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Reliability of A utomatic CPAP T itration in OSAS Treatment

Reliability of A utomatic CPAP T itration 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.

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Reliability of A utomatic CPAP T itration in OSAS Treatment

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  1. Reliabilityof Automatic CPAP Titrationin OSAS Treatment Bülent Çiftçi MD bciftci@superonline.com Ankara

  2. If AHI>15, PAP is the first choice for all patients • If AHI>5, PAP can be a first choice for some patients

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

  4. 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!)

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

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

  7. 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

  8. 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.

  9. 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

  10. 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

  11. Recommendations of Standards of Practice Committee of the AASM

  12. A diagnosis of OSA must be established by an acceptable method

  13. 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.

  14. APAP devices are not currently recommended for splitnight titration. • No enough data

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

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

  17. 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

  18. 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

  19. 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.

  20. Two major problems with APAP • Mask leak • Central apneas

  21. Mask and Mouth Leaks • Mask leak accelerate the blower, more air increases the leak • Some devices give alarms in case of mask leak

  22. 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

  23. What effects the pressure during the night? • Rebound sleep • REM rebound • Slow wave sleep rebound • Sleep position

  24. 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

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

  26. Reduction in upper airway edema with PAP treatment • Edema results from vibration of the soft tissues of the upper airway

  27. 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.

  28. 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

  29. 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 1996;154:1755-1758

  30. 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 1997;52:72-75

  31. 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

  32. 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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  34. Teşekkürler…

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