5 Modes of PAP TitrationCPAP - Titrate positive pressure throughout recording to determine single fixed pressure that will eliminate respiratory disturbances during subsequent nightly usage at homeBPAP - device may be used when a patient demonstrates difficulty acclimating to high airway pressure during the expiration phase of breathing.BPAP allows the sleep technologist to separately increase inspiratory or expiratory pressures during the polysomnography to arrive at two pressures for subsequent use in the home.Servoventilation device (SV) - a computer-controlled valve to adjust airway pressure breath by breath to maintain steady ventilation.Heplful for patients with periodic breathing abnormalities such as Cheyne Stokes respiration and central apnea seen in heart failure or patients with complex sleep apnea
6 The goals should be individualized to meet the needs of each patient. Goals of PAP TitrationKeep the upper airway open (airway management).Stabilize breathing patterns by monitoring the patient’s response to therapy.Adjust user-set parameters as needed for optimal therapy efficacy and adherence.The goals should be individualized to meet the needs of each patient.
8 PAP Titration StudyManual PAP titration during attended PSG is current AASM standard for :Select optimal therapeutic pressureMust be administered by well- trained sleep technologistPAP educationHands on equipment demonstrationCareful mask fitting and acclimation to device prior to titrationArt and not a cookbook – using clinician’s experience and judgment
9 Optimal Pressureeffective pressure that eliminates SDB events without creating any untoward pressure related side effectsShould be effective in all positions and stages of sleepThere is a trade off between increasing pressure to yield efficacy in eliminating respiratory events, and decreasing pressure to minimize emergence of pressure related adverse effects
10 Lower than Optimal Pressures Mouth breathingclaustrophobiaHigher than Optimal PressureAir leaksWorsening of nasal congestionRhinorrheaExacerbating central apneaPoor tolerance to PAP
11 Factors influencing Optimal Pressure sleep position,Rapid eye movement (REM) sleep,sleep durationdegree of respiratory effortthe length of the soft palate.Factors not affecting optimal pressureSeverity of AHIBMI
12 Optimal TitrationThe Respiratory Disturbance Index (RDI) is < 5 per hour for a period of at least 15 minutes at the selected pressure and within the manufacturer’s acceptable leak limit.The SpO2 is above 90% at the selected pressure.Supine REM sleep at the selected pressure is not continually interrupted by spontaneous arousals or awakenings.
13 Good TitrationThe Respiratory Disturbance Index (RDI) is < 10 per hour (or is reduced by 50% if the baseline RDI was <15) for a period of at least 15 minutes at the selected pressure and within the manufacturer’s acceptable leak limit.The SpO2 is above 90% at the selected pressure.Supine REM sleep at the selected pressure is not continually interrupted by spontaneous arousals or awakenings.
14 Adequate TitrationThe Respiratory Disturbance Index (RDI) is NOT < 10 per hour, but the RDI is reduced by 75% from baseline.Criteria for optimal or good titration is met but you did NOT get a sample of supine REM at the selected pressure.
15 Respiratory Parameters during PAP Titration Airflow sensor – airflow signal generated by PAP device (because pressure transducer under nares with mask leads to poor mask seal) – flow signalRespiratory effort sensor – RIP beltSampling Rate – minimum 25 Hz; prefer 100 Hz (to assess artifacts and cardiogenic oscillations)Filter settings : LFF 0.1 Hz, HFF 15 Hz.Most machines provide a signal reflecting an estimate of leak
16 Hypopnea during PAP Titration Same definition as during PSGDifferent signal sourceOxygen desaturation criteria – 3%, 4% or noneAssociated arousal
17 Educational ProgramAdequate PAP education, hands-on demonstration, careful mask fitting, and acclimatizationDone prior to a diagnostic study with high clinical suspicion of OSAMask fitting goalsMaximizing comfortCompensation for nasal obstructionMinimizing leakMask interface – nasal, nasal pillow, full face/ oro-nasalAccessories – chin strap, heated humidifierAcclimatizationWearing interface with pressure on prior to lights off
18 PAP Titration (AASM protocol) Start patient on 5 cm H2O (may start higher pressure for higher BMI or for re-titration studies)Increase pressure until respiratory events are eliminated : apneas, hypopneas, RERAs, and snoringIncrease pressure at least 1cm H2O, no sooner than ever 5 minutes (for at least 2 obstructive apneas, or at least 3 hypopneas, or at least 5 RERAs, or at least 3 minutes of loud or unambiguous snoring)Exploration pressure – may increase 2-5 cm to overcome upper airway resistance – to normalize shape of inspiratory flow limitationDown Titration – not necessaryIf patient still hypoxic after respiratory events are resolved, do not increase pressureMaximum CPAP pressure – 15 cm H2O
19 PAP Titration – AASM protocol Bi-Level PAPPatient intolerant or uncomfortable of high pressure on CPAPContinued obstructive events at 15 cm H2O CPAP during titration studyNot more effective or superior to CPAPTITRATIONStarting pressure 8/4; maximum IPAP – 30 cm H2O; minimum difference 4; maximum difference 10
20 Expiratory Pressure Relief 20% using CPAP complaints of sensation of exhaling against a high pressurePressure reduction during expiration (EPR, C-flex) on pressure relief CPAP MAY be more comfortable for patients requiring higher CPAP pressure
22 Adaptive Servo-Ventilation Uses an algorithm that varied Pressure Support to achieve 90% of measured long term minute ventilationUsed in management of Central Sleep Apnea, and Complex Sleep ApneaUses negative feedback loop
23 Re-Titration Study How often – in stable patient Things to do before Re-Titration StudyClinical evaluation – sleep historyMask fitting and LeakReview of PAP downloadAuto PAP Trial and adjustment of pressure based on data
24 PAP NAP Study Previous night sleep restriction 1 – 3 hours of sleepNo napping prior to PAP-NAPMask fitting, desensitizationDetermine best mask for patient, Full Face vs. Nasal vs. Direct Nasal PillowMask fitting for comfort, lack of leak, lack of pressure pointsPressure desensitizationPAP Therapy Hookupchannel hookup is used, including pressure transducer, snore, PAP therapy pressure, mask leak, respiratory effort belts, heart rate, pulse oximetry, video monitoring, and body position SPAP Therapy Testing60 to 120 minutes spent in bed with PAP device in placeGoal is to help patient adapt to PAP therapy sensationPressure changes for comfort, to improve airflow signal, to increase physiologic exposure, but not to titrate
25 PAP Titration Deciding factor for therapy Patient – AHI, BMI, gender TechnicianSleep Disorders CenterReviewing Physician
26 Baseline AHI & PAP Titrations What AHI one should not titrate?In survey of SDC – 15/84 – AHI <10Who should get Split Night studies – 16/84 had AHI >60
27 EPR 31/84 Technicians SDC Should everyone have EPR 1/9 (minimum)4/4 (maximum)SDC2/1810/11Should everyone have EPRWhat Level : 1,2 or 3
28 PAP Masks Full Face – 63 Technicians (Full Face mask) SDC Quattro – 43Simplus – 17Others - 3Technicians (Full Face mask)8/9 (maximum)1/4 (minimum)SDC16/18 (maximum)6/11 (minimum)Nasal Pillow- 9 (one technician 3/4)Nasal- 12
29 PAP Mode of therapy Fixed Pressure Auto Titrating 37/ 42 (maximum) 2/18 (minimum)Auto Titrating3/42 (minimum)16/18 (maximum)
30 PAP Mode of therapy CPAP Bilevel 40/42 Maximum 11/19 Minimum 1/42 minimum (1/9 for technician when >5 studies)8/19 maximum (one technician 5/9)