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Mode selection for titration of positive airway pressure in adults with obstructive sleep apnea

Mode selection for titration of positive airway pressure in adults with obstructive sleep apnea
Authors:
Neil Freedman, MD
Tomasz J Kuzniar, MD, PhD, FCCP, FAASM
Section Editor:
Susan M Harding, MD, FCCP, AGAF
Deputy Editor:
Geraldine Finlay, MD
Literature review current through: Dec 2022. | This topic last updated: Mar 04, 2021.

INTRODUCTION — Positive airway pressure (PAP) is the cornerstone of therapy for most patients with obstructive sleep apnea (OSA).

Several modes of PAP are available. Selecting the initial mode for titration of PAP and the setting where this titration takes place are discussed in this topic. Discussion of the indications for PAP and the available modes and modules for titration of PAP are discussed separately. (See "Management of obstructive sleep apnea in adults", section on 'Indications for treatment' and "Titration of positive airway pressure therapy for adults with obstructive sleep apnea".)

INITIAL MODE AND SETTING OPTIONS

Mode options — Patients with OSA in whom PAP therapy is indicated should have their PAP device titrated to determine the optimal settings for that individual. For most patients, fixed-level continuous PAP (CPAP) is the first-choice therapy. Other modes including auto-titrating CPAP (APAP), and rarely, bilevel PAP (BPAP), are options in select patients.

Fixed-level CPAP delivers PAP at a level that remains relatively constant throughout the respiratory cycle. Titration by an attending sleep technologist occurs in the sleep laboratory using polysomnographic (PSG)-based monitoring, thereby requiring an overnight stay.

APAP devices utilize proprietary algorithms to resolve obstructive sleep-disordered breathing as detected by the device and are generally performed at home.

BPAP delivers PAP at different levels during inspiration (IPAP) and expiration (EPAP), and an attended in-laboratory PSG-monitored assessment is necessary to assess its efficacy.

Sometimes confusing matters is that devices used to determine the optimal settings for PAP may be the same as or different to those used for therapy. For example, a CPAP or APAP device can be used to determine the optimal fixed-level of CPAP to be delivered through a CPAP device, and an APAP device can be used for both titration and treatment of OSA.

Setting of testing (home versus in-laboratory) — The setting in which the titration takes place (ie, in-laboratory or home), may vary. While an attended in-laboratory PSG-based PAP titration is the traditional gold standard and preferred method of determining an effective level of PAP, select patients may undergo PAP titration at home using an APAP device. The choice of the setting affects the device that will be used for PAP testing. For example, in-laboratory PSG testing typically involves fixed-level CPAP or BPAP devices while at-home titrations use APAP devices (ie, without polysomnographic monitoring).

Factors influencing the setting — In patients with OSA, several factors that influence the setting in which the titration is performed.

Device type — The choice of the setting of testing is affected by the perceived appropriateness of a given patient for CPAP, BPAP, or APAP. For example, patients who are candidates for APAP can be tested at home while patients who need BPAP can only be tested in the laboratory.

Presence of complicating disorders or states that affect sleep — OSA can be complicated or uncomplicated. This distinction can affect the choice of testing:

Complicated OSA – Patients who have OSA complicated by coexisting conditions that can affect sleep (ie, complicated OSA) are not typically suitable for home testing with APAP and generally require in-laboratory titration for fixed-level CPAP.

Disorders that can affect sleep are listed in the table (table 1) and include severe chronic obstructive pulmonary disease, congestive heart failure, central sleep apnea, neuromuscular diseases and hypoventilation syndromes, including hypoventilation due to drugs. Notably, this list of conditions is not consistently recognized by insurers as reasons for in-laboratory testing and they may require initial in-home testing with APAP before approving an in-laboratory titration. Additionally, patients with prior uvulopalatopharyngoplasty [UPPP] are thought to not be good candidates for APAP titration since algorithms employed by APAP devices are not designed for this population.

Uncomplicated OSA – Uncomplicated OSA refers to the absence of such conditions in patients with OSA. Patients in this category can generally undergo initial titration at home with APAP or in-laboratory CPAP titration. Data to support this approach are discussed below. (See 'Uncomplicated obstructive sleep apnea' below.)

Preference or need to eliminate a separate stay in the sleep laboratory — The primary advantage of in-home titration with APAP is the elimination of a separate stay in the sleep laboratory (table 2). This strategy may reduce both the costs and any delay, depending upon the time necessary to access sleep laboratory services in any given location, and may also extend care to patients in areas that lack sleep laboratories. In addition, several studies have demonstrated that for patients with uncomplicated moderate to severe OSA (table 1), APAP provides similar outcomes to CPAP titrated in a laboratory setting.

Others — Several additional practical factors also weigh into whether in-laboratory or home titration is chosen. As examples:

APAP is not suitable for patients suspected to have a significant air mask leak (eg, facial abnormalities), since leaks can change airflow [1] or for patients with suspected or known central apneas since the detection of such events by APAP is relatively poor when compared to in-laboratory testing [2].

The need for a technician to choose, adjust, and adjudicate the patients-device interface may necessitate an in-laboratory stay since a technician is not available during in-home APAP titration. The growing variety of nasal pillows, face masks, and hybrid interfaces that are available makes this limitation of APAP increasingly pertinent.

Patients with uncomplicated OSA who have previously failed in-home APAP titration are candidates for in-laboratory testing. Such a failure is defined as a perceived inability to start PAP therapy or persistent problems with adherence with APAP, despite adjustments by the managing team to the mask interface and PAP settings.

Patients who need additional PAP education, and patients who may have medical problems (eg, severe arthritis) or cognitive difficulties (eg, dementia) that may limit in-home titration success should undergo fixed in-laboratory CPAP titration.

Access to a sleep laboratory may not be feasible in some patients and in-home titration may not be feasible in others (eg, those who are bedbound, reside at a nursing home, have major medical or cognitive issues, or are homeless).

Cost may also impact the decision in select patients since some insurers will not reimburse for an in-laboratory PAP titration study unless the patient has already failed a trial of APAP titration at home.

The practices of the institution or sleep expert may also affect the initial choice of setting for PAP titration.

INITIAL TITRATION — The approach described below is consistent with the published literature, our practice, and the American Academy of Sleep Medicine (AASM) practice guidelines for sleep-disordered breathing (algorithm 1) [3,4].

Uncomplicated obstructive sleep apnea — To determine a fixed-level of continuous PAP (CPAP) in patients with uncomplicated OSA, we suggest that an attended in-laboratory CPAP titration with a fixed-level device (or an unattended in-home titration using an auto-titrating CPAP [APAP] device) be used. In-laboratory titrations are typically combined with a diagnostic polysomnogram (ie, a split night study). While an attended in-laboratory approach is traditionally considered the gold standard, randomized trials and meta-analyses of patients with uncomplicated moderate to severe OSA have failed to demonstrate substantial difference in efficacy between in-laboratory and in-home APAP titration strategies [4-18]. This includes effects on daytime sleepiness, quality of life, and neurocognitive functioning as well as adherence. Although underrepresented in comparative trials, we suggest a similar approach for those with uncomplicated mild OSA in whom PAP is chosen as a therapy. Titration modules for in-laboratory CPAP titration and for in-home APAP titration are discussed separately. (See "Titration of positive airway pressure therapy for adults with obstructive sleep apnea", section on 'In-laboratory fixed-level continuous positive airway pressure (CPAP)' and "Titration of positive airway pressure therapy for adults with obstructive sleep apnea", section on 'Auto-titrating continuous positive airway pressure (APAP)'.)

The best level of evidence that supports this strategy is a meta-analysis of 21 studies by the AASM which found no differences in the residual apnea hypopnea index (AHI) between APAP and CPAP titration strategies in patients with uncomplicated moderate to severe OSA [4]. Similarly, the same meta-analysis also showed no difference in the nightly hours of CPAP or APAP use (ie, adherence), or in daytime sleepiness, quality of life, and neurocognitive function. Furthermore, there was no discernable difference in the side effect profile between the two modes, although it was inconsistently found that patients receiving APAP complained of less pressure-related discomfort compared with CPAP. Limited data also suggested that there was a patient preference for APAP.

The AASM clinical practice guideline [3] states that “the majority of well-informed adult patients with OSA and without significant comorbidities would prefer initiation of PAP using the most rapid, convenient, and cost-effective strategy,” underlining that this recommendation “assumes that adequate education on PAP use and mask fittings with or without daytime acclimatization by trained staff are available.” It also states that the final decision on which strategy to implement in an individual patient should be based upon “patient preferences and abilities, the sleep clinician’s judgment, anticipated or known previous difficulty with PAP treatment, and availability of resources and cost of each strategy in a particular region” [3]. These and other factors that influence the choice of home or in-laboratory PAP titration are discussed above. (See 'Factors influencing the setting' above.)

Bilevel PAP (BPAP) devices are not typically used as the initial approach for titrating PAP in patients with uncomplicated OSA. BPAP devices are used to treat OSA patients who fail or cannot tolerate CPAP, or have complicated sleep-disordered breathing (eg, central sleep apnea and/or hypoventilation syndromes). (See 'Complicated OSA' below and 'Attended in-laboratory bilevel PAP (BPAP)' below and "Mode selection for positive airway pressure titration in adult patients with central sleep apnea syndromes".)

Other approaches using prediction formulas or empiric titration strategies are not as well validated and are not typically used by clinicians in practice unless in-laboratory and in-home titration are not options. (See "Titration of positive airway pressure therapy for adults with obstructive sleep apnea".)

Complicated OSA — Complicated OSA refers to the presence of conditions that can potentially affect respiration and create additional respiratory abnormalities over and above OSA itself (eg, severe chronic obstructive pulmonary disease or heart failure) (table 1) (see 'Presence of complicating disorders or states that affect sleep' above). In this population, most clinicians start titration with in-laboratory CPAP titration. However, BPAP may be initiated in select populations thought to have a predominance of central sleep apnea or hypoventilation or in patients who fail CPAP. The rationale for in-laboratory titration is based upon the limited ability of home devices to detect complex sleep disturbances that can occur in this population. Other approaches using in-home APAP devices, prediction formulas, or empiric adjustment are not suitable for this population. Titration modules for in-laboratory CPAP titration and for BPAP titration are discussed separately. (See "Titration of positive airway pressure therapy for adults with obstructive sleep apnea", section on 'In-laboratory fixed-level continuous positive airway pressure (CPAP)' and "Titration of positive airway pressure therapy for adults with obstructive sleep apnea", section on 'Bilevel positive airway pressure, spontaneous mode (BPAP-S)'.)

Follow-up after initial titration — After initial PAP titration, titration data from the polysomnogram (ie, from in-laboratory reports) or from the device (ie, from in-home auto-titrating devices) should be examined to assess the adequacy of titration. Patients should be assessed for residual symptoms and tolerance (eg, the sensation of pressure, mask fit, nasal symptoms). Determining whether optimal pressures have been achieved during titration depends on the mode selected and is discussed separately. (See "Titration of positive airway pressure therapy for adults with obstructive sleep apnea", section on 'Adequacy assessment of CPAP titration' and "Titration of positive airway pressure therapy for adults with obstructive sleep apnea", section on 'Assessment of APAP titration adequacy'.)

For those who can tolerate PAP and achieve optimal pressures during titration, PAP therapy should be initiated with follow-up in 1 to 8 weeks. (See 'Patients with optimal titration' below.)

For patients who cannot tolerate PAP or whose titration did not result in a level of PAP sufficient to resolve sleep-related events, an assessment for the underlying reasons should be sought and treated. The titration should then be repeated, most often with the same device. (See 'Patients with suboptimal titration' below.)

PATIENTS WITH OPTIMAL TITRATION

Initiation of therapy — For patients with OSA in whom optimal titration and tolerance is achieved, PAP should be prescribed at that level. (See "Management of obstructive sleep apnea in adults".)

In many patients with uncomplicated OSA, ongoing therapy involves treatment with fixed-level continuous PAP (CPAP). Auto-titrating CPAP (APAP) is an alternative particularly in patients with uncomplicated OSA, who have poor tolerance of the degree of fixed CPAP necessary to prevent respiratory events in all sleep positions and stages, and patients subjected to factors that might significantly vary their pressure requirement (eg, alcohol and nasal congestion, patients with wide variations in body weight or higher pressure requirements in REM sleep and/or when sleeping in the supine position). It is infrequent in patients with uncomplicated OSA that bilevel PAP (BPAP) is needed.  

For patients with complicated OSA, CPAP (titrated using in-laboratory setting) is the first choice rather than APAP or BPAP, although this depends upon the complication (eg, BPAP is preferred in those with neuromuscular disease).

Follow-up is critical to the success of PAP. In general, most patients are clinically assessed at approximately one to eight weeks. Some data suggest that early evaluation, for example within one to two weeks after starting PAP, may improve adherence. The Centers for Medicare and Medicaid Services (CMS) and some insurers require evaluation no longer than 90 days after PAP therapy starts. Symptoms assessed at follow-up include daytime sleepiness, snoring, mask tolerance, and oronasal effects. Device-recorded data should also be reviewed. Devices can be interrogated for the apnea-hypopnea index (AHIflow), mask leak, and adherence data. Adjustments can be made accordingly. During follow-up, patient education, treatment of complications, comfort of the patient-device interface, and support of the patient's bed partner are critical in ensuring success. (See "Downloading data from positive airway pressure devices in adults" and "Assessing and managing nonadherence with continuous positive airway pressure (CPAP) for adults with obstructive sleep apnea" and 'Follow-up after initial titration' above.)

Limited data suggest that many patients do not achieve optimal settings. Post-hoc analyses from randomized studies that tested the efficacy of CPAP in OSA patients estimated that only 50 to 60 percent of patients achieve an optimal setting, and 30 to 40 percent achieve an adequate or inadequate setting [19,20] (see "Titration of positive airway pressure therapy for adults with obstructive sleep apnea", section on 'Adequacy assessment of CPAP titration' and "Titration of positive airway pressure therapy for adults with obstructive sleep apnea", section on 'Assessment of APAP titration adequacy'). The reasons for this are unclear but may be due to difficulty achieving an optimal setting from the outset or the limited ability of a single study to estimate variable pressure needs over a more prolonged period of use. Thus, many patients on CPAP or BPAP therapy, even those who undergo attended titrations in the sleep laboratory, may be receiving suboptimal pressure settings. Since the efficacy of suboptimal PAP levels is unknown, we advise that the threshold be low to perform additional titration efforts, particularly when symptoms persist despite PAP therapy. Switching to a different mode of PAP therapy necessitates re-titration according to the chosen mode. (See 'Follow-up after initial titration' above.)

For patients in whom PAP therapy is initiated using prediction formulas or empiric strategies, some adjustments can be made based upon presence or absence of daytime symptoms and snoring, as well as device data if available. However, the efficacy of this approach is unknown. (See "Downloading data from positive airway pressure devices in adults".)

For some patients with OSA who have severe nocturnal oxygen desaturations and have undergone APAP, follow-up oximetry is appropriate to ensure that desaturations have been adequately treated. Patients with a higher body mass index (BMI >30 kg/m2) or patients with evidence of hypoxemia despite good OSA control are also candidates for oximetry (eg, patients with OSA and persistent polycythemia).  

PATIENTS WITH SUBOPTIMAL TITRATION — When patients with OSA are intolerant of a given level of continuous PAP (CPAP), have residual symptoms of excessive daytime sleepiness or snoring, and/or have residual obstructive events observed on CPAP therapy at a pressure of ≥15 cm H2O, we typically assess the patient for potential etiologies that may explain these phenomena (see 'Evaluate and manage the suspected etiology' below). Once addressed, patients should undergo retitration, most often with the same modality (ie, typically in-laboratory fixed-level CPAP or in-home auto-titrating CPAP [APAP]) (see 'Re-titration' below). Should patients with uncomplicated OSA fail this strategy, we agree with the American Academy of Sleep Medicine (AASM) who suggest that bilevel PAP (BPAP) therapy (usually in the spontaneous mode) be administered, for which, in-laboratory titration with a BPAP device is necessary [3]. (See 'Attended in-laboratory bilevel PAP (BPAP)' below.)

Evaluate and manage the suspected etiology

Mask, tubing, nasal issues — In general, three types of masks, nasal, oronasal (full face), and nasal pillows are used for PAP therapy. Some patients report claustrophobia due to the mask; this can be addressed by gradual mask desensitization or finding the smallest, least confining mask interface. Poorly fitting or leaking masks, as reported by the patient and/or detected from device-related data, may be the reason for nonadherence. In cases of nasal and nasal pillow masks, this may be due to mouth breathing which may be remedied by the addition of a chin strap. Condensation within the tubing may be addressed by utilizing a heated tube. Nasal dryness may be addressed by heated humidification and nasal congestion may be treated with topical glucocorticoids. Patients with significant nasal obstruction may need further evaluation by an otolaryngologist. Further details regarding choosing the correct interface are provided separately. (See "Titration of positive airway pressure therapy for adults with obstructive sleep apnea", section on 'Choosing the correct patient-device interface' and "Titration of positive airway pressure therapy for adults with obstructive sleep apnea".)  

Intolerance of pressure — For patients who complain of discomfort from the pressure, pressure relief or a pressure ramp may be employed on the device. Patients should be re-titrated using the same device. Should patients fail these maneuvers, switching from fixed-level CPAP re-titration with in-home APAP is appropriate; in this setting APAP is used as a “pressure-relief” strategy since the device may reach higher pressures only when needed (eg, the patient is supine and/or in rapid eye movement [REM] sleep) but remain at lower, potentially more tolerable, mean pressures otherwise. For the same reason, patients intolerant of the pressure in whom BPAP is indicated, auto-titrating BPAP can be considered as a “pressure relief” measure, although algorithms for auto-adjustment for auto-BPAP devices are not well validated; thus, adjustment should occur in an attended setting. (See "Titration of positive airway pressure therapy for adults with obstructive sleep apnea".)

Variable pressure requirement — Patients subjected to factors that might significantly vary their pressure requirement may benefit from a trial of APAP. Variable pressure requirements may be due to use of alcohol, nasal congestion from allergies or upper respiratory infections leading to nasal obstruction, wide variations in body weight, or higher pressure requirements in REM sleep and/or when sleeping in the supine position.

Inadequate pressure, residual or new symptoms — When patients have residual symptoms or when PAP is tolerated but pressures have not sufficiently resolved sleep-related events, setting a higher pressure limit (eg, for fixed-level CPAP devices) or raising the upper limit of the pressure range (for APAP devices) may be tried before switching to an alternate mode such as BPAP.

As examples:

For patients on fixed-level CPAP with residual symptoms of snoring or daytime sleepiness on CPAP of <20 cm H2O, we sometimes empirically increase the fixed level of CPAP in increments of 2 cm H2O, up to 20 cm H2O. Alternatively, re-titration in an attended laboratory setting allows more accurate assessment of the response to higher than usual levels of CPAP. In general pressures above 20 cm H2O are ineffective and poorly tolerated. Failing this, re-titration with BPAP is indicated.

For patients on APAP devices with a residual apnea hypopnea indexflow (AHIFlow) derived from downloaded device-related data that is greater than 10 events per hour, a normal leak profile, and data to suggest that the patient frequently reaches the maximum of the APAP pressure range, we typically empirically increase the top of the pressure range by 2 cm H2O (eg, initial pressure range of 8 to 14 cm H2O would change to 8 to 16 cm H2O) and re-evaluate the patient's symptoms and adherence data in two to four weeks. Additional empiric changes can be made based on the response to the initial titration. For patients with persistent symptoms, an AHIFLow >10 events per hour, and/or high levels of leak despite empiric changes in pressure, an attended in-laboratory titration with CPAP or BPAP therapy is recommended with polysomnography (PSG) monitoring. (See "Titration of positive airway pressure therapy for adults with obstructive sleep apnea", section on 'In-laboratory fixed-level continuous positive airway pressure (CPAP)' and "Titration of positive airway pressure therapy for adults with obstructive sleep apnea", section on 'Bilevel positive airway pressure, spontaneous mode (BPAP-S)' and "Downloading data from positive airway pressure devices in adults".)

It should be kept in mind that increases in PAP settings could increase the risk of PAP intolerance, lead to excessive mask leak, and/or result in adverse outcomes such as inducing treatment-emergent central sleep apnea. (See "Downloading data from positive airway pressure devices in adults" and "Treatment-emergent central sleep apnea".)

Complex sleep-related breathing disorders — Complex sleep disorders other than OSA (central sleep apnea, hypoventilation syndromes) may be suspected or discovered during titration as contributing to sleep-related events, although auto-titrating devices are less accurate in detecting central-related apneas than polysomnography. When sleep disorders other than OSA are suspected or known, re-titration studies should be repeated in an attended in-laboratory setting, typically with CPAP unless a clear indication for BPAP is present (eg, patients with obesity hypoventilation who have previously failed CPAP, patients with hypoventilation syndromes). (See "Titration of positive airway pressure therapy for adults with obstructive sleep apnea", section on 'In-laboratory fixed-level continuous positive airway pressure (CPAP)' and "Titration of positive airway pressure therapy for adults with obstructive sleep apnea", section on 'Bilevel positive airway pressure, spontaneous mode (BPAP-S)'.)

Others — Some patients sleep poorly during the initial titration and require repeat titration when sleep quality is likely to be better; this, in some cases, may require in-home titration modalities.

Some patients may require supplemental oxygen during titration to eliminate nocturnal desaturation not explained by sleep-related events.

Re-titration — Once the suspected reason for failure of initial titration has been addressed, patients should undergo re-titration, most often with the same modality (ie, typically in-laboratory fixed-level CPAP or in-home APAP). Several attempts at re-titration may be necessary before resorting to BPAP. Although an attended in-laboratory APAP is technically feasible, it is only occasionally performed to assess APAP efficacy during follow-up.

Attended in-laboratory bilevel PAP (BPAP) — BPAP is typically a second-line therapy for patients with OSA. BPAP delivers PAP at different levels during inspiration (IPAP) and expiration (EPAP). An attended in-laboratory PSG-monitored assessment is necessary to assess efficacy of BPAP. Additional details regarding a recommended module for in-laboratory BPAP titration and what is considered an optimal response are provided separately. (See "Titration of positive airway pressure therapy for adults with obstructive sleep apnea", section on 'Bilevel positive airway pressure, spontaneous mode (BPAP-S)'.)

Following BPAP titration, patients should be followed up in a similar manner to that described above. For those who fail, options for an alternate mode may be limited, although auto-titrating BPAP may be attempted. (See 'Follow-up after initial titration' above and "Titration of positive airway pressure therapy for adults with obstructive sleep apnea".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Sleep-related breathing disorders in adults".)

SUMMARY AND RECOMMENDATIONS

Positive airway pressure (PAP) is the cornerstone of therapy for patients with obstructive sleep apnea (OSA). Patients in whom PAP therapy is indicated should undergo PAP titration to determine optimal settings. (See 'Introduction' above.)

For most patients with OSA, fixed-level continuous PAP (CPAP) is the first-line therapy but other modes including auto-titrating CPAP (APAP), and, rarely, bilevel PAP (BPAP) are options in select patients. PAP titration can take place in the sleep laboratory or at home. Several factors such as the presence of coexisting conditions that can affect sleep (table 1) as well as pragmatic issues regarding suitability and feasibility of in-home and in-laboratory titration strategies (eg, access to a laboratory, space constraints, transient homelessness, medical or cognitive dysfunction, patient preferences, and cost) influence the setting in which PAP titration occurs. (See 'Initial mode and setting options' above.)

In general, for initial mode selection for titration of PAP, we suggest the following:

For patients with uncomplicated moderate to severe OSA in whom a fixed-level of CPAP needs to be determined, titration can be performed with either an attended in-laboratory CPAP titration with a fixed level device or an unattended in-home titration using an APAP device. This approach is based upon randomized trials and meta-analyses of patients with uncomplicated moderate to severe OSA that show similar efficacy and adherence between in-laboratory CPAP and APAP titration strategies. For patients with uncomplicated mild OSA in whom PAP is selected as a therapy, we also suggest a similar approach, although APAP titration is as not well validated in this population. BPAP devices or prediction formulas are not typically used to titrate PAP in patients with uncomplicated OSA. (See 'Uncomplicated obstructive sleep apnea' above.)

For patients with complicated OSA (table 1), we suggest PAP titration in an attended sleep laboratory setting with polysomnography (PSG)-based monitoring rather than with an auto-titration device (Grade 2C). In most cases, we suggest that CPAP be the first modality tried; BPAP is used when specific comorbidities exist (eg, central apnea, hypoventilation). The rationale for this approach is based upon the limited ability of home devices to detect complex sleep disturbances that can occur in this population. (See 'Complicated OSA' above.)

After initial PAP titration, data from the polysomnogram (from in-laboratory reports) or from the device (from in-home auto-titrating devices) should be examined to assess the adequacy of titration (eg, any residual obstructive events). In addition, patients should be assessed and treated for residual symptoms and tolerance (eg, residual daytime sleepiness and/or snoring, the sensation of pressure, mask fit, nasal symptoms, sleepiness and snoring). (See 'Follow-up after initial titration' above and "Titration of positive airway pressure therapy for adults with obstructive sleep apnea".)  

For those who can tolerate PAP and achieve optimal pressures during titration, PAP therapy should be initiated with follow-up in one to eight weeks. For most patients with uncomplicated OSA, ongoing therapy is typically with CPAP or APAP. For patients with complicated OSA, CPAP is the first-choice rather than APAP or BPAP. BPAP is generally reserved for those who cannot tolerate or fail CPAP. In all cases, close clinical assessment and examination of data downloaded from devices allows for further optimization or changes in the mode or setting. Switching to a different mode of PAP therapy necessitates re-titrating according to that mode. (See 'Patients with optimal titration' above.)

For patients who are intolerant of a given level of CPAP, have residual symptoms of excessive daytime sleepiness or snoring, and/or have residual obstructive events observed on CPAP therapy at a pressure of ≥15 cm H2O, we typically assess patients for potential etiologies that explain these phenomena. Once addressed, patients should undergo re-titration, most often with the same modality. Should patients fail this strategy, we suggest that BPAP titration (usually in the spontaneous mode) be administered in an attended in-laboratory PSG-monitored setting. (See 'Patients with suboptimal titration' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Won Lee, MD and Lee Brown, MD, who contributed to an earlier version of this topic review.

  1. Berthon-Jones M. Feasibility of a self-setting CPAP machine. Sleep 1993; 16:S120.
  2. Rigau J, Montserrat JM, Wöhrle H, et al. Bench model to simulate upper airway obstruction for analyzing automatic continuous positive airway pressure devices. Chest 2006; 130:350.
  3. Patil SP, Ayappa IA, Caples SM, et al. Treatment of Adult Obstructive Sleep Apnea with Positive Airway Pressure: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med 2019; 15:335.
  4. Patil SP, Ayappa IA, Caples SM, et al. Treatment of Adult Obstructive Sleep Apnea With Positive Airway Pressure: An American Academy of Sleep Medicine Systematic Review, Meta-Analysis, and GRADE Assessment. J Clin Sleep Med 2019; 15:301.
  5. Planès C, D'Ortho MP, Foucher A, et al. Efficacy and cost of home-initiated auto-nCPAP versus conventional nCPAP. Sleep 2003; 26:156.
  6. Hukins C. Comparative study of autotitrating and fixed-pressure CPAP in the home: a randomized, single-blind crossover trial. Sleep 2004; 27:1512.
  7. Masa JF, Jiménez A, Durán J, et al. Alternative methods of titrating continuous positive airway pressure: a large multicenter study. Am J Respir Crit Care Med 2004; 170:1218.
  8. Vennelle M, White S, Riha RL, et al. Randomized controlled trial of variable-pressure versus fixed-pressure continuous positive airway pressure (CPAP) treatment for patients with obstructive sleep apnea/hypopnea syndrome (OSAHS). Sleep 2010; 33:267.
  9. Pépin JL, Tamisier R, Baguet JP, et al. Fixed-pressure CPAP versus auto-adjusting CPAP: comparison of efficacy on blood pressure in obstructive sleep apnoea, a randomised clinical trial. Thorax 2016; 71:726.
  10. Cross MD, Vennelle M, Engleman HM, et al. Comparison of CPAP titration at home or the sleep laboratory in the sleep apnea hypopnea syndrome. Sleep 2006; 29:1451.
  11. Corral J, Sánchez-Quiroga MÁ, Carmona-Bernal C, et al. Conventional Polysomnography Is Not Necessary for the Management of Most Patients with Suspected Obstructive Sleep Apnea. Noninferiority, Randomized Controlled Trial. Am J Respir Crit Care Med 2017; 196:1181.
  12. Ayas NT, Patel SR, Malhotra A, et al. Auto-titrating versus standard continuous positive airway pressure for the treatment of obstructive sleep apnea: results of a meta-analysis. Sleep 2004; 27:249.
  13. Smith I, Lasserson TJ. Pressure modification for improving usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea. Cochrane Database Syst Rev 2009; :CD003531.
  14. Xu T, Li T, Wei D, et al. Effect of automatic versus fixed continuous positive airway pressure for the treatment of obstructive sleep apnea: an up-to-date meta-analysis. Sleep Breath 2012; 16:1017.
  15. Ip S, D'Ambrosio C, Patel K, et al. Auto-titrating versus fixed continuous positive airway pressure for the treatment of obstructive sleep apnea: a systematic review with meta-analyses. Syst Rev 2012; 1:20.
  16. Antic NA, Buchan C, Esterman A, et al. A randomized controlled trial of nurse-led care for symptomatic moderate-severe obstructive sleep apnea. Am J Respir Crit Care Med 2009; 179:501.
  17. Skomro RP, Gjevre J, Reid J, et al. Outcomes of home-based diagnosis and treatment of obstructive sleep apnea. Chest 2010; 138:257.
  18. Berry RB, Sriram P. Auto-adjusting positive airway pressure treatment for sleep apnea diagnosed by home sleep testing. J Clin Sleep Med 2014; 10:1269.
  19. Su CS, Liu KT, Panjapornpon K, et al. Functional outcomes in patients with REM-related obstructive sleep apnea treated with positive airway pressure therapy. J Clin Sleep Med 2012; 8:243.
  20. Lettieri CJ, Quast TN, Eliasson AH, Andrada T. Eszopiclone improves overnight polysomnography and continuous positive airway pressure titration: a prospective, randomized, placebo-controlled trial. Sleep 2008; 31:1310.
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