Article

Clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea.

Stanford University Center of Excellence for Sleep Disorders, 401 Quarry Road, Suite 3301, Stanford, CA 94305-5730, USA.
Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine (Impact Factor: 2.83). 04/2008; 4(2):157-71.
Source: PubMed

ABSTRACT Positive airway pressure (PAP) devices are used to treat patients with sleep related breathing disorders (SRBDs), including obstructive sleep apnea (OSA). After a patient is diagnosed with OSA, the current standard of practice involves performing attended polysomnography (PSG), during which positive airway pressure is adjusted throughout the recording period to determine the optimal pressure for maintaining upper airway patency. Continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BPAP) represent the two forms of PAP that are manually titrated during PSG to determine the single fixed pressure of CPAP or the fixed inspiratory and expiratory positive airway pressures (IPAP and EPAP, respectively) of BPAP for subsequent nightly usage. A PAP Titration Task Force of the American Academy of Sleep Medicine reviewed the available literature. Based on this review, the Task Force developed these recommendations for conducting CPAP and BPAP titrations. Major recommendations are as follows: (1) All potential PAP titration candidates should receive adequate PAP education, hands-on demonstration, careful mask fitting, and acclimatization prior to titration. (2) CPAP (IPAP and/or EPAP for patients on BPAP) should be increased until the following obstructive respiratory events are eliminated (no specific order) or the recommended maximum CPAP (IPAP for patients on BPAP) is reached: apneas, hypopneas, respiratory effort-related arousals (RERAs), and snoring. (3) The recommended minimum starting CPAP should be 4 cm H2O for pediatric and adult patients, and the recommended minimum starting IPAP and EPAP should be 8 cm H2O and 4 cm H2O, respectively, for pediatric and adult patients on BPAP. (4) The recommended maximum CPAP should be 15 cm H2O (or recommended maximum IPAP of 20 cm H2O if on BPAP) for patients < 12 years, and 20 cm H2O (or recommended maximum IPAP of 30 cm H2O if on BPAP) for patients > or = 12 years. (5) The recommended minimum IPAP-EPAP differential is 4 cm H2O and the recommended maximum IPAP-EPAP differential is 10 cm H2O (6) CPAP (IPAP and/or EPAP for patients on BPAP depending on the type of event) should be increased by at least 1 cm H2O with an interval no shorter than 5 min, with the goal of eliminating obstructive respiratory events. (7) CPAP (IPAP and EPAP for patients on BPAP) should be increased from any CPAP (or IPAP) level if at least 1 obstructive apnea is observed for patients < 12 years, or if at least 2 obstructive apneas are observed for patients > or = 12 years. (8) CPAP (IPAP for patients on BPAP) should be increased from any CPAP (or IPAP) level if at least 1 hypopnea is observed for patients < 12 years, or if at least 3 hypopneas are observed for patients > or = 12 years. (9) CPAP (IPAP for patients on BPAP) should be increased from any CPAP (or IPAP) level if at least 3 RERAs are observed for patients < 12 years, or if at least 5 RERAs are observed for patients > or = 12 years. (10) CPAP (IPAP for patients on BPAP) may be increased from any CPAP (or IPAP) level if at least 1 min of loud or unambiguous snoring is observed for patients < 12 years, or if at least 3 min of loud or unambiguous snoring are observed for patients > or = 12 years. (11) The titration algorithm for split-night CPAP or BPAP titration studies should be identical to that of full-night CPAP or BPAP titration studies, respectively. (12) If the patient is uncomfortable or intolerant of high pressures on CPAP, the patient may be tried on BPAP. If there are continued obstructive respiratory events at 15 cm H2O of CPAP during the titration study, the patient may be switched to BPAP. (13) The pressure of CPAP or BPAP selected for patient use following the titration study should reflect control of the patient's obstructive respiration by a low (preferably < 5 per hour) respiratory disturbance index (RDI) at the selected pressure, a minimum sea level SpO2 above 90% at the pressure, and with a leak within acceptable parameters at the pressure.) (14) An optimal titration reduces RDI < 5 for at least a 15-min duration and should include supine REM sleep at the selected pressure that is not continually interrupted by spontaneous arousals or awakenings. (15) A good titration reduces RDI < or = 10 or by 50% if the baseline RDI < 15 and should include supine REM sleep that is not continually interrupted by spontaneous arousals or awakenings at the selected pressure. (16) An adequate titration does not reduce the RDI < or = 10 but reduces the RDI by 75% from baseline (especially in severe OSA patients), or one in which the titration grading criteria for optimal or good are met with the exception that supine REM sleep did not occur at the selected pressure. (17) An unacceptable titration is one that does not meet any one of the above grades. (18) A repeat PAP titration study should be considered if the initial titration does not achieve a grade of optimal or good and, if it is a split-night PSG study, it fails to meet AASM criteria (i.e., titration duration should be > 3 hr).

Download full-text

Full-text

Available from: David Gozal, Jun 16, 2015
1 Follower
 · 
316 Views
  • [Show abstract] [Hide abstract]
    ABSTRACT: Study Objectives: Compare auto-adjusting positive airway pressure (APAP) treatment with positive airway pressure (PAP) titration by polysomnography (PSG) followed by CPAP treatment in patients diagnosed with obstructive sleep apnea (OSA) by home sleep apnea testing (HSAT). Design: Prospective randomized treatment study. Setting: Tertiary Veterans Administration Medical Center. Participants: 156 patients diagnosed with OSA by HSAT (apneahypopnea index [AHI] >= 10/h) suitable for APAP treatment. Interventions: APAP arm: Treatment with an APAP device, CPAP arm: PSG PAP titration followed by CPAP treatment. Measurements: Mean PAP adherence, Epworth sleepiness scale (ESS), Functional Outcomes of Sleep Questionnaire (FOSQ). Results: The mean (+/- SD) age, BMI, and diagnostic AHI (APAP: 28.6 +/- 18.5, CPAP: 28.3 +/- 16.0/h, p = NS) did not differ between the study arms. After 6 weeks of treatment, 84.6% of 78 patients started on APAP and 84.3% of 70 patients started on CPAP (8 declined treatment after the titration) were using PAP, p = NS. The 90% APAP and level of CPAP were similar (10.8 +/- 3.1, 11.7 +/- 2.5 cm H2O, p = 0.07). The average nightly PAP use did not differ (APAP: 4.45 +/- 2.3, CPAP: 4.0 +/- 2.3 h, p = NS). The improvements in the ESS (APAP: -4.2 +/- 4.7, CPAP: -3.7 +/- 4.8, p = NS) and in the FOSQ (APAP: 2.6 +/- 3.5, CPAP: 2.2 +/- 3.7, p = NS) were not different. Conclusions: Following diagnosis of OSA by HSAT, treatment with APAP results in equivalent PAP adherence and improvement in sleepiness compared to a PSG titration and CPAP treatment.
    Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine 10/2014; 10(12). DOI:10.5664/jcsm.4272 · 2.83 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Positive airway pressure therapy for hypoventilation syndromes can significantly improve health-related quality of life (HR-QOL), healthcare costs, and even mortality. The sleep-disordered breathing in such individuals are quite complex and require sophisticated devices with algorithms that are designed to accurately detect and effectively treat respiratory events that includes hypoventilation, upper airway obstruction, lower airway obstruction, central apneas and central hypopneas and reduce the work of breathing while maintaining breathing comfort.
    Sleep Medicine Clinics 09/2014; DOI:10.1016/j.jsmc.2014.06.002
  • [Show abstract] [Hide abstract]
    ABSTRACT: (1) Determine claustrophobia frequency in adults with obstructive sleep apnea (OSA) after first CPAP night; (2) determine if claustrophobia influences CPAP non-adherence. Claustrophobia is common among CPAP-treated OSA adults yet few studies have examined the problem. Secondary analysis of prospective, longitudinal study of OSA adults (n = 97). CPAP-Adapted Fear and Avoidance Scale (CPAP-FAAS) collected immediately after CPAP titration polysomnogram. objective CPAP use at 1week and 1month. Sixty-three percent had claustrophobic tendencies. Females had higher CPAP-FAAS scores than males. FAAS ≥25, positive score for claustrophobic tendencies, was influential on CPAP non-adherence at 1week (aOR = 5.53, 95% CI 1.04, 29.24, p = 0.04) and less CPAP use at 1month (aOR = 5.06, 95% CI 1.48, 17.37, p = 0.01) when adjusted for body mass index and CPAP mask style. Claustrophobia is prevalent among CPAP-treated OSA adults and influences short-term and longer-term CPAP non-adherence. Interventions are needed to address this treatment-related barrier. Copyright © 2015 Elsevier Inc. All rights reserved.
    Heart and Lung The Journal of Acute and Critical Care 03/2015; 44(2):100-6. DOI:10.1016/j.hrtlng.2015.01.002 · 1.32 Impact Factor