An interesting one for those of you who are technically minded.

Might be useful as a 'Sticky' ? Mods ???

Daniel.


Clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea.
KUSHIDA CA, CHEDIAK A, BERRY RB, BROWN LK, GOZAL D, IBER C, PARTHASARATHY S, QUAN SF, ROWLEY JA.
J Clin Sleep Med 2008;4(2):157-71.
Stanford University Center of Excellence for Sleep Disorders, 401 Quarry Road, Suite 3301, Stanford, CA 94305-5730, USA
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).


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The untreated Sleep Apnoea sufferer died quietly in his sleep.......
Unlike his three passengers who died screaming !!!!!!

(Anon)

Good Info Daniel...Thanks for posting it.....I agree...should be a sticky.

 Due to my fog I had difficulty focusing on it...only thinking others may benefit from each of the 18 lines having a break between them.


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BiPAP Auto M 13/8 Mirage Nasal Swift. 20 years+ undx'd. RLS/PLMD, Hypersomnia & more.

Quote:

(1) All potential PAP titration candidates should receive adequate PAP education, hands-on demonstration, careful mask fitting, and acclimatization prior to titration.

Ooops! The American sleep profession is falling on its face already!

Quote:

(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.)

And what, pray tell, is a leak w/in acceptable parameters? What are the acceptale parameters?


_________________
Some people are like Slinkies... Not really good for anything, but they still bring a smile to your face when you push them down a flight of stairs.
Resmed VPAP Auto. Humidaire 3i, Simplicity & Micro masks, ResScan 3.4, S8 ResLink, Embla oximeter.

Unfortunately they are only guidelines.  Doc's, sleep centers, and dme's can ignore them because they are JUST guidelines :-/

Yeah, I sounded a bit sarcastic when I didn't mean to w/my last remark. (I DID mean to w/the first remark). Really, tho what is considered an acceptable leak rate during a titration?

If we dig thru our xPAP's literature we can usually find an approximate upper limit of leak the device can compensate for. BUT, what are the parameters for an acceptable leak rate during a titration - or at least the GUIDELINES or SUGGESTED leak rate parameter?

I mean, assuming we use the same mask during our titration as the mask we use at home. It would seem that the leak rates should be fairly close.

Yet how many of us encounter a totally unacceptable leak rate at home w/our mask used during titration? And how many of us encounter an unacceptable leak rate as far as our xPAP's compensation abilities yet that is never addressed by our sleep doctors when they "supposedly" go over our downloaded data on follow up?

One would assume that if the titration allows for an unacceptable leak rate one could be titrated at a higher pressure than is really necessary IF the leak rate is brought under control at home?

Can I assume most of today's CPAPs' compensatory abilities are pretty much the same across brands and models and that it is the leak rate limit that is considered acceptable during a titration study?


_________________
Some people are like Slinkies... Not really good for anything, but they still bring a smile to your face when you push them down a flight of stairs.
Resmed VPAP Auto. Humidaire 3i, Simplicity & Micro masks, ResScan 3.4, S8 ResLink, Embla oximeter.

Mrs Rip Van Winkle wrote:

Good Info Daniel...Thanks for posting it.....I agree...should be a sticky.

 Due to my fog I had difficulty focusing on it...only thinking others may benefit from each of the 18 lines having a break between them.

yes i also have trouble reading this.  i am not i'm afraid very "technically minded".  tee hee ;)

i read somewhere here that AutoPap can be dangerous?  why?
that is what i am on, since they were not able to get a "tiration" (see i'm learning - haaha! ;) ) on me at my at home sleep study.

I just wanted to say thanks for having all the definitions to the shortcut letters so I can understand the meanings. Really good info should be promonent somewhere.
Deb