Subject Characteristics

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CPAP and BPAP Titration
BYAHMAD YOUNES PROFESSOR OF THORACIC
MEDICINE Mansoura faculty of medicine
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Titration of Positive airway pressure

• Positive airway pressure (PAP) devices such as
  CPAP and BPAP are used to treat SDB.
• At an optimal pressure, PAP devices eliminate SDB
  events without creating pressure-related side
  effects.
• The gold standard method for identifying the
  optimal pressure is attended overnight laboratory
  based polysomnography during which a sleep
  technologist manually titrates the PAP devices to
  eliminate SDB events, such as apneas, RERAs, and
  snoring

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• Using a nasal pressure transducer or a thermistor
  during the titration portion of the
  polysomnography may not be feasible because of
  problems obtaining a good seal with the mask
  interfaces.
• During a titration study, recordings from the
  airflow signal generated by the PAP device, or
  estimating the airflow through measuring the
  pressure difference between the mask and the
  outlet machine using a transducer, are acceptable
  methods to detect apneas, hypopneas, and RERAs.
• Titration protocols to identify the optimal
  pressure for PAP devices to treat SDB vary widely
  among sleep centers. Therefore, it is very likely
  that the same patient undergoing a titration
  study at different accredited centers may end up
  with different optimal pressures.

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SPLIT-NIGHT TITRATION

• The criteria that is typically used is an AHI of
  40 or more per hour with a minimum of 120 minutes
  of sleep, or an AHI of 20 to 40 per hour
  accompanied by significant oxygen de-saturation .
• The Center for Medicare Medicaid services (CMS)
  requires either -
• the documentation of an AHI of 15 or more per
  hour with a minimum of 30 events , or
• an AHI of 5 to 14 per hour with a minimum of 10
  events, along with documentation of one of the
  following excessive sleepiness, impaired
  cognition, mood disorder, insomnia, hypertension,
  ischemic heart disease, or history of stroke.

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• The optimal pressure for PAP devices to treat SDB
  is the effective pressure that eliminates SDB
  events without creating any untoward
  pressure-related side effects for the patient.
• Pressures lower than the optimal pressure, apart
  from inadequately treating the SDB, may also
  result in mouth breathing and claustrophobic
  symptoms.
• Pressures exceeding the optimal pressure may lead
  to air leaks, mouth breathing, worsening of nasal
  congestion, and rhinorrhea exacerbate central
  apneas and of course lead to difficulty
  tolerating the PAP, resulting in decreased
  overall adherence.
• The optimal pressure should be effective in all
  sleep positions and sleep stages.

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GOALS OF PAP TITRATION

• The goal of PAP titration is to identify the
  optimal pressure that
• 1- eliminates SDB events (apneas, hypopneas,
  RERAs, oxygen desaturation, and snoring),
• 2- restores normal respiratory patterns , and
• 3- improves the patients quality of sleep.
• The optimal pressure from PAP that accomplishes
  all this should be adequate during all stages of
  sleep and in all sleep positions (particularly
  supine position), because the severity of OSA is
  commonly worse during sleep in the supine
  position, and during REM sleep, whereas the
  severity of CSA might be worse during supine and
  non-REM sleep.

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Optimal titration is obtained when the AHI is lt
5 per hour for at least 15 minutes and includes
supine REM sleep at the optimal pressure.

• Good titration reduces the AHI to lt 10 per hour
  and includes supine REM sleep at the selected
  pressure on the PAP device.
• Adequate titration is obtained when the AHI
  cannot be reduced to lt 10 per hour, but is
  reduced by 75 from baseline, or when the
  titration grading of optimal and good are
  obtained even though supine REM sleep did not
  occur.
• An unacceptable titration occurs if any one of
  the above grades are not met, at which time a
  repeat titration is necessary.
• Repeat full titration is also needed if only
  adequate titration was obtained, especially if it
  was part of a split-night protocol.

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PREPARATION FOR PAP TITRATION

• The AASM practice parameters recommend that all
  eligible patients receive adequate PAP education,
  hands-on demonstration, careful mask fitting, and
  acclimatization to the PAP device before
  titration.
• PAP education before titration could be in the
  form of a video describing sleep apnea,
  consequences of untreated sleep apnea, rationale
  for the use of PAP, the process involved during
  the diagnostic and PAP titration polysomnogram
  ,and side effects related to the PAP and mask
  interfaces.
• Showing and explaining the device along with its
  parts and equipment ,and having the patient try
  on the mask interface to experience the pressure
  generated by the device, are all important steps
  before implementing PAP titration.

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Indications for CPAP

• Most patients with OSA can be effectively treated
  with CPAP, which serves as a passive pneumatic
  splint to keep the upper airway from collapsing
  during sleep. It also tends to increase lung
  volumes and exerts tracheal traction (tracheal
  tug mechanism) to prevent collapsibility of the
  upper airway.
• The use of CPAP in reducing CSA (particularly in
  CSA/CSR and primary CSA) was found in some
  studies showing improvement in the left
  ventricular ejection fraction and Epworth
  sleepiness scale Therefore, performing a CPAP
  titration for CSA is reasonable to assess for
  effectiveness before switching to a different PAP
  device, such as BPAP in the spontaneous timed
  mode (BPAP-ST) or adaptive servo-ventilators.
  CPAP may not be effective in treating CSA caused
  by opioid use.

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CPAP TITRATION

• At the start of CPAP titration, pressure is
  usually initiated at 4 to 5 cm H2O.
• Some patients may experience insufficient
  pressure at the start of titration, even with
  pressure at 5 cm H2O. In these cases, the
  pressure can be increased until the patient is
  comfortable and then, once the patient falls
  asleep, the pressure is reduced in decrements of
  1 cm H2O at 5-minute intervals until SDB returns
  or the patient awakens.
• CPAP is then increased incrementally by 1 cm H2O
  at intervals of no less than 5 minutes until all
  SDB events are eliminated.
• CPAP increments are performed in the presence of
  at least two obstructive apneas, or at least
  three hypopneas, or at least five RERAs, or at
  least 3 minutes of loud snoring.

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CPAP TITRATION

• The recommended maximum pressure to titrate CPAP
  is 20 cm H2O, at which time BPAP titration will
  need to be considered if SDB events are still
  occurring.
• Adding supplemental oxygen for sleep-related
  hypoxemia or hypoventilation may also need to be
  considered.
• If the SDB events are not controlled with CPAP
  because of patient complaints of increased
  pressure side effects (even at CPAP lt20 cm
  H2O),then adding a humidifier for nasal
  congestion or instituting a pressure-relief
  mechanism at end expiration, such as with C-flex
  or expiration pressure relief, should be
  considered.
• If SDB events are persistent, one may then need
  to proceed with BPAP.

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CPAP TITRATION

• The optimal pressure is attained in the supine
  position and REM sleep for at least 15 minutes if
  possible. If this is not attainable, a repeat
  titration study should be considered.
• If the patient is unwilling to undergo or
  insurance does not cover another night titration,
  clinicians could consider prescribing the best
  pressure attained on the titration with a
  follow-up overnight oximetry on the optimal CPAP
  settings. Some prescribers might advocate an
  auto-CPAP in these situations. A follow-up study
  is usually required on auto-CPAP to ascertain
  whether the SDB is well controlled.

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CPAP TITRATION

• The titration protocol using CPAP for CSA/CSR is
  a bit different from that for OSA. Titration with
  CPAP can be started at 4 to 5 cH2O, and then
  titrated upwards by 1 cm H2O every 5 minutes
  until CSA/CSR is eliminated.
• CPAP beyond 10 cm H2O is unlikely to be helpful
  in controlling CSA/CSR, although exploring higher
  pressures may sometimes help identify the optimal
  pressure for treating CSA/CSR.
• Persistent or worsening CSA on CPAP titration
  will necessitate BPAP titration. Also, although
  CPAP can decrease the AHI to less than 5 per hour
  in OSA, this may not occur in CSA/CSR.

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Treatment-Emergent CSA

• Some patients may have central apneas that become
  apparent after CPAP alleviates OSA during CPAP
  titration. This event is commonly referred to as
  treatment-emergent CSA, or complex sleep apnea.
• One option is to proceed directly to adaptive
  servo-ventilation to address treatment-emergent
  CSA on CPAP to treat OSA. This approach may lead
  to the use of an expensive device without proven
  long-term benefits.
• Second approach is to decrease CPAP by 1 to 2 cm
  H2O and monitor for 5 to 10 minutes. If central
  apneas persist, pressure can be decreased further
  by 1 to 2 cm H2O as long as no recurrence of OSA
  is seen.

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Treatment-Emergent CSA

• This downward titration can be attempted until
  the centrals disappear as long as OSA does not
  recur. If centrals persist or OSA recurs at a
  lower pressure, then proceeding with one of the
  other approaches discussed is advisable.
• A third approach is to perform an upward
  titration with CPAP, not beyond 5 cm H2O above
  the pressure that eliminated the OSA. This upward
  titration may help in certain cases, especially
  when the central apneas may have been
  misclassified as OSA.
• If central apneas worsen with this upward
  titration, the pressure should be lowered to the
  previous level that alleviated OSA.

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Treatment-Emergent CSA

• BPAP may also be tried.
• Data suggest that these central apneas dissipate
  over time with CPAP use. Therefore, some
  providers may choose to treat these patients with
  CPAP for 2-to 3-months before repeating another
  titration study.
• If central apneas persist on CPAP with the repeat
  titration study, then treatment should proceed
  using other modalities, such as adaptive
  servoventilation

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BPAP TITRATION

• Upper airway instability in OSA tends to occur
  during not only the inspiratory phase but also
  the expiratory phase hence the rationale in
  using BPAP.
• The EPAP tends to stabilize the upper airway at
  end expiration so that the airway is sufficiently
  patent to permit the patient to trigger delivery
  of IPAP by generating low-level inspiratory
  volume or flow during the subsequent effort.
• The IPAP level is set to prevent upper-airway
  closure and partial obstruction (hypopnea) during
  the inspiratory phase of breathing.
• Different types of BPAP devices are available,
  with the most commons being the conventional
  spontaneous mode (patients may breathe with their
  own frequency, with the BPAP supporting both
  phases of respiration based on the pressure
  settings of IPAP and EPAP) and the backup rate
  mode (BPAP-ST mode) guarantees a certain number
  of pressure cycles (or breaths) per minute, which
  changes to the higher pressure (IPAP) if the
  patient does not initiate a breath within a
  specified period. Inspiratory time must be set on
  the BPAP-ST machines, which tells the machine the
  maximum time allowed for inspiration.

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Indications for BPAP Use

• Several studies comparing the effectiveness of
  BPAP and CPAP, with and without coexisting
  respiratory disorders, showed no differences in
  the improvement of AHI, ESS, sleep quality, no
  differences have been seen in adherence or
  comfort level in the treatment of OSA without
  coexisting respiratory disorders.
• OSA who have comorbid obesity and daytime
  hypercapnia prefer BPAP over CPAP in the
  treatment of OSA.
• BPAP still tends to be considered for OSA
  treatment, even in patients without comorbid
  respiratory disorders, particularly when they are
  unable to tolerate CPAP because of a high
  pressure requirement or have persistent OSA on
  CPAP even at a pressure of 20 cm H2O.

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Indications for BPAP Use

• The use of BPAP is well defined in patients
  presenting with acute respiratory failure related
  to COPD exacerbation. The role of BPAP during
  sleep in patients with stable chronic COPD and
  chronic hypercapnic respiratory failure is less
  well defined
• Guidelines, BPAP can be considered in the
  presence of symptoms such as fatigue, morning
  headache, or daytime hypersomnolence, and one of
  the following
• (1)PaCO2 gt 55 mm Hg,
• (2) PaCO2 of 50 to 54 mm Hg and nocturnal oxygen
  saturation of 88 or less for 5 minutes while
  receiving oxygen therapy of gt2 L/min), or
• (3) PaCO2 of 50 to 54 mm Hg and hospitalization
  related to recurrent episodes (gt2 in a 12-month
  period) of hypercapnic respiratory failure.

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Indications for BPAP Use

• BPAP coverage in patients with restrictive
  thoracic disorders are
• 1- documentation exists of a progressive
  neuromuscular disorders or severe thoracic cage
  abnormality.
• 2- either (a) PaCO2 of gt 45 mm Hg while the
  patient is awake and breathing the usual FIO2
  or
• (b) sleep oximetry shows an oxygen saturation
  of 88 of less for at least 5 continuous minutes,
  performed while the patient is breathing the
  usual FIO2, or
• (c) for a progressive neuromuscular disorders
  (only) ,maximal inspiratory pressure is lt 60 cm
  H2O or forced vital capacity is lt 50 predicted
  and
• COPD does not contribute to the patients
  pulmonary limitation
• BPAP in the ST mode is useful to treat patients
  with CSA syndromes, specifically primary CSA and
  CSA/CSR. BPAP-ST can also be used in CSA caused
  by opioids.

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BPAP titration for OSA
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BPAP titration for OSA

• Patients requiring BPAP to treat OSA normally do
  not require an ST mode the S mode is usually
  sufficient.
• If a patient is switched from CPAP to BPAP, the
  EPAP is started at the CPAP level at which the
  obstructive apneas were eliminated. Otherwise,
  the EPAP is started at 4 cm H2O and increased in
  increments of 1 cm H2O at intervals no shorter
  than 5 minutes until the obstructive apneic
  events are eliminated.
• The IPAP in all these situations is usually
  started 4 cm H2O higher than the EPAP, and
  titrated upward along with the EPAP in increments
  of 1 cm H2O, maintaining the IPAPEPAP difference
  at 4 cm H2O until the obstructive apneic events
  are treated.
• Increases in IPAP and EPAP are performed if at
  least two obstructive apneas are observed.
• Once the optimal EPAP is obtained to eliminate
  the obstructive apneic events, the IPAP is then
  increased in increments of 1 cm H2O every 5
  minutes in the presence of at least three
  hypopneas or five RERAs, or at least 3 minutes of
  loud snoring .

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BPAP titration for OSA

• The maximum recommended IPAP is 30 cm H2O in
  adults because of reports of increased risk for
  barotrauma when IPAP exceeds 30 cm H2O.
• The minimum IPAPEPAP differential is 4 cm H2O
  and the maximum IPAPEPAP differential is 10 cm
  H2O.
• The AASM task force recommends not adjusting the
  BPAP settings in the event of oxygen
  desaturation-resaturation as long as they are not
  associated with any obstructive events. The
  members do not recommend exploration by
  increasing the IPAP above the optimal pressure
  that achieved control of SDB events.
• If a patient develops treatment-emergent central
  apneas,
• 1- decreasing the IPAP could be attempted. If
  this does not help,
• 2- changing to the ST mode with backup rate might
  be helpful.

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BPAP titration for CSA

• Most if not all patients require a BPAP-ST mode
  rather than an S mode to treat CSA.
• If CSA worsens with BPAP, changing to adaptive
  servo-ventilation should be considered.
• If OSA is mixed with CSA during the diagnostic
  polysomnogram, the EPAP is usually started at the
  CPAP level that eliminated the OSA events.
  Otherwise, the EPAP is usually started at 4 cm
  H2O, with the IPAP at 4 cm H2O higher than EPAP
  along with ST backup rate.
• The backup rate is usually started below the
  patients spontaneous awake breathing rate and
  then increased slowly after the patient falls
  asleep. If central apneic episodes persist, the
  backup rate is increased by 1 to 2 breaths every
  5 minutes to a maximum of 16 breaths per minute
  or until the trigger artifact from the BPAP-ST
  results in a flow signal. If there is a trigger
  artifact from the ST backup rate with very
  minimal flow, the IPAP is increased at increments
  of 1 cm H2O every 5 minutes until the hypopneic
  events are corrected .
• Once the airflow improves or apneic events are
  controlled, the ST backup rate and IPAP are not
  titrated further. If the patient is uncomfortable
  with the increase in respiratory rate, the rate
  is decreased slowly to 12 breaths per minute or
  to a rate that the patient is comfortable,
  without necessarily compromising the titration.

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BPAP titration for CSA

• In the presence of obstructive apneic events in
  patients with CSA, the EPAP is increased by 1 cm
  H2O every 5 minutes, maintaining an IPAPEPAP
  difference, until the obstructive apneic events
  are corrected.
• Subsequent titration of IPAP is based on the
  presence of hypopneas and central apneas.
• The authors do not recommend the maximum IPAP to
  exceed 20 cm H2O and recommend maintaining the
  minimum IPAPEPAP at 4 cm H2O. Also, increasing
  the IPAP-EPAP differential has the potential to
  worsen CSA by decreasing PaCO2.
• Every effort should be made to identify the
  optimal BPAP settings during supine and non-REM
  sleep, because CSA tends to worsen during these
  situations.
• If CSA events are persistent after the maximum
  IPAP of 20 cm H2O is reached, other modalities
  should be considered, such as adaptive
  servoventilation to treat CSA.

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BPAP titration for COPD

• BPAP is started in the S mode. BPAP use for COPD
  in the setting of acute respiratory failure used
  high inspiratory pressure in the range of 15 to
  20 cm H2O, to help with gas exchange. Increasing
  the pressure support increases tidal breathing,
  resulting in increased minute ventilation and
  improvement in hypercapnia.
• Presence of OSA with apneic episodes should be
  treated by adjusting the EPAP to eliminate apneas
  while maintaining an IPAP-EPAP difference of 4 cm
  H2O. EPAP and IPAP are increased in increments of
  1 cm H2O every 5 minutes.
• If OSA is not a concern and no apneic episodes
  occur, the EPAP is usually left alone and the
  IPAP is slowly increased by increments of 1 cm
  H2O every 5 minutes to correct hypopneas and
  hypoventilation in patients with COPD.
• Maximum IPAPEPAP difference exceeding 15 cm H2O
  may become uncomfortable for patients.

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BPAP titration for COPD

• Every effort should be made to assess and titrate
  BPAP during REM sleep because patients with COPD
  are most vulnerable to hypoventilation during
  this stage.
• Some may require a backup rate with the ST mode
  during REM sleep.
• With the machine triggered breaths, a pressure
  support of 4 cm H2O (IPAP-EPAP difference) may
  not be sufficient to deliver adequate tidal
  volume. In these situations ,the IPAP will need
  to be increased to deliver adequate tidal volume.
  
• Despite obtaining adequate BPAP settings to treat
  hypoventilation, occasionally supplemental oxygen
  is required (for sleep-related hypoxemia) if
  oxyhemoglobin desaturations persist.
• An arterial blood gas is obtained within a few
  minutes of waking to assess PaCO2 levels.

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BPAP titration for neuromuscular disorders

• BPAP is usually started in the ST mode with a
  rate at or near the patients spontaneous
  breathing rate (generally at least 1012 breaths
  per minute) for patients with neuromuscular
  disorders.
• If OSA is not a concern, the EPAP is initially
  set low (46 cm H2O) with the IPAP generally 4 cm
  H2O higher.
• Patients with neuromuscular disorders patients
  may find higher EPAP settings to be uncomfortable
  due to difficulty exhaling. Therefore the
  titration of EPAP and IPAP may need to proceed
  slowly.
• The EPAP is increased in increments of 1 cm H2O
  in intervals no shorter than 15 minutes to
  eliminate apneic events.
• Once the optimal EPAP is obtained based on
  elimination of apneic episodes at a pressure that
  is comfortable for the patient, the IPAP is then
  adjusted by increments of 1 cm H2O in intervals
  no shorter than 15 minutes to eliminate hypopneas
  and hypoventilation.

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BPAP titration for neuromuscular disorders

• In patients with only neuromuscular disorders, it
  is unlikely that they will need supplemental
  oxygen. The predominant underlying
  pathophysiology is hypoventilation during sleep,
  which normally should be corrected by BPAP alone.
  
• Use of supplemental oxygen alone (without BPAP)
  in patients with neuromuscular disorders may
  depress the drive to breathe.
• Every effort should be made to titrate BPAP
  during REM sleep since patients with
  neuromuscular disorders are most vulnerable to
  hypoventilation during this stage.
• The initial requirement for the back up rate
  occurs during REM sleep when hypoventilation is
  the worst resulting in the patient not triggering
  the BPAP.
• Obtaining an arterial blood gas within a few
  minutes of waking up the following morning of the
  titration is also recommended to assess PaCO2
  levels.

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SUPPLEMENTAL OXYGEN TITRATION

• If the patients awake supine baseline
  oxyhemoglobin saturation is less than 88,
  supplemental oxygen is usually initiated at 1
  L/min at the start of the PAP titration and
  titrated upward by 1 L/min at intervals no
  shorter than 15 minutes.
• Supplemental oxygen should be started during the
  titration study if the patients oxyhemoglobin
  saturation is less 88 for 5 or more minutes in
  the absence of OSA events.
• Supplemental oxygen is titrated up at a rate of 1
  L/min at intervals no shorter than 15 minutes to
  maintain oxyhemoglobin saturation of more than
  88.

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SUPPLEMENTAL OXYGEN TITRATION

• Patients who have persistent sleep-related
  hypoxemia or hypoventilation that is not
  effectively treated with a PAP device will need
  supplemental oxygen to maintain oxyhemoglobin
  saturation of more than 88.
• In these situations, supplemental oxygen is
  connected to the PAP device outlet and not the
  mask.
• Patients who were on supplemental oxygen before
  PAP titration are likely to need a higher amount
  of oxygen with the PAP device because of higher
  flow rates reducing the effective oxygen
  concentration for a given supplemental oxygen
  flow.
• Ideally in those patients who required
  supplemental oxygen or upward titration of the
  previously used oxygen, an arterial blood gas is
  performed the following day, usually within a few
  minutes of waking, to assess for hypercapnia.

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