PAP titration

Sleep Round part 2

Topics
 Indications of PAP titration
 Types of PAP titration
 How to perform CPAP/BPAP titration
Management of suspected OSA
1. Diagnosis (Polysomnography)
2. Treatment
Positive airway pressure therapy

 Positive airway pressure (PAP) remains the mainstay of

treatment for moderate-to-severe obstructive sleep apnea
(OSA) in adults.

Loube DI. Chest 1999

Gay P et al.Sleep 2006
 The few randomized controlled trials (RCT) of CPAP
efficacy in patients with milder OSA have produced
conflicting results.

 CPAP in patients with mild and moderate OSA is

associated with
◦ Improved patient-reported function and quality of life.
◦ Improved daytime alertness, mood, and diastolic blood
pressure.

J Clin Sleep Med 2007 Apr 15; 3(3): 263–264

Mechanism of action

Pneumatic Splinting

Increases Upper airway

dimension
Largest in lateral direction

Increase in LUNG
volume

Abbey NC et al. Sleep 1989; 12:420–422

Series F et al . J Appl Physiol 1990; 68:1075–1079
 Indications of PAP therapy
 PAP treatment is considered the treatment of choice in patients
with

Moderate-to-severe OSA defined as an apnea-hypopnea index

(AHI) 15/h with or without symptoms.

 Patients with an AHI (>5 < 15/h) with

 Symptoms (daytime sleepiness, insomnia, impaired cognition, mood
disorders) or
 Comorbid conditions (hypertension, a previous cerebrovascular
accident, or ischemic heart disease)

Kushida CA et al.Sleep 2006; 29:375–380

US Department of Health and Human Services, 2002
Various PAP devices

Not Tolerating CPAP high pressures or OHS

To increase Adherence

Central sleep Apnea/ Cheyne Stokes

breathing
BPAP CPAP

CPAP BPAP

APAP

BPAP ASV
Alternative to PAP therapy

 Positional therapy:
1. Supine position is associated with an increased number
of apnoeas/hypopnoeas [Bidarian-Moniri et al. 2015].
2. Postural OSA is diagnosed when the obstructive events
take place exclusively or mainly in the supine posture
(the AHI in the supine position is at least double with
respect to the non-supine position) [Frank et al. 2015]
◦ Tennis ball technique
◦ Supine alarms (Night shift)
◦ Postural pillows
 Oral appliances
 Surgical treatment
 Educational and behavioral intervention
 Weight control and bariatric surgery
◦ Bariatric surgery offers significantly greater improvement
than non surgical alternatives [Ashrafian et al 2015].
Effects of PAP therapy

 Higher levels of evidence (multiple randomized controlled

trials)
1. Reduction in the AHI (<10/h)
2. Improvement in subjective sleepiness
3. Improvement in objective sleepiness
PAP treatment

 The elimination of nocturnal apneic events and intermittent

hypoxia is a key goal to controlling OSA effectively.

 Adequate level of PAP is required to keep the upper airway

open during sleep and eliminate Obstructive events.
PAP titration
 PAP titration aims to determine the level of positive
airway pressure required to eliminate obstructive
respiratory events including
◦ Apneas
◦ Hypopneas
◦ RERAs and
◦ Snoring
Determinants of PAP level

The level of pressure that eliminates the Obstructive

respiratory events depends upon
1. The severity of OSA
2. Stage of sleep (REM vs NREM)
3. Position of the body (Supine or non supine)

Supine REM sleep is the situation requiring the highest pressure

PAP titration

Indicated in patients with

AHI > 15 /hr with or with out symptoms
AHI > 5 / hr with symptoms
 Types of PAP titration

In Hospital /Lab Out of center/ Home

Full Night

Recommended Auto

Manual Gold standard

Split Night

Split-night polysomnography was introduced to obtain a diagnosis and determine an

effective PAP on a single night.
Full night PAP titration

 After a full night in Lab Diagnostic PSG /HST

Split Night PAP titration

1. AHI > 40 during 2hr of initial diagnostic portion of Sleep test

2. AHI 20-39 plus (Long apnea/ Severe desaturation)
3. 3hr remain for PAP titration.
4. Repeat PSG for PAP titration if inadequate PAP titration portion of study

Kushida et al. Positive Airway Pressure Titration Task Force , AASM, 2008
Underestimation of the severity of sleep apnea (no or minimal REM sleep in the
first half of the night) and inadequate time for PAP titration are potential
disadvantages of this approach

Pressures determined from split-night studies may be lower for patients with
mild-to-moderate OSA who may not manifest the maximal severity of their
condition during the limited titration portion of the night.

Split night PSG underestimates SEVERITY of OSA and less pressure

determination during PAP titration

Iber C et al.Sleep 1991

Aim of the study : Whether the AHI derived from partial-night PSG accurately
discriminated between patients with severe OSA and other subjects.

Patients with Symptoms

suggestive of OSA(198)

Underwent Full night PSG

AHI from full night PSG was

Partial night AHI was calculated
calculated
at: 1,1.5,2,2.5,3,4,5 and 6h
Taken as reference std.

KUN-TA CHOU et al .Respirology (2011) 16, 1096–1102

 The diagnostic validity of 2-h PSG was computed at different
AHI cut-off points (25/h, 30/h, 35/h, 40/h, 45/h), and
accuracy, sensitivity, specificity, positive predictive value and
negative predictive value were determined.

An AHI cut-off point of 30/h gave the highest accuracy of 90.9%,

compared with other AHI cut-off points (25/h, 35/h, 40/h
Results: Data from 198 PSG recordings was processed. For 2-h PSG, an AHI cut-
off point of 30/h gave the highest accuracy of 90.9%. Comparing areas under the
ROC curves (AUC), 2-h PSG (AUC = 0.97) was as good as 2.5-h PSG (AUC = 0.977,
P = 0.057) and 3-h PSG (AUC = 0.978, P = 0.125), but was better than 1.5-h PSG
(AUC = 0.955, P = 0.016).

Conclusions: Partial-night PSG is effective for diagnosing severe OSA. If there is

an unabridged PSG recording indicating an AHI of 30/h for 2 h, severe OSA can
be diagnosed and PAP titration initiated.
Titration protocol
Continuous Positive Airway Pressure Titration Guidelines

Adults and Children > 12 y

Beginning pressure cm H2O 4
Maximum pressure cm H2O 20
Increase CPAP in at least 1 cm H2O Increase pressure for
increments no more frequently than • > 2 Obstructive apneas
every 5 min • > 3 Hypopneas
• > 5 RERA’s
• > 3 min Loud snoring

Switch to BPAP Intolerant to CPAP

Events still present on CPAP of 15cm H2O
(optional)
 Maximum CPAP limit
20 cm H2O Patient can be transitioned to BPAP if breathing
event continue at 15 cm H2O
> 15cm H2O

To overcome Residual airway

To reduce high residual airway resistance
resistance “Exploration” of pressure

> 30 minutes without breathing

2 to < 5 cm H2O event with > 15 min in REM supine
In case of split sleep
night
2-2.5 cm pressure
• > 2 Obstructive apneas
Titration > 1cm H2O • > 3 Hypopneas DOWN
• > 5 RERA’s titration
5 minutes • > 3 min Loud snoring
> 1cm
H2O/10min
> 1cm H2O • > 2 Obstructive apneas
• > 3 Hypopneas
• > 5 RERA’s
Set initial CPAP Stop in case of re-emergence of
5 minutes • > 3 min Loud snoring
4 cm H2O higher breathing events
in Obese
Indication for supplemental O2

Berry R. Fundamentals of sleep medicine. 2012

Diagnostic PSG CPAP titration

REM time=27 min

Total sleep time 148 min
Apnea 10, Hypopnea=12, RERA=3

At CPAP of 10 cm H2O
Respiratory EVENTS

Desaturations

Starting pressure
 REM sleep
Decrease in Respiratory events

At CPAP 6 cm H20
 Re emergence of respiratory
events at 9 cm H20

R R R

No respiratory EVENT

Exploration pressure

CPAP titration 10 cm
At CPAP of 10 cm H20
H20
Adequacy of titration
1. Optimal titration
 Reduces AHI to less than 5 /hr at selected pressure for at least 15 min
including REM supine position without repeated arousals.
2. Good titration
 AHI < 10/hr or at least a 50% reduction in the AHI if the baseline AHI
is less than 15/hr. e.g., from AHI 14/hr to 7 /hr.

3. Adequate titration
 AHI not < 10/hr, but is reduce by 75% from baseline. E.g., from AHI
80/hr to 20 /hr or if criteria of optimal or good titration is met with
the exception that supine REM sleep did not occur.

In optimal, good, & acceptable titrations, the SaO2 should remain > 90%
 Unacceptable titration:
◦ An unacceptable titration is one that does not meet any
one of the above grades.

◦ A repeat PAP titration study should be considered if the

initial titration does not achieve a grade of OPTIMAL or
GOOD.
Alternative methods of starting PAP treatment

 Starting PAP after a diagnosis of OSA without the use of a PSG

PAP titration.
◦ Unwilling or Unable to have a standard PSG titration.
1. Treating the patient with Auto CPAP (APAP), titration not required.
2. Auto-titration at Home for few days to week and subsequent CPAP
treatment based on the results.
3. Using Prediction EQUATION to calculate CPAP required (adjusted
based on nocturnal oximetry and Symptoms)
where BMI = body mass index and
NC = neck circumference in centimeters

 A patient with BMI= 30 kg/m2, NC= 16 inches and PSG suggestive

of AHI 30/hr. patient did not tolerated CPAP titration and seems to
be unwilling for subsequent PAP titration.

Predicted CPAP based on prediction EQUATION

CPAP = 7 cm H2O

Prediction EQUATION considerably underestimates the required pressure,

especially in men.

Cancelo et al Sleep Medicine. 2013, Basoglu et al. Sleep Breath. 2012

 Auto-PAP titration

1. Patient is made familiar with Interface,

device and is allowed short nap of 15 to 20
min.
2. Patient is then asked to use APAP at home .
3. Pressure limit of 4- 20 cm H2O.
4. For obese patients starting pressure of 8-10
cm H2O.
5. For pressure intolerant patients lower upper
limit is set.

Required CPAP is calculated from data obtained from the APAP.

90-95 percentile of the pressure is prescribed for use.

In case of suboptimal APAP titration , repeat APAP titration is done.

In case of 2nd suboptimal titration , PSG titration is REQUIRED.
 102 patients
RANDOMIZED

HST f/b
In Lab PSG
APAP 1 week
With Full night or
Fixed CPAP (95% of
Split PAP titration
APAP)

Outcome measured
4 weeks • ESS
• Sleep quality(PSQI)
• Quality of life(CSAQLI)
• BP
• CPAP adherence
 Aim of the study
 In CPAP-naive patients, Compared CPAP titration performed
by an
1. Unattended domiciliary AUTO-ADJUSTED CPAP device or
2. With a PREDICTED FORMULA
3. CPAP titration performed by FULL POLYSOMNOGRAPHY.

 Outcome
1. The main outcomes were the apnea–hypopnea index and
the subjective daytime sleepiness.
 Randomization
1. Patients were randomly allocated into three groups: STANDARD, AUTO
ADJUSTED, and PREDICTED FORMULA titration with domiciliary
adjustment. The follow-up period was 12 weeks
Conclusion
There were no differences in the objective compliance of CPAP
treatment and in the dropout rate of the three groups at the
end of the follow-up.

Autoadjusted titration at home and predicted formula titration

with domiciliary adjustment can replace standard titration.

These procedures could lead to considerable savings in cost and

to significant reductions in the waiting list.
 Can optimum pressure be determined from APAP

51 patients with obstructive sleep apnoea (OSA) (mean AHI = 50.6 ± 18.6 /h)
who were newly diagnosed after an overnight full polysomnography and who
were willing to accept CPAP as a long-term treatment were recruited for the
study.
Manual titration during full polysomnography monitoring and unattended
automatic titration with an automatic CPAP device (REMstar Auto) were
performed.
Results: The treatment pressure derived from automatic titration (9.8 2.2
cmH2O) was significantly higher than that derived from manual titration
(7.3 1.5 cmH2O; P < 0.001) i

Conclusions: The results suggest that automatic titration pressure derived from
REMstar Auto is usually higher than the pressure derived from manual titration.
Those aged 18– 75 years with excessive daytime sleepiness (Epworth
Sleepiness Score > 9) and proven OSA on a one night in hospital respiratory
PSG were considered eligible

Subjects with more than 10 dips per hour in the arterial oxygen saturation
(SaO2) of > 4% confirmed as being caused by upper airway obstruction were
eligible for inclusion in the study. All were CPAP naı ¨ve.
Were randomised prospectively to three different methods of CPAP delivery for 6
months: (1) Autotitration pressure throughout; (2) Autotitration pressure for 1 week
followed by fixed pressure (95th centile) thereafter; and (3) Fixed pressure (based on
algorithm)
 If patient is uncomfortable or intolerant to high CPAP
pressures/ continued obstructive events.
Maximum IPAP limit 30
cm H2O
To reduce high residual airway resistance
“Exploration” of pressure

> 30 minutes without breathing

IPAP + 5 cm H2O event with > 15 min in REM supine
sleep

IPAP and EPAP > 1cm H2O

for apneas & IPAP for • > 2 Obstructive apneas
other events • > 3 Hypopneas DOWN
• > 5 RERA’s titration
5 minutes • > 3 min Loud snoring
IPAP and EPAP > 1cm H2O IPAP> 1cm
for apneas & IPAP for H2O/10min
other events • > 2 Obstructive apneas
• > 3 Hypopneas
• > 5 RERA’s
Minimum IPAP • > 3 min Loud snoring Stop in case of re-emergence of
5 minutes breathing events
8 /EPAP 4 cm H2O
In 2007, the AASM released HST clinical guidelines concluded
that

HST could be performed in patients with moderate to high risk of

OSA in the absence of comorbid conditions such as heart failure,
intrinsic lung disease, neurological and neuromuscular disease, or
suspected or known comorbid sleep disorders such as insomnia,
narcolepsy, movement disorders, and central sleep apnea.
Advantages of HST
• Increases patients satisfaction (Performed in Home
environment)
• Decrease in cost
• Decrease in waiting time for diagnosis and treatment
• Achieve a more representative night sleep
 Probability

Comorbidities

Home Sleep Testing for the Diagnosis of Obstructive Sleep

Apnea De Cruz et al
Disadvantages of HST
• High rate of signal loss (un supervised) ---increase study
failure (more than 1 HST ma be required)
• As fewer recording channels are used (lack scoring of sleep
architecture and arousals) ----calculate RE /hour of recording
and not sleep--- under estimates severity of OSA.

• HSTs are only approved for the diagnosis of OSA and can miss
snore arousals, parasomnias, and movement disorders.
Thank you