients with that mask know that they can get clips that will help to tighten the mask more, and they can get a little bit longer life out of their mask. You also need to, you can suggest to them if they have one of the hybrid nasal pillows, if they have seals, they might want to change to inserts or vice versa to see if that would help give them a slightly better fit. Sometimes you'll need to refer them back to their durable medical equipment company for more education, or you may need to refer them back for a mask fit. I try to talk to them a little bit about what I suggest without being a micromanager and telling them an exact mask, but I'll say I would like it to be smaller. I'd like maybe the fit to be a little differently, not as pushing into your eyes or different things. I also may show them the newer style masks that I describe to patients as the Teletubby mask, because I think they'll remember that. And I like to show them the advantage of getting the tubing out of the way, which might be something they also like, as well as a lower-profile mask. For mouth opening, this can be more subtle. So you usually have to really dig a little bit to figure this one out. Patients don't typically come into you saying that they are opening their mouth. So you can ask them about middle-of-the-night removals that are unintentional. They may have a leak on the report, but they don't really hear that much. The bed partner may say they're making Darth Vader noises or other descriptions, or they have a dry mouth. I find sometimes what I see is I see a leak and I ask them about a dry mouth, and that's when they say, oh, yeah, well, I do have a dry mouth. Even though I ask it on the questionnaire and they haven't marked it yet, as you dig a little deeper, you will get that complaint. And then you need to troubleshoot that, which is going to be a few steps. For me, my first step is always increase humidification, unless they're at a high level already. And I'm going to walk through some options with that on a future slide. After they increase humidification, which, by the way, is something they normally can do at home without extra equipment, then I'm going to have them add a chinstrap and talk through the advantage of that. I always let them know that I want their chinstrap to circle the crown of the head so that it's going to stay in place better than just the one-band styles. And then I'm going to ask them, suggest to them they might want to change their mask if these other things don't work. But I try other things first because I try not to go to a larger mask because I may fix mouth breathing but then end up with other leak problems instead. So I might consider a full face mask or a hybrid full. I have not used a hybrid full as a solution as often because sometimes I just replace one problem with leak with a new problem with leak. For eye irritation, first try to correct the reason for the leak itself, either by using a nasal bridge pad or by changing the mask and the fit. Or separately, we would try to protect the eyes or simultaneously if it's going to be a while before you can address the mask issue. See if you can protect the eyes and there are some options for you here. Sometimes you might even consider reducing pressure because, of course, some CPAP is better than none. And if a patient's about to abandon therapy, maybe you can drop a little bit better seal and then wait until they're eligible for mask replacement to be able to get a new mask style. For positional leak, we tend to think about how to help them not have leak when they're moving into a different position. So side sleepers, maybe they need the pillow with the cutouts, especially if they have a full face or hybrid full so that they have some room for the mask and it doesn't get bumped against as much. Of course, we'll also recommend changing the mask itself to something smaller so it's not as wide and prone to getting hit when they're on their side. And then we might consider some things for the tubing to try to help their tubing weight not pull against their mask or try the Teletubby mask again that pulls the tubing to the top of the head. If they're having pressure-related leak, you'll see controlled leak in the beginning and then leak as the night goes on. They may give you that report or you may see it on the detailed report. And this is happening because they're fitting their mask at lower pressure and not realizing that they're going to need it to be fit tighter once they hit higher pressure. And this can happen when they're using RAMP or when they're on a low APAP setting. So for RAMP, you want to think about what type of machine they have because the solution will be different. With the AirSense, you will use a mask fit feature which allows them to bypass the RAMP which is automatically activated and get to a higher pressure to fit their mask. Or they can turn their RAMP off. For the DreamStation, it's a patient-activated RAMP, so just make sure that they know they should fit their mask first before they hit the RAMP. And then if they're on APAP, you want to bring up their minimum pressure a bit so that they are starting at a pressure more similar to their average pressures during the night. You can also have a leak in the circuit, so it's helpful to remember that as you're trying to troubleshoot leak. Think about whether they have anything in the tubing. Often they'll tell you this because they can hear it or see it. The tubing may get poked by cats using their nails or it can also rip. They may have a connection, either something in the mask that's leaking or you can also have those O2 ports added and they don't realize they need to take that off if they're not an oxygen user. I've had it happen where a patient was in the hospital, added oxygen, came home, still had that port there, didn't realize they needed to now take it off. Sometimes you also can get it in the machine itself. Now, this is less common but always something to keep on your radar. So if a person is saying their machine's really loud, it sounds like a vacuum, they need to have it, bring it into someone to hear it. Either you can listen to it because you know what the machine should sound like or they take it to the medical equipment company. If it's real loud, then someone needs to also look at the machine internally itself. Some clues to think about leaks in the circuit, I've talked about some already, but the loud noise is particularly one or they hear the noise away from the mask and away from the face. And they may, you may even see it on the report. Some other suggestions would be if it's tubing, they need to keep the tubing away from the cat or be more careful if it's ripped. They'll need to take whatever connectors are on the tubing or they can replace the mask and then anything with the machine goes to the dermal medical equipment company. For dryness, this is the thing that I troubleshoot the most. So it's always important for you to have strategies, for you to give resources to patients and maybe even give resource to support staff as well because this is a common thing that we can help patients with when they're starting on PAP. They may say they're dry or they may have more of a rhinitis congestion type complaint that's not their typical allergies or a cold or sometimes we'll even have patients who mention that they're having some problems with dentition over time and we may need to reassess what they're doing with their humidification. Both Ann and I like to use heated tubing and it's standard on my new PAP orders. I find that automatic algorithms do not work for some of my patients. I tend to take patients off of the automatic algorithm. On AirSense, I will have them move to a humidity level five to six rather than a four and then the tube temp might be in the mid-70s. For DreamStation, I try to make sure the humidity is in the three to four range and tube in the three to four range as well for tube temp. I've actually created some instructions and you're welcome to go to the site and we'll give you this address at the end of the presentation as well. This takes you to a Google Doc. So for some of you at certain institutions, you may not be able to open it from work but you may be able to open it at home. Takes you to a Google Doc that then has links to other handouts and videos. One of those handouts actually is a step-by-step humidifier instruction. I used to tell my patients they could go to the manual to get that information and then I read the manual and realized that was not the most helpful strategy for patient education and so we now have some step-by-step instructions. So for dryness, I always start with humidification. It's easy to access other than getting heated tubing if they don't have it. But patients need education. They don't know how to use it. They don't understand the two-part humidification. I do caution them maybe not to go too high on their tube temp as it could have a drying effect. But also add nasal saline and other products, a biotin mouthwash if needed. Some patients even have to add a room humidifier. I think this is a strategy Ann uses in Denver with a much drier environment more often than I might use in the Midwest. And also sometimes we'll need to actually put more water in the system. So sometimes people will run out of water. You typically see it with high leak or you will see it also even with leak relatively well controlled with a dream station sometimes. The design of the dream station seems to lend itself to sometimes having more problems with running out of water. It's a wider base. The reservoir is a little smaller compared to the system one. So patients who are fine on a system one may have difficulty when they get to a dream station. In that case, they may need to add more water in the middle of the night. You could have them swap out an extra water chamber like with the other machines except that one has a little wider opening at the top and maybe a little more prone to spill. Of course, you want to address mask leak as a first step. Sometimes you're more successful than others. And make sure that you're thinking about a room humidifier if needed. For tubing condensation, it's pretty easy to figure out. Usually they're complaining about water either in the face and the mask or they can hear it in the tube. And in this situation, you want to add heated tubing if you don't already have it or raise the temperature of the tubing. Move the tube away from anything that could cool it like fans and vents. Cover it or insulate it. There's a lot of ways to insulate it. There's many products online. People can make their own cozy out of fleece. They can use socks, all sorts of things. And next, Anne is actually going to be presenting. And the one, a couple reminders before Anne gets started. We are recording this session. And this can be shared also within your team. So please, if you have others who are not able to join, and you can provide this education to them as a resource to share. Of course, CME credit is individual. And we will do a Q&A at the end. There's a written Q&A where answers can be submitted. And then we'll go through those as time allows. Okay. Thanks, Loretta. Hold on. Having a little bit of a technical glitch. Oh, there we go. All right. Hold on. I'm having a little bit of difficulty changing the slides here. There we go. All right. So next thing we're going to talk about is mass discomfort. You know, kind of like getting new shoes. Sometimes it just takes a while for patients to get used to it. Sometimes patients complain of general mass discomfort. Sometimes they complain of something specific, like my nostrils hurt, my face hurts, my forehead hurts, the back of my neck hurts, or the mask won't stay in place. So if the patient is complaining of nostril tenderness, this is typically with a nasal pillow mask. You want to make sure that they're not on too big of a size. If the nasal pillow is too big, it can kind of stretch their nostril out a little bit. So making sure that they have an appropriate size. Nasal saline gel can be really helpful. So if you put some kind of saline gel in the nose and in the nares before doing the nasal pillows, they get that nice barrier so the plastic is not coming in contact with the skin and that can usually alleviate that. If they still have issues you might try nasal pillows that have a shorter stem. So, Philips Respironics does have a couple different nasal pillow options where the nasal pillows do not stick very far into the nares. And then if they still have nostril tenderness maybe switch to a traditional nasal style mask so that there's nothing going up in the nose. If they have nasal tenderness or face discomfort you want to make sure they're not over tightening the mask. That's probably the biggest mistake that patients make is over tightening it and then just getting too much pressure on their skin especially on the bridge of their nose is particularly sensitive. If their skin is getting irritated there are all kinds of gel pads and liners so that the plastic is not coming in contact with your skin and we'll show some pictures of that in a little bit. Replacing the old seal can help or switching to the mask with a memory foam cushion like Loretta mentioned earlier. It is important when you're fitting the mask that they should be laying down instead of sitting up because they're generally not sitting up in bed and their mask will fit different when they're laying down. Loretta I might need to have you take over there we go. I might need to have you take over because these slides aren't progressing real fast. If patients complain of pain or irritation on their cheeks or their neck strap covers are really helpful. There's a couple of options here. Women tend to claim plain more about indentations or marks or irritation on their face. Men complain more about it on the back of their neck. So there's all kinds of covers that the patients can purchase on the internet or they can make their own. Sometimes patients will complain that the mask is hurting their scalp or causing irritation or pulling out their hair. Wearing some kind of a hat or bandana or scarf underneath the mask can be helpful for this. If they still have mask discomfort particularly if the straps tend to be a source of the discomfort there are a couple of masks on the market that do not have any straps. The tap mask is the mask that's pictured here. It's a nasal pillow interface that is attached to a bite plate so it's a soft wax that the patient bites into and it molds to their teeth. They wear the mouthpiece over their upper teeth and that holds the nasal pillows in place. There's a new one that came out called the bleep which has the nasal pillows that attach to the nostrils with adhesive. All right let's move on to pressure. So if a patient complains that the pressure is too much or too forceful on their machine you have to do a little bit more digging to find out if it's a patient issue, if it's a true pressure issue, or if it's a machine issue. Patient issues, these are the patients who they're on very low pressures of six, seven, eight and they feel like it's blowing their head off. And then there are people who are legitimately on really high CPAP pressure. So if they're on CPAP at a pressure of 18 that's really high and we would kind of expect that people would have some difficulty with that pressure. Or it may be that the machine is not set correctly or the machine is malfunctioning. A clue to this might be that the patient tolerated it well during their sleep study or their titration but they're not doing well at home. Okay so you always want to check the pressure on the CPAP report and the machine. It is not uncommon that medical equipment providers will set the machines incorrectly. So make sure that what they are set on is what you actually ordered and intended them to be on. If the patient is on a very low pressure setting but they feel like it's very very high, first you want to check their machine to make sure that it's functioning properly. Occasionally you get a machine with a bad motor or bad motor it may say it's blowing 8 but if you test it up to a manometer it's blowing 25 or 30 and they just got a bad machine. So make sure that it is actually blowing what it says it is. And then you really have to work with patients on basically acclimatizing to pressure over time. So start them on a lower pressure and then as they build up tolerance you can slowly increase their pressure setting over time. People that have difficulty with the pressure due to claustrophobia are sort of a different breed. I will talk about claustrophobia a little bit more at the end. All right if you have a patient that is on very high pressure or average pressure and they are having difficulty with it you could do this with the low pressure patients as well. You really want to use the comfort features on the machines. So utilizing the ramp is really helpful. Many patients don't know that there is a ramp or how to use it. So educating them about that either adding the ramp if it's not already activated or lengthen the time of the ramp. And I'll give you some more details about the ramp in a couple more slides. You can turn on pressure relief features. So this is a feature on machines that allows the machine to sync with the patient's breathing and when they exhale it backs off a little bit on the pressure to make them feel more comfortable. And I will talk about the differences between the different machines in a few minutes. You may just need to lower the pressure. You can change the pressure in a few different ways. You can send the prescription to the DME company. You can change it remotely via the modem the software technology if you are connected to the machine or you can change it manually on the machine. Be aware if you do change the patient remotely via the modem it doesn't always take. So it is a good idea to go back after a couple days and make sure that the pressure change actually took. You could make an algorithm change to make them more comfortable. I'll talk about that more in a little bit. You could try a larger mask. So generally the bigger the mask the more diffused the pressure is going to be across their face. So patients who are on high CPAP pressures sometimes do better with nasal masks or full face masks instead of smaller nasal pillow masks. If you've tried all these things and they are still not tolerating the high pressure then that would be an indication to switch to a bi-level machine. You could also do combo therapy. So adding an oral appliance. I do this not uncommonly if I have patients particularly if they have a very high BMI. They have very severe sleep apnea and require very high PAP pressures and they just can't tolerate it. I will get them an oral appliance and by pulling that lower jaw forward it can substantially reduce the amount of air pressure that they need on their machine. Okay sometimes patients say they can't tolerate the pressure but it's vague. You try to ask them more questions like is it too hard when you're starting out? Is it too hard when it ramps up? Is it too hard all the time? And sometimes they're just sort of vague like I don't know I just I just don't like it I don't I don't like it. So with those patients I generally find that it's more helpful to bring them in the clinic and try them on a whole bunch of different settings in the office. And then you can kind of glean is it more of an inhalation issue or an exhalation issue? And I'll do it kind of like you do with the eye doctor. Do you like option one or option two? Option two or option three? And that can be helpful. If the patient has lost weight and they're complaining that the pressure is too forceful you want to lower their pressure. And again the manometers can be helpful. It's nice if you have those in your office but if not you can ask your DME company to check the patient's pressure output. So some additional information on the ramp because it is quite different on the DreamStation models by Phillips Respironics. The patient has to use or activate the ramp every single time. So if they're not hitting the ramp button it's not ramping. The patient has complete control over this so the patient can set the length of the ramp or the time and the starting pressure. There is a smart ramp option which keeps the pressure low until the patient is asleep and having sleep apnea and then it ramps up. On the ResMed AirSense the ramp is automatically activated whether the patient chooses to use it or not. So if it's just turned on it will automatically ramp. The patient can adjust the length of the ramp but not the starting pressure. That is clinician or DME controlled. And then ResMed has the auto ramp which keeps the pressures low until the patient is asleep. It is important to know the differences in the pressure relief features between the machines because they are quite different. So Phillips Respironics their pressure relief is called Flex. There are levels 1, 2, and 3. Level 1 gives you a little bit of pressure relief. Level 3 is going to back off the most when they exhale. ResMed is EPR which stands for expiratory pressure relief. Levels 1, 2, and 3 actually correspond with a 1, 2, or 3 centimeter pressure drop. So if you have a patient that is on CPAP at 10 and their EPR is set to level 3 that means their machine is 10 centimeters when they inhale but it is 7 centimeters when they exhale. So you can get quite a substantial pressure drop that can affect their sleep apnea. It's different in different regions. In my area the DME's turn this on automatically set to level 3. So if you have a patient where they did fine during their CPAP titration but on that setting at home they continue to have obstructive sleep apnea events that may be because their EPR and their pressure is dropping too low with exhalation. The patient can turn the EPR on or off but the level of EPR is controlled by the clinician and the EPR can be used all the time or just doing the ramping period. The ResMed bi-level devices also have something called easy breathe which gives the air curves a little bit more of a rounded shape so it feels a little bit more natural in terms of inhalation and exhalation. Most patients like that feature turned on. These are a couple of algorithm changes on the machines that you could make if patients are having pressure intolerance issues. Respironics dream stations have something called easy start. This eases patients into their prescribed pressure over time. So on night one they start at their 50% of whatever they were prescribed. So if you prescribe the patient setting of 16 centimeters night one they're going to start at 8. Every night they use the machine more than four hours. The next day the machine will increase their pressure by one. If they use it less than four hours it will stay at the same setting. After 30 days if the patient has not yet hit their prescribed pressure it's going to increase their pressure by one centimeter every single day regardless of use. So that can be a nice way to ease the patients in slowly without you having to look at their download and make pressure changes every few days. If they're in CPAP mode and they're having difficulty with air pressure consider changing them to autopap mode. A lot of DMEs and in our region if we prescribe a CPAP machine they're typically going to get an auto CPAP machine in CPAP mode. So you have the capability to flip them over to autopap mode. In general when a patient is in autopap mode the ResMed algorithm is more aggressive in response faster to airflow limitation than the Philips Respironics devices. If you have a patient on a ResMed machine and they feel like the pressure is waking them up in auto mode you can change the response from standard to soft so that it's less aggressive and that may be helpful for some of those patients. Okay the flip side is air hunger. So these patients say they can't get enough air, they wake up gasping, choking. So you want to do basically everything opposite that we just said. So you want to decrease their pressure relief or turn it off, shorten the length of the ramp and raise the ramp starting pressure, increase their minimum auto CPAP setting. You could consider some different algorithms which I'll talk about in a minute. If they've previously been doing fine and all of a sudden they are not getting enough air that's when you really want to check all the connections and filters because they may be losing air somewhere. And if the patient has recently gained weight and they're complaining of air hunger then you typically need to raise their air pressure. So these are some algorithm options. Respironics DreamStation machines have a feature called OptiStart. This is only available on their auto CPAPs. What this does is it increases their auto CPAP minimum pressure closer to what the patient is actually needing. So if you start them on a pressure range of 5 to 20 and they're averaging 18 you don't want them to keep starting at 5 because they have to have a lot of sleep apnea to get up to 18 and a lot of times that's when the patients will complain of air hunger. So what this does is every 30 hours it will slowly increase their start pressure to be more in line with their actual pressure needs. So this is a feature that you could turn on. Just a little tidbit the only way you can see what the OptiPressure start is is by looking at a detailed download. So if you're looking at a summary or a trend you can see if OptiStart is turned on but you can only see what the pressure is by looking at the detailed download. The other option if the pressure is too low is to put the patient in auto mode as a trial. So if it's a patient that has a CPAP machine and you think they need higher pressure but you don't really know what pressure this is a good option. So say a patient comes into your clinic for an annual follow-up they've gained 40 pounds in the last year they have high AHI on download you know they need pressure but the question is how much more. They have a CPAP so you can't just put them in auto mode so you could do this auto trial. You basically put the machine in automatic mode for a short period of time and then at the end of that trial period the machine converts itself back to CPAP mode at whatever the 90th percentile pressure was during the trial. So you when you do this you tell the machine how many days you want the other auto trial and the minimum and maximum pressure. Aerophagia literally means swallowing air so air is going into their belly. Patients will complain of burping, passing gas in the morning, being really distended or bloated in the morning. This is something that a lot of times patients will necessarily equate these symptoms to their PAP therapy so you specifically want to ask about it because they won't necessarily offer that up. Things that can help with aerophagia make sure that you're using the pressure relief feature so the flex or the EPR. If they're on CPAP mode try auto PAP mode. You may try just reducing the pressure. If you reduce the pressure a little bit you may just want to tolerate slightly higher AHI if it means that the patient's going to wear the mask all night. You could try changing masks switching from a full face mask to a nasal mask may help. You certainly want to look into issues of GERD and dietary intake. If none of these things help then at that point we typically switch patients to bi-level machines and almost all of the time switching to bi-level alleviates this situation. Sometimes patients come in and they complain that the machine turns itself off or the machine starts alarming in the middle of the night and it wakes them up. This is typically associated with leak. Some machines have features where if it's not detecting airflow it shuts itself off. So sometimes when the leak is so profound the machine is no longer thinking that they're wearing it so it shuts itself off. So you want to make sure that the leak is dealt with whether it's a mask leak or a circuit leak. You can turn these automatic features off so that the machine will never turn itself off and unless the patient turns itself off. You can turn the alarms off. You may need to ask your DME for assistance. If you have a patient that's on an advanced machine if they're like on advanced bi-level or NIV therapy there are a lot of alarms and you may need to ask your DME for assistance changing the alarm parameters or turning those off. Skin irritation or rash. The masks are all latex free. That's a question we get a lot. There's no latex but they are generally made of silicone and some people develop an allergy to the silicone or they just generally get irritated from having plastic on their face all night because that's not really natural. Suggestions for this would be having the patient make sure they wash their face before they put their mask on and wash their mask on a daily basis. These patients if they get real irritated skin sometimes can tolerate nasal pillows. Not always. There are some cloth mask options so circadian spice sleep weaver makes several different cloth masks that are on the market. They don't always hold a good seal but for some people they work well and then certainly barrier to the skin so using some kind of a mask liner or cover and there are tons on the market to help alleviate the mask from touching the skin. Sometimes patients complain of marks from the straps or indentations from the straps. Again make sure they're not over tightening the mask. Try loosening the straps. Strap covers are great for this purpose. If they still continue to have issues particularly I find people that have a real wide face kind of right near their temple area they tend to get just a lot of extra pressure from the straps in that area so you may need to find a different mask style and if the straps continue to be a problem using one of the masks that does not have any straps would be a great solution for that. Getting tangled in the tubing. So their tubing catches on their shoulders, their torso, their pillow, their headboard. You can use what Loretta called the teletubby mask before so some kind of mask where the tubing is coming up off the top of the head instead of off the front of the face that can get the hose up and out of the way. There are all sorts of tubing support hooks and arms and tubing holders that patients can buy on the internet that hold the hoses up and out of the way. Sometimes getting longer tubing will help. A six-foot hose is going to come standard with CPAP. Patients can get eight or ten foot tubing. The longer tubing does not come in heated though it's just standard. We don't like patients to go longer than ten foot hoses because it increases the dead space. Sometimes I have patients come in and they've taped multiple hoses together. We do not recommend that. And then nasal congestion. So often this is due to inadequate humidity though it can be from colds or sinus issues or allergies. We definitely recommend maximizing the humidity using heated tubing if they're not using it already. I I'm in a very dry climate so we get a lot of dryness and a lot of nasal stuffiness with CPAP. I recommend nasal saline washes quite a lot. Sometimes we'll do nasal steroid sprays which are all over the counter now. If it seems to be real allergy related, sometimes we'll recommend oral allergy treatment like antihistamines. And if they still have difficulty breathing through their nose, we will usually recommend that they switch to a full face mask so if their nose is stuffy, they can still breathe through their mouth. And then if it still goes on, sometimes you need to refer them to ENT or the allergy clinic. All right, and then claustrophobia. So these are a special breed of patients. I think true claustrophobia on CPAP is fairly rare. There's definitely a lot of discomfort in getting used to it, but true claustrophobia where people really feel anxious, I find less often. It is more common in people that have any history of abuse, trauma, near drowning episodes, people with severe lung disease. They generally have a harder time with using PAP therapy. With these patients, you need to go slow and you need to be patient. So what we do is graded exposure and you can do this with any CPAP patient, not just claustrophobia patients, but the claustrophobia patients really, really need this graded exposure. So you start them with just a little bit of use, a little bit of exposure, and then you gradually increase the amount they're able to use the machine over time. So maybe you start with them wearing it for one minute in the office, and then the next day they try to do two minutes. The next day they try to do five minutes. They gradually increase their use. Sometimes just even putting the mask on can be very anxiety provoking. So sometimes you have to just have them hold the mask in their hand, then maybe hold the mask on with the air blowing, then maybe get it near their face. So you have to go at the pace of the patient, setting small goals, small steps is really helpful. You don't want to rush them. These are patients that you're gonna follow up a lot with on the phone and see in the clinic frequently. And then it's important if they're mental health professionals as well. Okay, so just kind of an overview of the main points that we've talked about today. So with humidification, you wanna be really aggressive. Make sure that the patients are aware of how to use their humidifier and how to make changes. Educate the clinical staff and provide resources to the staff and patients as to how to change the humidification. With masks, try to start with a small mask if possible. If they're having dryness, add humidity, and then add a chin strap for mouth breathing. Make sure the patients are aware of the issues with mouth breathing. If the patient is having issues with the pressure, you wanna make sure you know the different comfort features available on the machine and try to figure out if it's more a patient issue, more a machine issue, or a pressure issue. In terms of the software, you should learn how to log in. Encourage your patients to use the phone app so that they can track their own data and be alerted to if there is an issue. In terms of reports, train your staff to pull the report if patients call with issues. If there are leak or AHI problems, make sure you look at a detailed report to get the most information. Review their humidity settings. If a patient is on a ResMed AirSense machine, you cannot see their humidity settings on a download. The only way you can do that is by looking on the machine itself or online. You can't see it on the report. Train your staff how to identify and deal with claustrophobia. Learn how to change settings on the machines, both remotely and in the software. In the clinic, so these CPAP follow-ups, this is a really good rule. Loretta and I are both APPs, but we find that this is a really good niche for us, doing these CPAP follow-ups and all this troubleshooting. Early troubleshooting and follow-up is best. Have the patients bring the equipment to the clinic. If you can have demo equipment, masks and machines and tubes in the office, that's really helpful to show patients different options. Train the staff in basic troubleshooting. It's also a good idea to meet regularly with your DME providers so that they are, you're making sure that they are getting your patients what you intend to get and the help that they need. You might also consider patient seminars and support groups to help provide the patients with some more education and support, because there certainly is a lot to know about CPAP. All right, that is all I have. That is Loretta's link for the handouts, and I'm gonna give the screen back to you, Loretta. All right, so we actually have the Q&A open. Just a reminder, you look for the place where you can go in and write questions, and we'll go through those and answer them. So Anne, the first one's a great one. How do you advise patients who think their PAP is making them sick? Well, their PAP may, in fact, be making them sick. So I have had patients get pretty sick from not cleaning their equipment. So educating them about how to properly clean and maintain their equipment. Generally, we recommend cleaning equipment once a week, but if they are prone to illness or if they are immunocompromised, sometimes we'll recommend doing it more often. We generally recommend soap and water and vinegar in water. There is hospital-grade disinfectant that patients can purchase on the internet to disinfect their equipment. I like this one. Who's authorized to set up CPAP? Is it a respiratory therapist? I have no control over this in my region, and so what I try to do more of is try to figure out how to best work with a DME so they know what my preferences are, and then communicate when I have issues in the clinic. I will pick up the phone and call, and I have a few people that are my contacts to say, like, you know, this person needs extra hand-holding. This is, you know, something we're gonna have to do out of the ordinary. Sometimes I'm asking them for a favor to go past the 90 days on a claustrophobic patient and not start sending them the mail about going to collections and scaring them because I need more time for them to acclimate. So I do end up communicating a lot with the DMEs to just work around whatever their resources are and their reimbursement has changed a lot in 10, 15 years. Yep, I agree. Favorite mask liner, Anne? Anne is the, she loves all the products, so she's good. I do, I'm kind of a gadget geek. You know, my favorite up to this point has been the, they're called CPAP comfort covers, and the reason I like them is because they very easily just go around the mask cushion with elastic. So those have been my favorite. Now, there were some new liners that kind of got debuted at the Sleep Conference in San Antonio, which I haven't had a lot of experience. I know my sleep nurse has been giving a lot of them out, so I think that those are working well, too, but my go-to for years has been the CPAP comfort covers. My go-to for years has been the CPAP comfort covers. You just want something that attaches to the mask. If you have, like, just the free-floating ones where you just stick a piece of cloth, not attached to anything, they tend to slide out of place. So I've got one here from, that I really like. What do you do when your patient insists on hacking into their own machine? And I sort of know Anne's answer, because she and I are similar. I tend to do the, okay, so tell me why you want to do it. I mean, I can't stop them from doing it, right? I'll say, why do you want to do it? Tell me what your goals are. I got to tell you what my goals are. I have to educate them more. We'll talk about the HI. We'll talk about symptoms to monitor for. And I have one patient in particular I can think of that I worked with him about six months because he hated high pressure, and he was actually more than six months. He hated high pressure. He had a mask he didn't like, but had to wait six months for the next one. And so I allowed him to lower his pressure so he could keep treating it. He was motivated because of his AFib. He kept treating, but he was suboptimal on the pressure compared to our recommendation. And then he, when he started feeling more comfortable, he would send me a MyChart message and say, I'm ready for a pressure increase. And then I would actually ask him to let me do it because I caught him doing it once and he did it wrong. Once he did that, then he stopped doing his own, but they want to do it. And so I just work with them rather than trying to fight them on it. They do. I have the advantage of being at high altitude in Denver. So central apneas are a very big problem here. And so I have to educate my patients. If you go too low, you're not gonna treat your sleep apnea, but if you go too high, you may cause central sleep apnea. And usually that is scared enough so that they usually don't mess with it too much. A question here about what do you do when complications come in the swallowing air? I'm not sure I've had that different from aerofasia. What about you? No, I would refer you back to the slides on aerofasia. So either using the flex or EPR settings, trying a BiPAP, addressing their, you know, if they have GERD, yeah. And there's a couple of questions about how do I get handouts? How do I get recordings? This will all be communication afterwards from the ASM. So just watch for that. They'll have to, you know, get everything ready to distribute. So give them a little bit of time for that. Yeah. And then another one is patients. So I think this is interesting because I had, I've had a couple of these and I'll tell you my experience. So another question from St. Louis, I believe. This is patients on full face mask, not getting full treatment, even on high pressures. And I think what the question is regarding is maybe that you're still seeing a high age eye. And I'm going to say, I've had a couple of patients where I had them on a full, and I think one was a hybrid. And when they switched off of those masks, and they were patients, I wouldn't expect an elevated age eye, difficult to control sleep apnea. One was a younger guy, relatively low BMI. And I think it was actually perhaps the algorithm misinterpreting some signal with the way the airflow in their mask was. And once they changed masks, I think that was really the key there. So that's an interesting troubleshooting. It's with very few patients experience. What about you, Ann? Yeah, I've seen that. You can try a different mask. You know, I will typically, you know, try a new mask, maybe try some different pressure settings. And if they're still not adequately treated, I'll send them to the sleep lab for a titration study. So here's another one. Complaining of high leak, already multiple mask changes. You find... So I think the question, I'm having trouble following completely, but I think the question is really like, would you decrease their pressure if they're having problems? And I would say yes, because my goal is always to keep them on pap. I can always go back up if I need to, if they like me and they keep coming back. Once they get too frustrated though, I can't salvage that. They just disappear. So I would always rather work with them and drop the pressure and just advise them that we're a little suboptimal, but we'll work on it. Yeah, exactly. Acclimating patients, would you use sleep aids? Yeah, sometimes. I find that if we do graded exposure, I don't need to do that very often. When I am ordering CPAP for my patients, I always tell them, I say, when you get it, put it in your living room and sit and watch TV and just practice and let your brain get time to use it before you're trying to force yourself to sleep with it. Once you're comfortable, move it to the bedroom and try sleeping with it. And I tell them to make sure they stick it out for a good month, that it takes at least that long to get used to. And if they kind of have that information upfront, I rarely have to use sleep aids, but I do sometimes, typically for the patients that are more anxious in general. The other part of that question was, how do you deal with patients with insomnia? And I'm gonna add a layer to this. How do you deal with patients with insomnia and mild sleep apnea? I find that one of the more frustrating groups. I tend to, well, it's really hard to get my patients in for CBT, our wait list is months and months and months. So I always tell them, let's start, we'll put you on the list to get in for that, but we'll start with treating your sleep apnea, because a lot of times if you treat the sleep apnea, the insomnia just goes away. And I can't get them in any sooner, so. I'll add to that. I also educate them that we might not actually improve their insomnia, because I think that group can become more frustrated. And so I really wanna give them extra education on, okay, here's some different goals. Are we improving your nighttime? Are we improving your daytime? Are we improving your health? And we may not accomplish all three. Your insomnia, sometimes they're very anxious in that visit. And I sort of say with they're really anxious in front of me, I think your insomnia might not be related to either your sleep apnea. Sometimes I find they've gotten oversold on CPAP by someone in the community or their doctor, like their primary or someone who said like, oh, everything will be so great. And when their insomnia is not any better, they get frustrated. And I really need to reset their goals for them and have them focus on other goals than improving all of their insomnia with CPAP. Oh, batteries, camping. Do you wanna talk about power outages, batteries? Yeah, so I live in Colorado and a lot of my patients are very active and like to go in the mountains and like to go camping. You can buy batteries for CPAP machines. They tend to be fairly pricey. I've had some patients get like a marine battery and just get, you can get cables for like 25 bucks to hook it up to like marine, deep cycle marine battery. If you get an actual CPAP battery, those can be like eight or $900. If I have patients that go camping a lot, sometimes I'll recommend an alternative like a dental appliance for camping or power outages if their insurance will pay for both. It's also, if your patient is the right candidate, may be an indication to use ProVent or nasal EPAP therapy if you're not familiar with that. They can have those on hand for that as well. There used to be for campers, it was called a Transcend, Transcend 2, and it has a solar, it has a battery with a solar charger. So they could like hike during the day, charge their battery and then use it at night. I think they may have recently discontinued those because they came out with a new model. Do you want to comment on the FitLife mask, the whole face mask? Yeah, I actually gave it to a patient two days ago. And particularly claustrophobia is where the question came from. Yeah, so the FitLife, if you're not familiar, is a total face mask. It's made by Philips Respironics and it covers the whole face from the forehead down to the chin. I find it helpful for patients who are either really on high pressure settings, like if you've got like a 400 pound man who's on like BiPAP 25 over 21, it's gonna be hard to tolerate the air and a lot of leak. So that mask can be helpful for that. But sometimes it's helpful for claustrophobia and you wouldn't think so. And it can be kind of a hard sell because initially they're not gonna want their whole face covered. But sometimes they feel like if you've got a, I'm doing this demonstration, like you guys can see my hands. But if they've got a mask kind of real snugly fit around their nose and mask, they can just feel like they're really being smothered or suffocated. But because this mask up opens their whole face, they don't really feel so closed in. It's not for everybody, but sometimes it works phenomenally. So I have a question that I'll answer quickly. A patient who has using a ResMed machine, but not a ResMed mask. And how does this affect leak measurement? You know, it's an approximate. Nasal pillows is an approximate nasal and full. And that's all you get in the AirSense machine. It's not really brand specific. But I find, I'm seeing my DMEs put the nasal pillow hybrid, the seal under the nose. I'm seeing them put that in as a nasal mask, actually. Yeah. I've got an interesting one because I don't know the answer. Let's see about you, Anne. Someone wakes up with clicking in the back of the nose or airway with CPAP use that wakes them up. ENT evaluation has been normal. Any thoughts? Clicking. I've not, in 10 years, I've not come across that. Me neither. That doesn't mean that all of you need to give us the hard questions. We like looking smart here. I don't know. That's my answer. I don't know. Okay. Maybe try lower pressure. I don't know. Yeah, or maybe dental appliance. That combo dental appliance might be something to think about, but I'm really stretching. Okay, then prone sleepers. What do you like to recommend? I've had this a lot lately. So I find that CPAP pillows definitely help. I did give a patient who really likes to sleep like prone with their face down. I suggested like a donut pillow so they can sleep face down. And then usually it's just a matter of getting the right mask and pillow combination. People with glasses. Well, they shouldn't be using their glasses or reading or watching TV in bed, but I know that it happens. It's generally nasal pillows are gonna be better or one of the hybrid full face masks. So there's nothing, it's something that's just not on the bridge of the nose that allows them to wear glasses. A couple of product questions. Bongo is another. Bongo is another nasal prop. We hadn't mentioned that one. And then Medistrom batteries, any experience? I've not heard of those. I haven't either, now we know. So here's a big one. What patient outcomes do you measure for OSA? And I think this is such an interesting question if you've gone through accreditation and had to think about this, because we tried to approach our outcomes questions from a, what can we get in our EMR? Like our EMR is already collecting data and I'm in a large health system. So I don't have the luxury of being able to get the EMR to do something for sleep. So I have to take what I can get. And so there's not much on the EMR side. We do track, we were able to track EPWR. Somehow that was put in early on in our EMR transition. But that's not great for all patient groups. And Penn is doing some nice research in this area of kind of the cohort or cluster of different manifestations of sleep apnea and how they might look different when you're thinking about outcomes. So I think it's a great question that we don't get, it's hard to answer here, and I tend to do a little bit of the symptoms, quality of life side of things. I don't promise patients an amazing change in blood pressure or would I track that? Because I don't think that clinically that's an easy measure to see a change in the way we measure and monitor versus statistical analysis. So what else would you put on there for outcomes? Yeah, I mean, in terms of hard data points, mostly like EPWR and their AHI. And then, I mean, you could follow like their weight and their blood pressure, I guess, but there's so many other variables that's kind of hard. Mostly, it's just subjective. So I'll bring up all the list of symptoms that the patients complained of at the first visit, and then go through, like, is this better, is this gone, is this better, is this gone, just kind of how they're doing clinically. Yeah, I have a follow-up questionnaire that I use that has a what's better section, what are your side effects, and then the upworth. And that's kind of my gauge. Sadly, that doesn't go into any data collection tool. It's just part of my standard documentation. So here's a question about DME doing early follow-up. Gosh, I wish we had that luxury, because you can tell when they are. If they are, it's great, but it's not very often. And so I've essentially, over time, you know, I started when the mom and pop shops were still in existence, and they're not in existence as much now. And I really, I've taken over some of that stuff that I used to rely on with DME, which is why I have this handout, because I need to have some education I can give in sort of mass distribution. And so we, in our office, our MAs are very liberal with, hey, did you know we have videos? Hey, do you know we have handouts, so that we can get that information back to the patient that they either don't get or they miss, because there's so much content in that first setup visit. They're not largely introduced to PAP in the lab anymore. And so we're really having to shift more education into the clinic, which is a good role for an advanced practice provider. Yeah. Oh, and someone's put on here a question about a standardized outcome measure. And one of the things I find hard with those is, first, getting access to them. Some are for fee. But some of them are really skewed towards sleepiness. And so if you don't have a sleepy patient, that might not be a place where you're going to measure a change. So I think I'm really interested to see more from Alan Pack's group as they tell us more about this cluster idea, because I think we're going to have to look at outcomes measurements differently in these groups, because the group that has more sleep disruption is not going to see a change in Epworth. The group that has more heart disease, I don't know how we would track that. But let's hope we're keeping them out of AFib and all of this. And then the sleepy ones are a lot easier. But thankfully, now we're seeing more than just the sleepy, now that more people understand sleep apnea as a more complex disease. Right. How about travel with CPAP and water options? You know, I tell people, if you're going somewhere where the tap water is clean, it's fine to use tap water or bottled water. If you're going somewhere where you don't want to drink the water, then I wouldn't use that water in your CPAP. But I've had people spend their whole vacation searching for distilled water. I tell them, don't do that. Just use bottled water or tap water if you're someplace clean. It's fine. And I do remind people about well water. I do give them that one. Like, please don't. Yeah. Yeah. And then the, oh, this is a person, that's it, from a home medical equipment company. How can we improve? Oh, this is a great one. How can we improve the interaction between our docs and our area? We're respiratory therapists heavily involved with patients with CPAP. Sometimes physicians don't seem to have the same concerns, such as a high HI. I think that's an interesting question that reflects different styles of management, for patient management, and also volume. Some of the physician practices, they might be seeing a patient every 20 minutes or more frequently. I have a little bit of luxury of a little bit looser schedule because I'm seeing all of our new APAPs. I see all of our insomnia. And so 20 minutes wasn't working for those two groups. But not everyone has that luxury. And so you do have to remember also a little bit of that. And it's hard because everyone's got a different practice style. I do find the APPs that we work with, the nurse practitioners and PAs, tend to be more hands-on in their management when they're in a sleep center. Maybe not on a primary care side, just because they're seeing so many patients. It's, again, a volume issue. But it's not easily solved. But I wish it was. No, and I would guess that the physicians that you're having trouble with are most likely not sleep physicians. But that's just a guess. If there's practices or providers that you're having issues with, I think meeting with them one-on-one. I mean, I know we're all crazy busy. But I think it's so important to have good relationships with the equipment providers. Meet with them one-on-one and say, this is what we're offering. How would you like us to handle these situations? Things like that. And that might help. And then, one I don't have an answer to, using off-brand filters, would those cause elevated pressures or AHI? Have you ever seen that? You know, I haven't. But I don't check the brand of their filters always when they come in. Yeah, that's information I might not know either. Here's one about AutoSV or Bi-Level. How long would you give them to set up before you might start intervening on high AHI? You know, it depends on the patient. First of all, I never make pressure changes without talking to my patients first. That makes them really mad when all of a sudden, they're like, oh, my pressure's higher. So usually, if I'm looking at a download or something and they're still high, I will usually reach out to them and say, how are you doing? How are you tolerating it? This is what's going on. Do you think you can tolerate it? Sometimes they'll say yes. Sometimes they'll say, no, I'm not ready. So it just really depends on the patient. Everyone's different. OK, here's one. Our local DME company uses the Respironics PAMS program, which does an amazing job of calling patients within three to five days. And then some other stuff here as well. I don't know what the PAMS program is. Ann, have you heard of this? I haven't heard of that. I don't know if my DMVs are using it. I'm guessing not, because most of my patients do not get that kind of follow-up. Well, all of you HME companies out there, you can expect your local providers to be asking you this question, thanks to this webinar. I would assume it's something that the DMVs have to pay for. Right. So sorry, guys, the question's coming. It sounds fantastic. But yeah, it would be great. We'd love it. And then, I don't know if you guys have heard of this. Oh, someone missed the live video. Yep, they're recording it. You'll get information through the ASM if you're a member or a member center. So just watch for that later. Condensation in the tube. I say heat it or insulate it. Canada is listening in. And they thought we were a great help. That's great. Hi, Canada. Canada. And then patient adherence management is what the PAMS program is. And yes, they do have to pay for it. Yeah. One person has asked a question about algorithms and just how they do it. I'll tell you, it's hard to get an answer to this question. I haven't even actually tried to ask even, like, when you push mass fit, what pressure is that? I actually have. Well, OK, so I do have the algorithms. I can give you guys my email, and I can email it to you. But I actually have the algorithm for Respironics and ResMed for their auto machine. So I'll give you my email right now. It's anan.m, is in Mary, .cartwright, C-A-R-T-W-R-I-G-H-T, at C-U Anschutz. It's a mouthful. It's C-U-A-N, is in Nancy, S-C-H-U-T-Z, .edu. And if you email me, I'm happy to send you that information. Someone's pointing out Epworth is not recognized by the ASM for outcomes. Correct. Good point, thank you. And then, trouble, oh, thoughts of DME's drop shipping machines. So not my favorite, but I will say those patients think I am amazing once they get to me, because I was much more helpful than the UPS guy. Yeah, I mean, you just have to work around what you can. So that's why we have more resources and handouts. Oh, let me actually mention, by the way, a quick little aside. Part of the reason I made these handouts was because I started telehealth. And all of a sudden, I realized I can't hand them anything. And so I needed a way to share information via the cloud. And that's why I have all these Google Docs that I've made is partly also to help on the telehealth side. But we're now using it with our clinic patients as well. Yeah, I meet with all my DME's regularly. I ask them, I say, please do not drop ship my patients. Sometimes they still do, but it's obviously not ideal. OK, so I can't tell if this is a question about one patient. I hope not, or general comments. Full face mask, edge of the mask, presses on the roots of the teeth. That can happen. Bruising on the bridge of the nose. Nasal pillows and nasal masks don't work for deviated septum. And then some patients are concerned about movement of the teeth if their masks are tight. These are all very helpful other things to think about and ask patients. Or don't be surprised if you hear. I agree. And then if this is all one patient, then you may want to consider either a dental appliance therapy or refer them for something like Inspire hypoglossal nerve stimulation. And then I want to just go back to that. I thought I really like you do more of the combo oral appliance and mask that I was not as familiar with. And I think that's a really cool idea to think about if finances allow it. Well, you may as well have that patient try a cloth mask. That was the other thing. Here's one that's good. Clinic setups in your location. So I don't know if this is HME asking the question or what, but I think this is another good question that will lead into a topic we hope to do in the future. And I'll say it out loud, so now we'll have to do it. We're wanting to talk about shared medical appointments in the future. We had someone at our, the seminar is a result of an ASM new program called the Assemblies, and we're the Advanced Practice Provider Assembly. And at our meeting this year at APSS, someone, Brittany, talked about shared medical appointments that they're doing within her clinic. And I think she was Cleveland Clinic, right? And they are doing group appointments. So that would be a time where group appointments would make sense. And a lot of the initial PAP and yearly PAP follow-up is another place where the model of shared medical appointments has some really interesting promise. So we're hoping to bring more information from Brittany's experience to the ASM membership, because we could see how that role could really be a nice role to help have more patients coming to the sleep center when we don't, we recognize that we don't have enough sleep providers for the volume if we were actually getting everyone diagnosed who has OSA. We have had the DMEs do inpatient setups in our clinic. So especially if it's a patient that really has a hard time with transportation, we'll try to coordinate if they're coming to the hospital for another appointment. And the RT will come here with the machine, and we'll have like a sleep appointment in a room, and they can do all the setup here. We've talked about doing that more widespread to even maybe try to get patients set up with their machines before they even leave the clinic. So it's something that we're exploring. We have a question about Somnaware software. I don't have any experience trying to interface EMR and DME. You know, we're still struggling with getting our orders to DME easily. You know, I wish this was as slick as electronic prescribing of medicines, and I would love it if someone could take that on and get my Epic to somehow communicate with a DME. I would love it. I've heard Somnaware is good. I don't have experience with it. We use something called GoScripts. So all of our stuff is submitted electronically, and we can upload documents like face-to-face visits and all of that electronically as well. So there's no faxing back and forth, and that's been really fantastic. And we do not have to pay for it, which is awesome. Is it only with a certain DME, or is it across multiple DMEs? The specific DME has to sign up for it, so the DMEs that we work with most often are all on GoScripts, and they love it. Yeah, we have one DME in our area that has, I can't remember the name of it off the top of my head, but they have one, and the problem with us was no other DME was using it. And then another kind of really goofy problem, but our system is set up in a way where they don't give scanners to individual staff, and so you have to sign up for a time on the scanner. And so it was easier for them to access a fax than a scanner the way it worked out, because the scanner was on a workstation that someone was working at. So you'll sometimes get these really silly process issues, but convince your health system that a scanner is a reasonable cost, and that can always be somewhat of a challenge, depending on where they're at with budgeting. Yeah. So someone asked about surgical interventions for OSA. I don't know. I can talk about that, because we do surgery at my site. So, you know, I generally tell patients we try to reserve any surgical intervention as sort of a last resort, depending on the patient. So if you're talking about surgery where you're trying to modify the size and shape of the upper airway, the doctors here don't really do UPPPs anymore. It's sort of modified. But any kind of upper airway surgery, it's extremely painful, extremely painful. There's a lot of downtime, and they usually get fairly limited improvement in their sleeve apnea. So we try to save that as a last resort. The Inspire, which you have to have surgery to implant it, but the Inspire's been out for a while now. It's a hypoglossal nerve stimulator. So every time the patient goes to take a breath, it causes the tongue to contract and pull forward. We've had great success with that. We do a lot of Inspire here, and so far things have been going generally pretty great with that. I have suggested mandibular advancement surgery for a couple of patients that were really young, had pretty bad sleeve apnea, and had very severe microretronathia. None of them have gone for it, but I don't recommend that very often. We've got another thing. Ear popping, tinnitus, or ear pain with CPAP. I have had that. Any circumstances for that? They had a patient at the end of therapy. Yeah, so I did send them to ENT, because they had some other stuff going on as well. I had the patient do, they kind of had some fluid in their ears, so I had them do some Afrin or Flonase for a little bit to kind of clear it up, and then we ended up putting her at a little bit of subtherapeutic pressure. So we're tolerating a little bit high AHI, but it's not affecting her ears. Interestingly, there's an ENT in my site that thinks sometimes tinnitus and dizziness can be caused from sleep apnea. She's researching that right now. This is also, just someone wanted to bring up that for Inspire, the indication is narrow, supine dominant, normal BMI. No, that's not. So for Inspire, they have to have a BMI less than 32, so they can be overweight, and they'd have to have an AHI between 15 and 65 and have failed CPAP. It doesn't matter if it's supine or non-supine. I'm not sure where that information is. Is there anything that would have said, I don't know, so I'm asking you, the supine might give more predictive of success or anything like that? Do you remember? Would you have ever seen that? Not that I've heard from my surgeons. Okay. I know they do the sleep endoscopy to make sure that there is not concentric collapse of the airway, but I don't think supine versus non-supine has anything to do with the Inspire getting approved or not. We've gone through the questions that came from the audience, and I actually wanted to put one on my list that I realized we didn't have in our slides. I've had problems when I have patients that need real high pressure so they can only get certain machines, and then they have a ton of alarms. So what they used to be on just straight CPAP, and now they have the little mini ventilators with all the fancy stuff. Do you want to comment a little bit on that, Anne? Well, the ventilators have tons of alarms, tons of bells and whistles, and they can be very aggravating. I turn most of them off, and you can change the parameters of the alarms so that they're not going off too often. So if that's not something that you're comfortable with doing, you don't have a lot of experience at, your DME, the RTA or DME can help you with that. But those advanced machines have tons of alarms. What are, are there options that are going to be non-mini ventilator at higher, that have higher pressure settings than others? This is going to be a brand specific question. I know you usually have these numbers in your head. You mean like machines that can go higher than 25? Yeah. So the, oh my gosh. I think the ResMed AirCurve STA can go up to 30. And I think the Respironix DreamStation AVAP maybe can go up. That might be capped at 25. Cause I think that's one of the solutions. Yeah, I think, I think that's a solution we ended up with. But the crazy thing was the, since the DME had dispensed the fancy Cadillac, then we had to pull that back and give them another machine and they had to go through like re-auth and stuff like that. But I think it's one thing to just think about is if you end up in that weird situation where you don't need true advanced modality, you're ordering it for high pressure. Check in with your DME and find out what machine options you have and maybe even compare notes across a couple DMEs cause they may have different stock of what you could use that's going to function more like a CPAP, less alarms and less like, cause I had someone who was successful and became unsuccessful just because of the alarms and so sensitive to leak and other issues she had where her dumb CPAP was, or dumb high level, whatever she'd had that was an old machine, it was fine, it just kept blowing air, you know. Right. So it was a hard transition for her. Yeah. Oh, and the other one I wanted to. Well, thanks everybody for the great questions. The one, the other one I wanted to bring up that I learned actually just today in a meeting. If you're in the lab setting, you want to also be careful to figure out what your humidifiers are at in the lab because I think my tech was saying that the humidifier default is quite low for their remote controlled PAP machine. And so they have to basically go in and start aggressively adding humidification, not relying on the starting point the machine has. Yep. Which I like if they're doing that because I'd like to try to avoid full face masks, going to those too quickly and trying to get higher humidification, chin strap or other options, even in the lab. Yeah. Okay. All right. Great. So I think we are done with questions. No one has chimed in. And so we're going to go ahead and close this for now. We appreciate everyone who attended and anyone who is attending after the fact in the recorded sessions. Thanks so much for coming. Thanks so much. Have a good day.

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