Reliability of Automatic CPAP Titration in OSAS Treatment

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Reliability of Automatic CPAP Titration in OSAS
Treatment
Bülent Çiftçi MD bciftci_at_superonline.com Ankara
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• If AHIgt15, PAP is the first choice for all
  patients
• If AHIgt5, PAP can be a first choice for some
  patients

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• If bilevel PAP is not indicated, then fixed
  continuous PAP should be used
• What is the effective pressure ???

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Goal of titration

• To detect the effective pressure level that
  abolishes
• Apnea
• Hypopnea
• Snoring
• RERA
• Effective pressure in any body position and sleep
  stage (REM supine!)

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• Different methods for CPAP titration
• Manual CPAP titration is gold standart
• APAP titration
• Attended
• Unattended

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APAP

• since 1995
• Pressure in mask shows variations with
• Sleep stages
• Body position
• Physiological changes in nasal resistance
• Fluctuations in body weight

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• How APAP works
• Snoring
• Apnea
• Hypopnea
• Flow limitation
• Upper Airway Impedance (Forced Oscillation
  Technique)
• Respiratory event increase pressure level
• No respiratory event for a time period decrease
  pressure level

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• Some APAP devices can record pressure, mask leak,
  apneas and hypopneas. Data can be transferred to
  computer. A constant pressure can be found by
  analysing the data.

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Attended APAP titration

• Titration with PSG, information about the
  structure of sleep
• Intervention for problems of mask fitting, mask
  leaks
• Intervention for persistent hypoxemia after
  airway patency is restored

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Unattended APAP titration

• Unattended APAP is successful in many patients
  (91) in determining a therapeutic positive
  pressure setting
• Reported AHI via Autoset is similar to that of PSG

Woodson BT, et al. Nonattended home automated
continuous positive airway pressure
titrationComparison with polysomnography.
Otolaryngology-Head and Neck Surgery2003353-357
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Recommendations of Standards of Practice
Committee of the AASM
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• A diagnosis of OSA must be established by an
  acceptable method

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Patients with the following conditions are not
currently candidates for APAP titration or
treatment

• Congestive Heart Failure
• Pulmonary diseases such as chronic obstructive
  pulmonary disease. Patients are expected to have
  nocturnal arterial oxyhemoglobin desaturation due
  to conditions other than OSA (e.g., obesity
  hypoventilation syndrome)
• Patients who do not snore (either due to palate
  surgery or naturally) should not be titrated with
  an APAP device that relies on vibration or sound
  in the device's algorithm.

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APAP devices are not currently recommended for
splitnight titration.

• No enough data

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APAP can be used for the detection of a fixed
CPAP pressure
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Treatment with APAP

• One potential use of APAP is to treat patients
  with OSA on a long-term basis

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Unattended APAP Titration

• The use of unattended APAP for determining
  initial pressures for fixed CPAP or for
  self-adjusting APAP treatment in CPAP naive
  patients is not currently established

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• Patients being treated with fixed CPAP on the
  basis of APAP titration or being treated with
  APAP must be followed for treatment effectiveness
  and safety

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• A re-evaluation and, if necessary, a standard
  attended CPAP titration should be performed if
  symptoms do not resolve or the CPAP or APAP
  treatment otherwise appears to be inefficient.

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Two major problems with APAP

• Mask leak
• Central apneas

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Mask and Mouth Leaks

• Mask leak accelerate the blower, more air
  increases the leak
• Some devices give alarms in case of mask leak

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Central apneas

• CPAP may worsen central apneas
• Cheynes Stokes respiration often develops in
  congestive heart failure
• Central apneas may worsen in CHF and in OSAS
  patients after OSAS treatment
• Central apneas may be seen after arousals or with
  high pressure levels of CPAP in OSAS patients

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What effects the pressure during the night?

• Rebound sleep
• REM rebound
• Slow wave sleep rebound
• Sleep position

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What effects night-to-night variability of
pressures?

• Age
• Sedative drugs, alcohol
• Weight fluctuation
• Nasal congestion
• Re-start to use after a few days without CPAP

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Nasal congestion

• CPAP without heated humidifier may trigger nasal
  congestion
• Allergic rhinitis !

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Reduction in upper airway edema with PAP
treatment

• Edema results from vibration of the soft tissues
  of the upper airway

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Sleep stage and sleeping position

• Loss of muscle tonus in REM sleep ,
• Supine position worsen sleep apnea in adults.
  Higher pressure levels may be required in supine
  position.

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Sleep stage, body position and APAP

• APAP may have specific indications in a subset of
  obstructive sleep apnea patients with sleep stage
  and body position dependent nocturnal breathing
  abnormalities.

Series F, Marc I. Importance of sleep stage- and
body position-dependence of sleep apnoea in
determining benefits to auto-CPAP therapy. Eur
Respir J 200118 170-175
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• 20 patients with OSAS all underwent both manual
  CPAP titration and APAP titration
• Final pressure
• Sleep quality did not differ on the methods

• Lloberes et al. Comparison of manual and
  automatic CPAP titration in patients with SAS. Am
  J Respir Crit care Med 19961541755-1758

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• 122 patients with OSAS underwent either manual
  CPAP titration or APAP titration
• Patient who had been titrated with APAP had CPAP
  acceptance and symptom relief that was at least
  as good as manual titration

• Stradling JR et al. Automatic nCPAP titration in
  the laboratory patient outcomes. Thorax
  19975272-75

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• 21 OSAS patients underwent unattended APAP in a
  sleep laboratory followed by attended manual CPAP
  titration
• 19 patients final pressure was found similar
  with both methods
• In 15 of the patients the device was well
  tolerated

• Juhasz J et al. Unattended CPAP titration.
  Clinical relevance and cardiorespiratory hazards
  of the method. Am J respir Crit Care Med
  1996154359-365

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P Levy, JL Pepin. Autoadjusting continuous
positive airway pressure what can we expect? Am
J Respir Crit Care Med. 2001163(6)1295-6.

• APAP can be used to perform titration, which
  could be done either in the ward or at home, and
  then used for 1 or 2 week at home with systematic
  clinical follow-up. This would allow selection of
  patients with the highest variability on the
  basis of more than a single test night

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• ???

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