Practice parameters for the use of continuous and bilevel positive airway pressure devices to treat adult patients with sleep-related breathing disorders

Stanford University Center of Excellence for Sleep Disorders, Stanford, CA, USA.
Sleep (Impact Factor: 5.06). 04/2006; 29(3):375-80.
Source: PubMed

ABSTRACT Positive airway pressure (PAP) devices are used to treat patients with sleep related breathing disorders (SRBD) including obstructive sleep apnea (OSA). Currently, PAP devices come in three forms: (1) continuous positive airway pressure (CPAP), (2) bilevel positive airway pressure (BPAP), and (3) automatic self-adjusting positive airway pressure (APAP). After a patient is diagnosed with OSA, the current standard of practice involves performing full, attended polysomnography during which positive pressure is adjusted to determine optimal pressure for maintaining airway patency. This titration is used to find a fixed single pressure for subsequent nightly usage. A task force of the Standards of Practice Committee of the American Academy of Sleep Medicine reviewed the available literature. Based on this review, the Standards of Practice Committee developed these practice parameters as a guideline for using CPAP and BPAP appropriately (an earlier review and practice parameters for APAP was published in 2002). Major conclusions and current recommendations are as follows: 1) A diagnosis of OSA must be established by an acceptable method. 2) CPAP is effective for treating OSA. 3) Full-night, attended studies performed in the laboratory are the preferred approach for titration to determine optimal pressure; however, split-night, diagnostic-titration studies are usually adequate. 4) CPAP usage should be monitored objectively to help assure utilization. 5) Initial CPAP follow-up is recommended during the first few weeks to establish utilization pattern and provide remediation if needed. 6) Longer-term follow-up is recommended yearly or as needed to address mask, machine, or usage problems. 7) Heated humidification and a systematic educational program are recommended to improve CPAP utilization. 8) Some functional outcomes such as subjective sleepiness improve with positive pressure treatment in patients with OSA. 9) CPAP and BPAP therapy are safe; side effects and adverse events are mainly minor and reversible. 10) BPAP may be useful in treating some forms of restrictive lung disease or hypoventilation syndromes associated with hypercapnia.

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Available from: Max Hirshkowitz, Apr 27, 2015
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    • "Positive airway pressure (PAP) continues to be the most effective treatment for obstructive sleep apnoea (OSA) [1]. A number of studies have shown the benefits of PAP treatment on measures of daytime function for patients treated for OSA [2] [3] [4] [5]. "
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    ABSTRACT: Introduction It has been found that mask style can affect the amount of continuous positive airway pressure (CPAP) required to reduce an apnea/hyponea index (AHI) to <5/hr on a titration study. However, it was not previously known whether switching from one CPAP mask style to another post-titration could affect residual AHI with CPAP. The purpose of this study was to investigate differences in residual AHI with CPAP treatment between oronasal and nasal masks. Methods 21-subjects (age M=62.9, BMI M=29.6 kg/m2) were randomized (14-subjects completed the protocol) to undergo an in-laboratory CPAP titration with either a nasal mask or oronasal mask. Subjects were then assigned this mask for three-weeks of at-home CPAP use with the optimal treatment pressure determined on the laboratory study (CPAP M=8.4 cm of H2O). At the end of this three-week period, data was collected from the CPAP machine, and the subject was given the other mask to use with the same CPAP settings for the next three-weeks at-home (if nasal was given initially, the oronasal was given and vice versa). On completion of the second three-week period, data on residual AHI was again collected and compared to the first three-week period on CPAP. Results A Wilcoxon Signed Rank Test (two-tailed) revealed that residual AHI with CPAP treatment was significantly higher with the oronasal compared to the nasal mask (z=-3.296, p<.001). All 14-subjects had a higher residual AHI with the oronasal vs. nasal mask, and 50% of the subjects had a residual AHI >10/hr in the oronasal mask condition, even though all of these subjects were titrated to an AHI of <5/hr in the laboratory. Conclusion A higher residual AHI was seen in all patients with the use of an oronasal mask compared to a nasal mask. Switching to an oronasal mask post-titration results in an increase in residual AHI with CPAP treatment, and pressure adjustment may be warranted.
    Sleep Medicine 06/2014; 15(6). DOI:10.1016/j.sleep.2014.01.011 · 3.10 Impact Factor
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    • "In our current multidisciplinary clinic, the most commonly debated clinical decision is the order in which CBTI and CPAP should be initiated. As noted earlier, CPAP is the first-line treatment for moderate to severe OSA (Epstein et al., 2009; Kushida, Littner et al., 2006; Loube et al., 1999) and clinical lore has been to apply the same guideline to patients who have OSA and insomnia. However, there is no empirical evidence to support generalizing the same approach to this comorbid population. "
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    ABSTRACT: OBJECTIVES: The goal of this article was to provide an overview of the diagnostic considerations, clinical features, pathophysiology, and treatment approaches for patients with obstructive sleep apnea (OSA) and comorbid insomnia. METHOD: We begin with a review of the literature on OSA and comorbid insomnia. We then present a multidisciplinary approach using pulmonary and behavioral sleep medicine treatments. RESULTS: OSA and insomnia co-occur at a high rate and such patients have distinct clinical features. Empirically supported treatments are available for OSA and insomnia independently but there are no standards or guidelines for how to implement these treatments for patients who suffer from both disorders. CONCLUSIONS: Multidisciplinary treatment holds promise for patients with comorbid sleep disorders. Further research should be aimed at optimizing treatments and developing standards of practice for this population.
    Journal of Clinical Psychology 10/2013; 69(10). DOI:10.1002/jclp.21958 · 2.12 Impact Factor
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    • "No treatment exists for OSA that is both completely effective and fully tolerated by all patients; many partially efficacious or partially tolerated treatments currently are in use. Although nasal continuous positive airway pressure (CPAP) is the recommended therapy for reducing apneas and hypopneas [8], adherence to CPAP often is low [9] [10]. Given the seriousness of the risks associated with untreated or ineffectively treated OSA, it is important for physicians and patients to have a wide variety of treatment options to increase the likelihood of a successful option [11]. "
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    ABSTRACT: We aimed to evaluate the impact of a novel noninvasive oral pressure therapy (OPT) (Winx®, ApniCure) system on polysomnographic measures of sleep-disordered breathing, sleep architecture, and sleep stability in obstructive sleep apnea (OSA). A 4-week, multicenter, prospective, open-label, randomized, crossover, first-night order of control vs treatment, single-arm trial was conducted in five American Academy of Sleep Medicine (AASM) - accredited sleep clinics and one research laboratory. Sixty-three subjects (analysis cohort) were studied from a screening cohort of 367 subjects. The analysis cohort was 69.8% men, ages 53.6±8.9 years (mean±SD), body mass index of 32.3±4.5kg/m(2), with mild to severe OSA. At treatment initiation, subjects received random assignment to one night with and one without (control) treatment, and they were assessed again following 28 nights of treatment. Breathing and sleep architecture were assessed each night based on blind scoring by a single centralized scorer using AASM criteria. Average nightly usage across the take-home period was 6.0±1.4h. There were no severe or serious device-related adverse events (AEs). Median apnea-hypopnea index (AHI) was 27.5 events per hour on the control night, 13.4 events per hour on the first treatment night, and 14.8 events per hour after 28days of treatment. A clinically significant response (treatment AHI ⩽10/h and ⩽50% of control values) was seen in 20 of the 63 subjects evaluated. Rapid eye movement percentage (REM%) was significantly increased, and N1%, stage shifts to N1 sleep, overall stage shifts, total awakenings, and arousals per hour were all significantly reduced at both treatment nights compared to controls. Mean Epworth sleepiness scale (ESS) was significantly reduced from 12.1 to 8.6 (Cohen d effect size, 0.68) in those untreated for two or more weeks prior to OPT study participation and remained unchanged in subjects who directly switched from continuous positive airway pressure (CPAP) therapy to OPT. Clinically significant improvements in sleep quality and continuity, AHI, ODI, ESS, and overall clinical status were achieved in an easily identified subgroup. OPT was safe and well-tolerated and nightly usage was high.
    Sleep Medicine 07/2013; 14(9). DOI:10.1016/j.sleep.2013.05.009 · 3.10 Impact Factor
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