Initiation and titration of positive airway pressure therapy for obstructive sleep apnea in adults

PSG: polysomnography; HSAT: home sleep apnea testing; CPAP: continuous positive airway pressure; BPAP-S: bilevel positive airway pressure in spontaneous mode; AHI: apnea-hypopnea index.
* Uncomplicated obstructive sleep apnea is that which is not complicated by other conditions associated with complex sleep-disordered breathing, including chronic obstructive pulmonary disease, heart failure, and obesity. Complicated obstructive sleep apnea is that complicated by other medical disorders including those associated with central sleep apnea or hypoventilation.
¶ In-laboratory titration is preferred in those in whom complex sleep-disordered breathing is suspected. In-home auto-titration may be preferred in those with anticipated or known variable pressure requirements (eg, obstructive sleep apnea exacerbated in supine or rapid eye movement [REM] sleep, variation in weight or use of alcohol, intermittent nasal obstruction) or if access to a sleep laboratory is delayed or inconvenient.
Δ Most patients undergo titration with CPAP. However, PAP titration with BPAP-S or other forms of positive pressure ventilation is sometimes indicated. Please refer to related UpToDate topics for details on choosing the method of PAP titration.
◊ Choosing among these options depends upon which method optimizes sleep quality.
§ CPAP titration may not be successful for many reasons, including intolerance of CPAP, air leaks, and identification of complex sleep disorders (eg, treatment-emergent central sleep apnea). Such issues need to be addressed individually and are best dealt with in a sleep laboratory setting during a PAP re-titration study.