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

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).

Figure 1

CPAP Titration Algorithm for Patients <12 years During Full- or Split-Night Titration Studies. Note: Upward titration at ≥ 1-cm increments over ≥ 5-min periods is continued according to the breathing events observed until ≥ 30 min without breathing events is achieved. * A higher starting CPAP may be selected for patients with an elevated BMI and for retitration studies ** The patient should also be tried on BPAP if the patient is uncomfortable or intolerant of high CPAP

Figure 2

CPAP Titration Algorithm for Patients ≥12 years During Full- or Split-Night Titration Studies. Note: Upward titration at ≥ 1-cm increments over ≥ 5-min periods is continued according to the breathing events observed until ≥ 30 min without breathing events is achieved. * A higher starting CPAP may be selected for patients with an elevated BMI and for retitration studies ** The patient should also be tried on BPAP if the patient is uncomfortable or intolerant of high CPAP

Figure 3

BPAP Titration Algorithm for Patients <12 years During Full- or Split-Night Titration Studies. Note: Upward titration of IPAP and EPAP ≥ 1 cm H2O for apneas and IPAP ≥ 1 cm for other events over ≥ 5-min periods is continued until ≥ 30 min without breathing events is achieved. A decrease in IPAP or setting BPAP in spontaneous-timed mode with backup rate may be helpful if treatment-emergent central apneas are observed. * A higher starting IPAP and EPAP may be selected for patients with an elevated BMI and for retitration studies. When transitioning from CPAP to BPAP, the minimum starting EPAP should be set at 4 cm H2O or the CPAP level at which obstructive apneas were eliminated. An optimal minimum IPAP-EPAP differential is 4 cm H2O and an optimal maximum IPAP-EPAP differential is 10 cm H2O.

Figure 4

BPAP Titration Algorithm for Patients ≥12 years During Full- or Split-Night Titration Studies. Note: Upward titration of IPAP and EPAP ≥ 1 cm H2O for apneas and IPAP ≥ 1 cm for other events over ≥ 5-min periods is continued until ≥ 30 min without breathing events is achieved. A decrease in IPAP or setting BPAP in spontaneous-timed mode with backup rate may be helpful if treatment-emergent central apneas are observed. * A higher starting IPAP and EPAP may be selected for patients with an elevated BMI and for retitration studies. When transitioning from CPAP to BPAP, the minimum starting EPAP should be set at 4 cm H2O or the CPAP level at which obstructive apneas were eliminated. An optimal minimum IPAP-EPAP differential is 4 cm H2O and an optimal maximum IPAP-EPAP differential is 10 cm H2O.