Educational Webinar: Treating Sleep Disorders: Effective CPAP and BPAP Strategies

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Hello, and thank you for joining us today. My name is Brandon Martin, here at McKesson Medical-Surgical. And I'm so excited to welcome you to today's presentation, Treating Sleep Disorders: Effective CPAP and BPAP Strategies. Before we get started, I'd like to direct your attention to a couple of our disclaimers. And while you're reviewing that information, I will remind you that this presentation is being recorded. And within a day or two, you can expect to receive a link to rewatch the presentation. If you have a question, please feel free to enter it into the Q&A panel. It should be just to the left of your webinar window. You can enter a question at any time, and we will do our best to answer at the end of the presentation. Of course, if we run out of time, we'll certainly reach out to you in the coming days. Our speaker today is Patty Reni, Senior Respiratory Clinical Program Manager here at McKesson Medical-Surgical. Patty has been a registered respiratory therapist and home care advocate for more than 35 years. Prior to this role, she held account manager positions with McKesson as well as the Med Group. And in these roles, Patty optimized best practices in the home medical equipment industry and helped businesses diversify revenue streams. Patty also previously served as the president of TMJ Consulting. In this role, Patty Specialties included compliance audits and programs, efficiencies and profitability, and, of course, staff training programs. Patty, thank you so much for joining us today. Thank you, Brandon. Great to be here. I really appreciate all of you here as well. And thank you for joining us today and understanding CPAP and BPAP and how it's going to work in skilled facilities, as well as anything in the home for our respiratory care patients. Today's objective is to understand the basic CPAP and Bilevel therapy. As we learn more about the proper use and maintenance of these devices, it will allow you to understand how to assist your clients and be in compliant with therapy, as well as how to deal with the potential challenges and solutions to enhance their own compliance. Because as you know, as they're compliant, they're going to be more proactive, healthier, active clients in your residence. Just a little introduction here on CPAP. Sleep disorders has been diagnosed for quite some time. I think one of the first CPAP was put out back in the mid-80s. And so sleep disorders includes obstructive sleep apnea, otherwise known as OSA, which is the prevalent in the United States. In the United States, it's about 39 million adults, with a global estimate of about 936 million adults. Now we're only talking adults here. We're not even talking children. Which children it's starting to also be on the rise. One of the most common symptoms is snoring. And that's present in 94% of OSA patients. So what happens if it's left untreated? First can lead to heart, kidney and metabolic health complications. As they recognize the symptoms and seek treatment, it will prevent other issues happening, so their overall health will improve. We also look at two-way relationships, how OSA impacts health, and how health influences impact OSA. Think about how Americans eat. Increased risk conditions like diabetes, high blood pressure, heart failure and more. And some of the things, as I look at this list, I think about even my own family, and could they have been treated differently if we had been more proactive in their health? So biologics, age, big one, gender weight influence. Those are the three top, that is what you've seen. Used to always be the male, women are definitely gaining traction, which is not a good thing, but that we are. Other risk includes hypothyroidism. Think about that as especially with your geriatrics, it's not unusual for geriatrics to have hypothyroid. So is that what's happening to them right now? Post-menopausal. Do they have heart or kidney failure? Alcohol use? I think if we all sit back and think, we've out with friends and we have a little bit too much wine, do you feel a little bit more congested that night? You might not have the best sleep. Yeah, you probably did have some obstruction. Smoking, facial anatomy. You get some people that do a lot of facial reconstructions that could also have an adverse effect. It could help, depending on what they're reconstructing, but it could also have an adverse. In the US right now, the prevalence of OSA is 12% to 18% in men and 3% to 8% in women. And as I said, it's growing. Untreated, we already talked about that. It's going to lead to heart metabolic. And I know I seem a little redundant here, but I can't stress understanding your patient in what you're looking at because this affects everyone around us. This is not just in facilities. This is your family, friends. So it's amazing who you would see, when you start talking, and all of a sudden they're like, "Oh, yeah, this one's on CPAP, this one's on CPAP. " So you look at your obstructive sleep, male, obese, hypertensive, typical stereotype. Women, I've had women who were very petite, very slight in their weight. They weren't obese at all, but they had a deviated septum or they had a central sleep apnea, which also will make an effect. So they still end up with that sleep disturbance breathing. The factor is, what is that disturbance? So with comorbidities, 83% of patients have drug-resistant hypertension. With that hypertension, think of also potential patients that wake up with high blood pressure. Like their blood pressure is fine throughout the day, and even with sleep, but when they wake up, it's extremely high. 160s, 170s, 180s. That could also be a sign of it. And CPAP could also help that. Approximately 72% have a Type 2 diabetic. So who's diabetic in your facility. Are they Type 2, Type 1 even? Should we have them tested? Would this give them better outcomes? 77% are obese, and 76% have chronic heart failure. So you're seeing in those co-morbidities that that's the general public. I wish I could say that it was the oddballs out, but it's not, it's they're very common. So where are the therapies come in? Continuous positive air pressure, which is CPAP or Bilevel BPAP. And again, I say by level and not BiPAP because BiPAP is a trade name with Philips Respironics. So the name is really Bilevel positive airway pressure breathing or Bilevel pressure airway. So you just want to make sure that we stay generic. They might have a dental appliance or maybe they had a UPPP. Sorry. Lights got sort of jumbled there. But UPPP is not unusual. But what I have found when they have that UPPP in one year, they are on CPAP, and that surgery is very uncomfortable, very painful. And for almost a year, their throat is always sore. And then at the end, they still have to do CPAP. So these patients get very frustrated. And they might have gastric bypass. Again, think of that different ways that we can treat. Usually, if they have gastric bypass, they probably also have CPAP. Definitely until they get to where they need to be if it's possible Again, I'm going to go over these risk factors again a little bit more in detail. Excess weight. Most but not all people with obstructive are overweight. Fat deposits around the upper airway. Think about the neck. If the neck is a very thick Neck, I always sort of pick on football players. Football players have a very, especially if they think they're, my husband will yell at me because I'll probably say the wrong thing. Like a defensive lineman or something like that. Their muscles are very produced within their necks and upper shoulders. As they lose that muscle, that airway becomes very flaccid and will collapse. So we always want to look at how do we keep that open. How do we keep that airway going? So with obesity, you could see hypothyroidism, polycystic ovary syndrome. And again, not everyone is overweight; thin people can also develop the disorder. Narrowing airways you may inherit naturally, maybe tonsil or adenoids may become enlarged. Just had a case not too long ago, if someone had, they had to get their tonsils removed at the age of 40. You just don't know. High blood pressure, again, we've talked about that. Chronic nasal congestion. The chronic nasal congestion often occurs more often. And it's consistent at night. So they might be fine all day long, but the minute they go to lay down there congested and they have a stuffy nose or they have that cough, a lot of phlegm production. And that in itself can be due to the narrowing airways. And again, some of that constriction in that neck. Smoking speaks for itself, diabetes, we already talked about that. Sex again, we talked about in general. Men are twice as likely as premenopausal women know that after menopause, their frequency increases considerably for OSA. Family history, possibly. It could be, especially if there's a chronic, other reasons in that family that could have it. And asthma, believe it or not has also found that the link between asthma and OSA. So it's amazing where you'll find it. It's not just the overweight person that you're seeing that has bad eating habits. There's a lot of other things that could go with that. This is like one of my favorite pictures because that was probably me and my husband. My husband's been diagnosed with OSA. He's had CPAP for over ten years. He's lost his weight. He's doing great. And his CPAP is only sitting about four centimeters, so he probably doesn't even need it, but he's afraid to take it off. But when he was snoring, though, boy, I wanted to just put a pillow over my head. I probably did put a pillow over my head. It gets loud. It's a very that sonorous sound, and it's moaning and it's disruptive. And you sit there and you count. How many times are they not breathing? For the significant other, whether it's a male or female, it's very makes your sleep very tense. What's the benefit of the CPAP or BiPAP therapy? CPAP, as well as BiPAP, will prevent the airway collapse. What I want you to think about is think of a splint. And if you splint your finger or your foot, it's to keep that in place so it can't move. Well, CPAP does the same thing. It splints the muscles or gene colossal[?] muscles that are in our neck area and our throat, and it keeps them from collapsing on each other. So it's a split. That's the easiest way. If you have to describe it for your patient, say we're splitting open your airway so you can read these here. They probably understand it. It improves the quality of sleep and it reduces daytime sleepiness. That's another big symptom. You're seeing somebody and they can't stay awake to save their soul. You might have seen them in meetings. Somebody fall asleep at a meeting and you're like, "How could you fall asleep? " They're talking. No, it's they lose concentration and it just goes out. They never have watched the news all the way or movie. They've never finished it, probably haven't even started it. So it's very typical when it comes to that daytime sleepiness. With bilevel, what you're going to get there is you get more respiratory support. So think of that more complex patient. They might have COPD. It improves that ventilation and the oxygenation. So we're CPAP is that positive airway. For bilevel we have pressure on both inspiratory and expiratory. So it makes it easier for them to exhale. And that's key if they have any type of other lung diseases. I like showing pictures because we don't really look at it in the anatomy of our head and our mouth. If we're all clinicians, yeah, we probably looked at the last type of a diagram like this when we were in school. Who knows how many years ago. So think about with normal breathing. Here in the front, you have the tongue. It's that pink part. You see the uvula coming down here? Well, if you look at this blue line, that's air passing through the nasal passages, and it's coming straight back behind the soft palate and then going into the trachea, into the lungs for breathing. That's normal breathing. That's what you and I do as we're sitting here and you're listening to me. That's how you're breathing. When you snore, you get a partial obstruction. So it's sort of like when water is boiling and you get that bubbling, it's the air and the gas obstructing each other, and that's what's causing those bubbles. So very generic definition. But that's the snoring. So if we look here trying to get my pointer here and it seems to be on my eye, there we go. Again, blue line through the nose. And you see that it's narrowed to the back of where the uvula is. The uvula has come down, almost touching against the back of the throat. Tongue is going down, you see. And they're also trying to breathe in through their mouth. So that's why you're getting that the disruption because it's usually nasal. Nasal can't make it. The mouth is trying. So they're pulling any way possible to get air into their lungs. When they do completely obstruct in this bottom picture you're seeing the air's coming through the nose. You can see this blue line. It's disruptive. It can't go anywhere. So it's just biting its way. Obstructed cannot make it past the uvula or the soft palate. And there's nothing coming in through the mouth because from where the tongue is and everything, everything is touching the back. And that's when they go apneic, and they stop to breathe. So when they're in a complete obstruction, they are lack of breathing. Again obstructive caused by blockage because of the tongue. Central sleep apnea, it's not the airway that's blocked. It's the brain, not telling the muscles to breathe. And it's not unusual for patients to have a mix of obstructive and central sleep apnea. We have to treat both of them and figure out what's the more predominant and and figure out therapy from that perspective. Sorry, I keep losing my arrows. So, what is snoring? I think we've already talked about that. I don't need to beat that in. But you know that vibratory sound trying to get it opened right. Hypopnea is another one. And that's partial. That's when you're partially obstructed. Usually, when you snore, you also have that hypopnea. And that's when the airflow is decreased by about 30% for seconds at least greater than 10s. So usually at that point we'll see the oxygenation. They might be sitting at 96% saturation. They'll drop to about 92, and then they'll pick back up again and then they'll drop again. So just by having a pulse oximeter on them, you'd be able to tell when they're having those little episodes. When they totally optic airflow stops. Greater than 10 seconds, all the muscles relax so much, it just blocks the airway. And you literally, if you have a significant other that is doing snoring and you're questioning, you know what? Wake up and watch. And I used to sit there. I should have been waking my husband up. But no, I was counting on my watch. I wanted to see how many apneas he had in a minute. Sorry. Clinical me came out at that point to his demise. No. He's good. But you wanted to figure out what's going on with them. We always look at how many apneas to how many hypopneas do they have in an hour. If the combined total is greater than 15, that's when we usually start them with CPAP. Okay. And central sleep apnea, and we talked about that already, that it's the brain not communicating to the diaphragm and the intercostal. So we talked about this. You already know the nighttime symptoms, the daytime symptoms. Think about that sometimes, a little bit more. Are they waking up feeling tired? Do they have headaches upon waking? Dry or sore throat? Excessive sleepiness during the day. Impaired memory. Why is their memory impaired? Is it because of lack of sleep? Or is it because they have an impairment? A lot of times, it's just because they haven't had sleep. Think about your own self. If you have a couple of nights that you didn't get good sleep, are you foggy the next day? Yeah, usually. So think about that in the whole generalized public. Impotence or decrease in sex drive, and again, that's how we find it, especially in the younger population. I'm saying younger under 65 to 70. That's the questions that they'll end up having. You'll also see waking up with a feeling to urge to urinate. They get it frequently to do that. And it's not because they really have to go to the bathroom, it's just that they were apneic and they had to wake themselves up. So they figured, "Oh, well, I'm awake. I might as well go. " So it's usually that concept that they're using. Again, what other factors, age-related, changes in sleep architecture? Did they move? Did they go from their home to an assisted living or to a long-term care? That changes everything because maybe they're not sleeping as well. Do they have an advanced sleep phase? So, when is that melatonin area hitting? Is it hitting too early, or is it not hitting at all? Some things that I've heard doctors are doing is they're checking at the cortisol levels too. Can that be something that they look at? The cortisol, the five HTP, what's actually happening in that area? Visual impairment, you're blurry-eyed. You have a tendency to get tired. I think of myself all day looking at a computer. At the end of a day, my eyes are so tired. I just want to go to sleep. And of course, you try to close your eyes and you can't sleep, but it just makes your whole mind tired. Daytime limited exposure to bright light or too much bright light. Nighttime environmental noise. Too hot. Too cold. Room sharing, think about that. You might have room sharing, and somebody does have severe OSA or obstruction, and the noise is too much. Or they like to have a light on, or maybe you have activities at the facility has and they open the main lights instead of using a flashlight or something to keep, again, from getting that patient into a full wake-up mode. So think about all those factors. Behavioral, and maybe they're not doing anything during the day. Their social activities have decreased, whether they're at home or in a home. Are they getting engaged, or are they just disengaged? Do they find or do you find that they're taking many naps during the day? Like every time you turn around and look at them, they're dozing off. Why is that? Do they have pain dyspnea? Again, we talked about cognitive impairment, depression, insomnia, restless leg syndrome. Somebody who doesn't exercise a lot might also find that their legs can't get comfortable at night, or, depending on just I mean, that syndrome itself, their legs could be just twitchy. So you have to understand what else is going on and what medications are they taking? Are they taking something new that they hadn't taken before, or are they still taking something old, and the doctor changed the medication, but there's taking the old and the new now? Seeing that as well. So they're going to get tested by using a polysomnography. They're going to be sleep test. The good news is some of these sleep tests can also be done in your facilities. So there's this home testing that can be done. So you could be getting that where they come in, and they can hook the patient up and collect the data. And they're ready to go the next day. So think about that. There's ways of being able to diagnose easier than having to bring them to a lab and make all those appointments. Again, we talked about all the methods of treating. There's also tongue exercises and implants. They have inspire, which is an implant that's in the upper chest that you push the button that's implanted in your chest. I'm not sure if I like that or not. And it detects if you're going apneic and stimulates you to breathe. I know one person that has that. She likes it. I don't know, it makes me nervous. We talked about the usage. Those that know Joe Biden, he was using OSA. Maybe that adds to a little bit of his times of non-clarity. He might not have been using it. And again we talked about the daytime sleepiness, and I'm sorry I know it seems redundant, but this is something that I can't stress enough. So when we use CPAP, and in this case it could be CPAP, which is continuous airway or APAP, which is auto pressure, positive airway pressure. I recommend truthfully in facilities go with auto-positive air pressure. That auto pressure with CPAP, you're getting one pressure. Let's say it's 12cm of water that's continuous through inspiration and expiration. So as they exhale against that mask that's either on their nose or their mouth, they're breathing against that 12cm at the same time, which could be difficult. And that's where sometimes non-compliance comes in. With an auto PAP, it means it starts at its lowest pressure, which is usually four centimeters up to 20, and it will variable throughout the night depending on what sleep pattern that patient is in. When they're in a deep a light a REM, it's adjust accordingly. And it makes it much easier for them to be compliant. Because when they're in a deep sleep, that's when their pressure is probably the highest. They're in a deep sleep, so they're not feeling it. It's a slow ramp-up, so it makes it much easier for them to tolerate and not fight that extra pressure that's coming at them. When using a bilevel, which is two pressures, you'll have a higher pressure on the inspiratory phase and a lower pressure during exhalation. So, usually it's someone who's going to be doing 12 to 15cm or higher on the inspiratory side, and then we usually have them back off 5 to 7cm on the exhalation. So they might breathe against 15 as they inhale. But when they exhale, it might drop to ten. Makes it easier. Again, increasing compliance, but what we want to also do is make sure that their airway stays open and they don't fight, and it collapses on them. So it makes it a slower exhalation phase, which somebody does have COPD is going to be a much more comfortable way of breathing. Okay, we've gone through this. I think you guys get it now. So let's go into the equipment. What do you use? There's so many things out there. How do we put this mask on? So, as you see in this picture, this is a nasal mask, but it's continuous pressure. It blocks the breathing. And people with obstructive. Let's go to this next one when we use it, you're going to wear the mask over your nose or your mouth while you sleep. The mask is connected to a hose that's connected to a machine that usually sits on the side of the bed on the nightstand, preferably. Please do not put it on the overbed table. The machine's just pumping air through the hose into the mask to again increase the airways. Keep them open while they sleep. That is the basic. That's a great little summary to be able to tell the patient. It's very easy, very explainable. So here's your machine. So in this picture here, you're seeing in one this is a humidifier. So the humidifier chamber fits in here. You can add water to it. Distilled or sterile is what you'd want to use. Please do not use tap water. Especially in some waters, it could be very hard water, and it will just leave a deposit and make the machine dysfunction. And two, here's where we turn the machine on. And again, know that your certain machine may be a little bit different than this. This is where the plug goes in. Your tubing could be heated. In this case, this is a heated one. And I know that because of this piece right here at the end, it's like a USB port. It sticks up a little bit, and that's what hits those electric elements to warm that tubing. So when the air comes through with that moisture, it keeps it warm so it doesn't condensate. Or it could be a non-heated and it just wouldn't have that, and it would just blow through. And then you've got your different type of mass hits. You could have nasal pillow, or you could have a nasal mask, or you could have a full face mask. The key thing, though, is a lot of times your residents are coming in with their CPAP in hand, so it's always best to get that user manual from the manufacturer. They're all on the website. You could talk to our reps, we have them on our website as well, but get that user manual so that your staff feels comfortable with handling, especially that night staff. You're usually shorter staff. This is when crazy things always happen. I know I worked nights for two years, so it's always good to have some of those tools handy to decrease that stress level. We talked about the machine stable surface fill the humidifier. Again, we talked about that. I want to move this along to make sure we're on time. So, how are you going to monitor? Well, initially, let's always get a baseline respiratory status. And what is that? That's oximetry. So what's their pulse ox? What's their blood pressure? Their pulse, color of skin. How are they breathing? Are they using accessory muscles? What's just going on? What's their total comfort level? And then ongoing once they get that CPAP monitor them. Is the math fitting correctly? We want to make sure that it seals, and I'll show you in subsequent pictures that the mask does need to seal around the nose and possibly the nose and mouth, because if it leaks, it has a tendency to go in towards their eye. And at that point, you're going to end up with conjunctivitis and other issues with dry eye. So we always want to make sure there's no leaks happening. Are they hot or are they cold? You know what's going on. Check their phase two. Sometimes we have a tendency to put that mask on too tight. People are taking those drops and dropping it off because we need to get it tight seal. Well, that ends up eroding into the skin, so you can end up with some pressure sores. So you need to be careful about that. So this is just a nice mask comparison that I found. So in this case, this is React Health, otherwise known as 3B comparing to ResMed, Philips Respironics, and Fisher and Paykel. So it's just a nice way because I have so many times people will say to me, well, they came in with X mask. We don't have that. What can you use? And I can't recommend, I don't know the patient. You see the patient. So how do we fit that? What is the most appropriate. And this will help you. So, in this case, the Rios that's a nasal pillow. They fit just in the nares to a nasal mask and to the full face mask. Let's look at the nasal pillows. You see in this picture single head gear strap. Just one strap. Usually, we'll go above the ears, you don't want it to go in the middle of the ears. Again, could cause some pressure sores on the ears. You want to keep it above them? It's going to go into the nose. You want to make sure it's not too tight. You don't want that nose, the nostrils, to be pulled upright, like a pug. You want to make sure that they're comfortable. So that's where we have to look and say, is it the small size or medium? What [inaudible] do they have? And then the other thing you need to understand is the headgear, regardless of the type of mask, goes with the mask and the manufacturer. It's very hard to swap a ResMed headgear with a respirator mask. You need to get the same manufacturers. These are the key manufacturers that you'll see out there that might come in here, and there are others, but these are the predominant. In this case, this is a nasal mask. You see, it's a halo mask that fits to the crown of the head. You've got the upper straps that are fitting above the ears and across the forehead. Where it attaches to the forehead. There's a forehead guard so that that plastic piece doesn't grind into the forehead, and also will cause a pressure score. At the bottom, you see in the straps or below the ears, we don't want them to come across the lobes. And you're going to usually tighten the top first. Make sure there's nowhere and then tighten the bottom. Whatever you do, you're tightening both sides, left and right bottom and then left and right top. You don't want to be doing the left and then the upper right. You want to stay consistent so that equal pressure is throughout the bottom of the mask as well as through the top. So again, you don't have that extra pressure sitting on the bridge of the nose or onto the cheeks. Your residents may have thinning skin, so we want to make sure that we really mitigate how much pressure is there. So we don't get any pressure sores, skin tearing because that would then increase your noncompliance. This is an oral mask. So it's not a full face. It's an oral. So somebody who's an obligate mouth breather they may feel comfortable with this. A few of them may get. We have not all four do, but it fits just in the mouth. It's like a mouthpiece. If you had a retainer, but with that plastic cover, and you're going to be breathing, but know that they have to always be breathing in and out through their mouth. They should not be breathing at all through their nose. So somebody might have bad deviated septum. And so they don't breathe much through their nose. So that might work. Again, it's going to depend on that patient. In this case, we have a full-face mask. This is very typical. There's two types. Here on the left, you're seeing again has the halo type mask that fits around the crown of the head. And then you have the upper straps that stay above the ear, and then the lower straps. And in this case, with the one on the left, it's fitting just over the nose and mouth. So the bridge of the nose is free. So you're not getting that extra pressure. But if you're pulling that too tight, everything from your nose and your mouth is going to be pushed backwards. So we want to make sure that it's secure, but not to the point where it's obstructing the patient because it's contorting their face. In this case, this is a full-face mask. You can see it's covering from the bridge of the nose. Look how close it is to the eye. If that leaks, consider they've got conjunctivitis. So we just really want to make sure that doesn't leak. And then it comes right underneath the lower lip. You can see again, we don't want it on the ears. And it comes across the top. Again, it'll have that same halo in the back. It has a cushion at the top of the forehead to again, give it a little bit of cushion. The one thing that's good about the masks today, versus the ones that I had set up back in the '80s, is that they're made of silicone and they're much more pliable. And they last longer. We couldn't get more than 30 days out of the full mask. Now, you can at least exchange those cushions. Usually, twice a month, you can move the cushions and put a new one in. It just makes it much more comfortable and easier again, the basic is for compliance. What do you need to do? You need to inspect daily. Clean the filters, there's just one small filter. Replace it as needed. Usually, it gets replaced twice a month. Again, you know your facility. Some facilities have more dust than others, or just drier than others. So it's just going to depend on where that patient is, whether they're in their home, high humidity, low humidity. Headgear to be cleaned weekly. Headgear, if they're home, you can put it in a laundry bag and into the washing machine, or you can put it in the sink, rinse it with a light soap and dry it. It'll be dry by that night. Tubing, same thing. You're going to pour water in the tubing, swish it around. There's a disinfectant that I like to use. That to me is very safe because it dries as a saline base that I like putting in the tubing, because that way, at least I know they're not going to be inhaling any other type of soap or smells or things like that. And then I have the recommendations of when to have everything change. So in an emergency, the good news is this is not life or death, okay? This is not a ventilator. The patient if they have to get up and go to the bathroom, I always recommend I'm going to go back here. Back there, slide, I recommend you have them take the tubing off. Keep the mask on. There's nothing worse than trying to put a mask on somebody who is partially asleep. So, have them keep the mask on. They can still breathe. Everything is fine. They're breathing right through this hole here where that tubing goes, and they go, they come back, and they hook the tubing in, and they're all set to go. I don't even turn the machine off. Keep the machine going. They just put it back on, and they're set to go. Makes it much easier. And then you know what to do for monitoring for signs of respiratory distress. Are they having a hard time breathing? Do they have dyspnea? Do they have tachypnea? What's going on with their breathing? What's going on with their saturation? And I'm a firm believer of always monitoring that saturation. So it's very important to educate your patients. Having them understand why they have to adhere is so key. If they understand that in the beginning, and they have a great experience when they're set up, you're going to find that they're going to have a tendency to be more compliant. Something to think about in facilities, there are a number of companies out there that do AI right mask bidding where they can actually do it from a cell phone or tablet, and you can measure it, and you can make sure that they're getting the right one. Think about that for your facility. Wouldn't that be much easier? So you always know that you're going to get the right one on their face. So, that's something to always look at. This is the CPAP frequency when to change everything. It's a good thing to adhere to this. This is per the manufacturers, and interestingly enough, which they've never done before, but CMS adopted what the manufacturers have recommended. And this is actually how CMS does reimburse. Granted, facilities are different. Home health is different, HMEs are different. But just understand, this is still the rate that you'd be safe on swapping things out if they needed to get a new piece of accessory. Okay, I just wanted to show you more. The pictures. This is a basic tubing called a slimline. You can see this is the heated, you see that little prong adapter now a little bit better, maybe here for the heated. Your filters, these are much bigger than they are. They're pretty tiny chamber, a chin strap. So somebody that maybe has multiple, I'm having a blank here, sorry. But MD, or they have ALS, and so they don't have the strength in their drawer, so when they do sleep, their jaw has a tendency to drop open. A chin strap works. If that's happening, and you don't have a chin strap, what we used to use prior to chin strap is an ace bandage. And you would take that ace bandage and you would just wrap it gently from the chin to the top of the head. And that just was enough to support the jaw from dropping. But chin straps are very comfortable. This is the disinfectant I was talking about. I wanted you to see it because it's really different. Because it does go into a saline base. I do have the SDS here for you to look at, obviously, it's your protocols, and you should always be following what your protocols state. But this is something that could definitely work and maybe make it easier for your staff to clean and make sure, or even if you have patients that have good cognition, they can learn how to clean their mask too, and even your staff wouldn't have to do it for them. They should be able to do it. Make sure when you're cleaning, though, clean every day needs to be washed with soap. You need to make sure that it's covered. You don't want to just leave it out in the open. You will get definitely dinged for that. And here's some F tags. I work very closely with our nurse clinician, Patricia Howell, who is our regulatory long-term care specialist. This is her bailiwick, but she understands these F tags like nobody does. And so I always make sure that when I'm looking at these, I review with her to say, "Does this make sense with what we're talking about? " And she's giving me her blessing on that. But quality of care, understand what could happen there. You never know when somebody is going to come in to do a survey. So I had a case where, again, the staff washed it, left it on the nightstand, didn't cover it, surveyor came in. They got dinged. You just don't know. So it's better to get into a good habit. Nutrition, hydration, again, we want to make sure that's all working well. Treatment services. Okay, prevent pressure ulcers. Again, as I said on the face, on the ears, top of the nose, could be the forehead. So we want to make sure we look at those. Make sure you have a good comprehensive care plan. Don't be just vanilla with them. Make it personable for them. Infection control. Yeah, we talked about cleaning and then making sure that it meets the professional standards. I want to take a moment to introduce you to our wonderful team here. At McKesson, we have our clinical center of excellence. And, yes, I'm respiratory and anything respiratory you can usually count on me, but we have quite a few wound care specialists and incontinence and oncology and ostomy and infection prevention and Inco and you name it, we have it. So, please never hesitate to talk to your McKesson brand, your McKesson rep. And they would direct you to which of our Clinical Center of Excellence professional would work best for whatever your need is. And with that, here are our resources. And I can't lie, I have more disclaimers. Got to make sure we have those disclaimers going. There we go. There's our product. There we are. Ask me anything. Questions? Thank you so much, Patty. We do have a number of questions in the chat. I can go ahead and answer this first one. Yes, the PowerPoint is available; if you don't see the link there in your display window to download it, not to worry. Everyone that's registered for this presentation will receive a copy of the slides and a recording. So, watch for that in the next couple of days. And then we had a question come in on the best method to handle an OSA patient during a procedure where sedation is used, because very often their airway can become occluded and they oxygenate during that procedure. Yeah. So if I'm understanding, we've got an OSA patient who's having a procedure done. They're using some type of an anesthetic, but they're not using a ventilator, there may be using an LMA or something like that. So I think the best thing to do is to whoever is doing that procedure should know that they have severe OSA. And that they need to make sure that if they sedate them, it might be an issue. I would say they might need to be on their CPAP, or they might need to be on a noninvasive ventilator for that treatment. And a lot of times, when you're doing various minor surgeries, again, they might just put a mask on with anesthesia. And you're breathing. That's a non-invasive type of circuit. So that could be a possibility. But I think if that's happening, I'm assuming that the person doing the procedure doesn't understand OSA. So it's always best to make sure you educate them. That's a great question. I've never had that one before. We've got another good one here. If someone cannot tolerate the full face mask and are primarily a mouth breather, could they use the nasal mask or pillows along with a chin strap? Yes. You're spot on. If they can't tolerate. Because a lot of times, people will feel claustrophobic. That mask is on there, and it's just overwhelming for them. So definitely they could use just the nasal pillows or the nasal mask, whatever they're comfortable on, chin strap is going to make it more secure. They're going to have a much more comfortable night, and they're going to end up being more compliant and happier. And if they're happier, that means you have a happier resident who's not getting sick and not having to have readmissions. And ultimately, that is our goal. How do we minimize their readmissions? Great questions. Brandon? Yes. How about, could you talk a little bit about the long-term effects of higher PEEP? Could you talk a little bit about the long-term effects of Positive end-expiratory pressure. So when we're talking CPAP, we don't think about PEEP. We think about PEEP only when we're doing full-on ventilation. And although you would think if they always had that end expiratory isn't going to be a problem. And it depends on what's going on with that patient. I've had people that have been on PEEP for years, five centimeters is just how they tolerate it. Keeps the airway open. It keeps that from collapsing. So it depends on what's happening with the lungs, the muscle, the intercostal. For CPAP, that's why I like having that auto PAP because it really adjusts it and it keeps that flow very moderate and only gives them what they need when they need it. So again, PEEP ventilation, CPAP or bilevel is that non-invasive aspect for again obstructive breathing. Excellent. Got a couple of other questions here. This is something from early in the presentation, but do you have any insight on why sleep disorders are on the rise in young people? Something you mentioned earlier? Yeah. I have my opinions. If we think about young people today, are they going outside? Are they hanging in the house? Are they gaming or are they eating? Are they eating everything that's wrong for them? Are they staying up late? Do they have poor sleep habits? It's just sort of the way right now, and it's trying to say, "Hey, get outside and play. " For those of you that might be a baby boomer, such as myself, we've got out at 9:00 in the morning. We went out to play. We didn't come home until 5:00 PM and you played all day. We never had those issues. They don't play all day. Oh, it's too hot. I need to stay in or and it really has to do with I think again my opinion. I just think that today we need to have better eating habits and just good hygiene habits with exercise, and I don't know. That's my $0. 02. So, how about as far as wearing other oral or dental whole devices. Is that possible? Any trouble, they're using those in tandem with a CPAP. Okay. So let's say someone does have maybe a retainer that they use because they have maybe a TMJ. So they have night guards. It should be fine. It should not have any problem because it's fitting very close to the teeth. It's not affecting the palate at all. That should be fine. And again, it's going to depend on what's going on with that patient. I wish I could just coin everybody, but everybody's unique. I always figure that the more information that the treating position has, that the patient may have forgotten to tell them is helpful. So if they're sleeping well without a retainer, then, "Hey, then maybe they don't need it. " Maybe their TMJ is actually not as bad now because they are sleeping, so they're not grinding or clenching. So I think it's going to depend upon how that is. Dentures, again, I'm not a dentist. I couldn't tell you. I think if they have good-fitting dentures, that's going to be again up to the treating physician. Yeah. So a lot of that information that needs to come out in the discovery. And I guess that's a segue into another question that's come in. Just any extra strategies about helping patients choose a mask that works for them at time of setup? Yes. First thing, please do not give them too many options. If they have too many options, they want a new option every week, and it's going to make you crazy. So I always say you start them off with. And that's why I like that mask AI fit. Because when you can do that, you're going to find what's best for their base demographics, and you could say, "Well, based on this, it's going to be a nasal mask. Here are the options. " And you can give them options, but it might be within that realm. One thing that I told and like, even HME companies it's like don't have every vendor hanging out for your customers to see. The patients are seeing that they're going to want to try it. Hey, this might work better. This might work better. And it's just becomes a continual cycle. And nothing's ever going to make them happy. So it's minimized how many options they have. Find what's best for them and what's best for your organization. I have plenty of places that use formularies that say we're going to fit to X, and that's what they use. Because that way, they know all their staff knows the product. So if somebody is taking a nap during the day, they know what to put on them. If it's at night, it's the same thing. So it makes it consistent and easier for training your staff, especially if you have multiple facilities or locations. It just makes life a lot easier. Hope that answers. And if anything, if I'm not clear, you want more. Please don't hesitate to reach out to me. More than happy to have a conversation. Excellent. Well, thank you so much, Patty. This has been a great presentation. The hour just flown by. So as we near the end of the hour, first of all, I want to thank you for your time and expertise today. And thank you so much to our audience. Thank you for your questions. And we certainly appreciate you spending your time with us this afternoon. For a full list of our upcoming events, you can visit us at NMS. And you can register for a future webinar. Share events with your colleagues or sign up to receive regular updates on our webinar schedule. And you can also link to previous webinars at nms.McKesson.com/insights. Once again, Patty, thank you so much for joining us today. Thank you. This has been my pleasure. This is great. Excellent. Well, thank you, everyone, for joining, and I hope everyone has a great day.