Reliability of Automatic CPAP Titration in OSAS

Treatment

Bülent Çiftçi MD

bciftci@superonline.com

Ankara

If AHI>15, PAP is the first choice for all patients

If AHI>5, PAP can be a first choice for some patients

If bilevel PAP is not indicated, then fixed continuous PAP should be used

What is the effective pressure ???

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!)

Different methods for CPAP titration

Manual CPAP titration is gold standart

APAP titration Attended Unattended

APAP

… since 1995 Pressure in mask shows variations

with; Sleep stages Body position Physiological changes in nasal

resistance Fluctuations in body weight

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

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.

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

Unattended APAP titration

Unattended APAP is successful in many patients (91%) in determining a therapeutic positive pressure setting

Reported AHİ via Autoset is similar to that of PSG

Woodson BT, et al. Nonattended home automated continuous positive airway pressure titration:Comparison with polysomnography. Otolaryngology-Head and Neck Surgery:2003;353-357

Recommendations of Standards of Practice Committee of the AASM

A diagnosis of OSA must be established by an acceptable method

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.

APAP devices are not currently recommended for splitnight titration.

No enough data

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

Treatment with APAP

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

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

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

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.

Two major problems with APAP

Mask leak Central apneas

Mask and Mouth Leaks

Mask leak accelerate the blower, more air increases the leak

Some devices give alarms in case of mask leak

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

What effects the pressure during the night?

Rebound sleep REM rebound Slow wave sleep rebound

Sleep position

Age Sedative drugs, alcohol Weight fluctuation Nasal congestion Re-start to use after a few days

without CPAP

What effects night-to-night variability of pressures?

Nasal congestion

CPAP without heated humidifier may trigger nasal congestion

Allergic rhinitis !

Reduction in upper airway edema

with PAP treatment

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

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.

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 2001;18: 170-175

Lloberes et al. Comparison of manual and automatic CPAP titration in patients with SAS. Am J Respir Crit care Med 1996;154:1755-1758

20 patients with OSAS all underwent both manual CPAP titration and APAP titration;

•Final pressure

•Sleep quality did not differ on the methods

Stradling JR et al. Automatic nCPAP titration in the laboratory: patient outcomes. Thorax 1997;52:72-75

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

Juhasz J et al. Unattended CPAP titration. Clinical relevance and cardiorespiratory hazards of the method. Am J respir Crit Care Med 1996;154:359-365

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

P Levy, JL Pepin. Autoadjusting continuous positive airway pressure: what can we expect? Am J Respir Crit Care Med. 2001;163(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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