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: 3.05). 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).

    • "OSA was diagnosed, patients received a PAP titration following standard protocol (Kushida et al., 2008) as part of a split-night study or on a second overnight study. Once a successful PAP titration was completed and reviewed by the sleep physician, orders were sent to a Durable Medical Equipment vendor, who provided home setup of the PAP machine, education regarding care and maintenance of the machine, and follow-up for mask-related issues and PAP compliance data. "
    [Show abstract] [Hide abstract]
    ABSTRACT: The purpose of this study was to examine the process of care in an interdisciplinary sleep clinic for patients with obstructive sleep apnea (OSA) and comorbid insomnia. A mixed-methods approach was used to examine clinical and patient-centered measures for 34 patients who received positive-airway pressure for OSA or cognitive-behavior therapy for insomnia. The results revealed baseline-to-follow-up improvements on several self-reported sleep parameters and measures of daytime functioning. Qualitative analyses from patient interviews revealed three themes: conceptual distinctions about each sleep disorder, importance of treating both sleep disorders, and preferences with regard to the sequence of treatment. These findings indicate that patients with OSA and comorbid insomnia encounter unique challenges. A dimensional approach to assessment and treatment is proposed for future research.
    No preview · Article · Dec 2015 · Behavioral Sleep Medicine
  • Source
    • "All patients had a baseline polysomnogram followed by a full night CPAP titration study or had a split night study with the initial portion performed off CPAP and the remainder of the night consisting of a CPAP titration. CPAP titrations were performed using recommended guidelines [25] with the patient's prescribed CPAP pressures based on studies that were considered optimal, good, or adequate as described in the guidelines. All of the polysomnogram studies were initially scored by a single senior technologist. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Purpose. We hypothesized that socioeconomic factors and a language barrier would impact adherence with continuous positive airway pressure (CPAP) among Hispanics with obstructive sleep apnea (OSA). Methods. Patients with OSA who were prescribed CPAP for at least 1 year and completed a questionnaire evaluating demographic data, socioeconomic status, and CPAP knowledge and adherence participated in the study. Results. Seventy-nine patients (26 males; 53 ± 11 yrs; body mass index (BMI) = 45 ± 9 kg/m(2)) with apnea-hypopnea index (AHI) 33 ± 30 events/hr completed the study. Included were 25 Hispanics, 39 African Americans, and 15 Caucasians, with no difference in age, AHI, CPAP use, or BMI between the groups. While there was a difference in educational level (P = 0.006), income level (P < 0.001), and employment status (P = 0.03) between the groups, these did not influence CPAP adherence. Instead, overall improvement in quality of life and health status and perceived benefit from CPAP influenced adherence, both for the group as a whole (P = 0.03, P = 0.004, and P = 0.001, resp.), as well as in Hispanics (P = 0.02, P = 0.02, P = 0.03, resp.). Conclusion. In Hispanic patients with OSA, perceived benefit with therapy, rather than socioeconomic status or a language barrier, appears to be the most important factor in determining CPAP adherence.
    Full-text · Article · Feb 2014
  • Source
    • "In adults and adolescents with obstructive sleep apnoea (OSA), the titration of CPAP is based on the polysomnographic disappearance of apnoea, hypopnoea, respiratory effort-related arousal and snoring, as recommended by the American Academy of Sleep Medicine (AASM) [7,8]. The diseases responsible for airway obstruction in infants differ from those of older children and adults with the predominance of anatomical abnormalities of the upper airways such as laryngomalacia or tracheomalacia, Pierre Robin syndrome or other maxillofacial malformations [3,6]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Noninvasive continuous positive airway pressure (CPAP) is recognized as an effective treatment for severe airway obstruction in young children. The aim of the study was to compare a clinical and a physiological setting of noninvasive CPAP in infants with nocturnal alveolar hypoventilation due to severe upper airway obstruction (UAO) or bronchopulmonary dysplasia (BPD). The breathing pattern and respiratory muscle output of all consecutive infants due to start CPAP in our noninvasive ventilation unit were retrospectively analyzed. CPAP set on clinical noninvasive parameters (Clinical CPAP) was compared to CPAP set on the normalization or the maximal reduction of the oesophageal (Poes) and transdiaphragmatic pressure (Pdi) swings (Physiological CPAP). Expiratory gastric pressure (Pgas) swing was measured. The data of twelve infants, mean age 10 +/- 8 months, with UAO (n=7) or BPD (n=5) were gathered. The mean Clinical CPAP (8 +/- 2 cmH2O) was associated with a significant decrease in Poes and Pdi swings. Indeed, Poes swing decreased from 31 +/- 15 cmH2O during spontaneous breathing to 21 +/- 10 cmH2O during CPAP, p<0.05. The mean Physiological CPAP level was 2 +/- 2 cmH2O higher than the mean Clinical CPAP level and was associated with a significantly greater improvement in all indices of respiratory effort (Poes swing 11 +/- 5 cm H2O, p<0.05 as compared to the Clinical CPAP). An expiratory abdominal activity was present during the Clinical CPAP and decreased during the Physiological CPAP. A physiological setting of noninvasive CPAP, based on the recording of the Poes and Pgas, is superior to a clinical setting based on clinical noninvasive parameters. An expiratory abdominal activity was present during spontaneous breathing and decreased during the Physiological CPAP setting.
    Full-text · Article · Jul 2013 · Critical care (London, England)
Show more