Initiation of positive airway pressure therapy for obstructive sleep apnea in adults
- Lee K Brown, MD
Lee K Brown, MD
- Professor of Internal Medicine and Pediatrics
- University of New Mexico School of Medicine
- Won Lee, MD
Won Lee, MD
- Associate Professor, Division of Pulmonary and Critical Care Medicine
- Medical Director, Sleep and Breathing Disorders Center
- University of Texas Southwestern Medical Center
Obstructive sleep apnea (OSA) is a disorder characterized by apneas and hypopneas due to repetitive collapse of the upper airway during sleep. Potential consequences of OSA include excessive daytime sleepiness, impaired daytime function, exacerbation of metabolic abnormalities (eg, impaired glucose tolerance, insulin resistance, type 2 diabetes mellitus, dyslipidemia), and an increased risk of cardiovascular disease, chronic kidney disease, and mortality. Several of these conditions appear to have a bidirectional risk association with OSA, including type 2 diabetes mellitus, chronic kidney disease, and left ventricular heart failure. (See "Overview of obstructive sleep apnea in adults", section on 'Complications and adverse outcomes'.)
Once a patient has been diagnosed with OSA, it should be determined whether treatment is indicated and, if so, which type of therapy is most appropriate. For the majority of patients, positive airway pressure (PAP) therapy is first-line therapy . The initiation of PAP therapy requires selection of a mode of PAP, device setting(s), and a patient-device interface.
The initiation of PAP therapy in patients with OSA is reviewed here. The diagnosis and management of OSA more generally are discussed separately. (See "Clinical presentation and diagnosis of obstructive sleep apnea in adults" and "Home sleep apnea testing for obstructive sleep apnea in adults" and "Management of obstructive sleep apnea in adults".)
MODES OF POSITIVE AIRWAY PRESSURE
There are two major positive airway pressure (PAP) modalities used to treat patients with OSA: continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BPAP) . CPAP is generally preferred for most patients because it has been well studied, is simpler to use, and is less costly. Each of these modalities requires choosing between fixed or auto-titrating technology.
Selecting the mode — Fixed CPAP is suggested as first-line treatment for most patients with OSA because its efficacy is well established and supported by extensive clinical experience . With the advent of home sleep apnea testing (HSAT), auto-titrating CPAP is becoming more commonplace, and studies suggest that it has comparable efficacy and adherence compared with fixed CPAP, although auto-titrating flow generators can be more expensive. (See 'Choosing between fixed and auto-titrating CPAP' below.)
- Epstein LJ, Kristo D, Strollo PJ Jr, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med 2009; 5:263.
- Ballard RD, Gay PC, Strollo PJ. Interventions to improve compliance in sleep apnea patients previously non-compliant with continuous positive airway pressure. J Clin Sleep Med 2007; 3:706.
- Pépin JL, Muir JF, Gentina T, et al. Pressure reduction during exhalation in sleep apnea patients treated by continuous positive airway pressure. Chest 2009; 136:490.
- Nilius G, Happel A, Domanski U, Ruhle KH. Pressure-relief continuous positive airway pressure vs constant continuous positive airway pressure: a comparison of efficacy and compliance. Chest 2006; 130:1018.
- Berthon-Jones M, Lawrence S, Sullivan CE, Grunstein R. Nasal continuous positive airway pressure treatment: current realities and future. Sleep 1996; 19:S131.
- Behbehani K, Yen FC, Burk JR, et al. Automatic control of airway pressure for treatment of obstructive sleep apnea. IEEE Trans Biomed Eng 1995; 42:1007.
- Berthon-Jones M. Feasibility of a self-setting CPAP machine. Sleep 1993; 16:S120.
- 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.
- Schwab RJ, Badr SM, Epstein LJ, et al. An official American Thoracic Society statement: continuous positive airway pressure adherence tracking systems. The optimal monitoring strategies and outcome measures in adults. Am J Respir Crit Care Med 2013; 188:613.
- 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.
- 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.
- 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.
- 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.
- 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.
- Morgenthaler TI, Aurora RN, Brown T, et al. Practice parameters for the use of autotitrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome: an update for 2007. An American Academy of Sleep Medicine report. Sleep 2008; 31:141.
- 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.
- Powell ED, Gay PC, Ojile JM, et al. A pilot study assessing adherence to auto-bilevel following a poor initial encounter with CPAP. J Clin Sleep Med 2012; 8:43.
- Gulati A, Oscroft N, Chadwick R, et al. The impact of changing people with sleep apnea using CPAP less than 4 h per night to a Bi-level device. Respir Med 2015; 109:778.
- Kushida CA, Chediak A, Berry RB, et al. Clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea. J Clin Sleep Med 2008; 4:157.
- Hirshkowitz M, Sharafkhaneh A. Positive airway pressure therapy of OSA. Semin Respir Crit Care Med 2005; 26:68.
- Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med 2017; 13:479.
- Kushida CA, Littner MR, Morgenthaler T, et al. Practice parameters for the indications for polysomnography and related procedures: an update for 2005. Sleep 2005; 28:499.
- Indications and standards for use of nasal continuous positive airway pressure (CPAP) in sleep apnea syndromes. American Thoracic Society. Official statement adopted March 1944. Am J Respir Crit Care Med 1994; 150:1738.
- Strollo PJ Jr, Sanders MH, Costantino JP, et al. Split-night studies for the diagnosis and treatment of sleep-disordered breathing. Sleep 1996; 19:S255.
- Sanders MH, Kern NB, Costantino JP, et al. Adequacy of prescribing positive airway pressure therapy by mask for sleep apnea on the basis of a partial-night trial. Am Rev Respir Dis 1993; 147:1169.
- Berry RB, Kushida CA, Kryger MH, et al. Respiratory event detection by a positive airway pressure device. Sleep 2012; 35:361.
- Berry RB, Budhiraja R, Gottlieb DJ, et al. Rules for scoring respiratory events in sleep: update of the 2007 AASM Manual for the Scoring of Sleep and Associated Events. Deliberations of the Sleep Apnea Definitions Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med 2012; 8:597.
- 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.
- 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.
- 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.
- Skomro RP, Gjevre J, Reid J, et al. Outcomes of home-based diagnosis and treatment of obstructive sleep apnea. Chest 2010; 138:257.
- Ng JR, Aiyappan V, Mercer J, et al. Choosing an Oronasal Mask to Deliver Continuous Positive Airway Pressure May Cause More Upper Airway Obstruction or Lead to Higher Continuous Positive Airway Pressure Requirements than a Nasal Mask in Some Patients: A Case Series. J Clin Sleep Med 2016; 12:1227.
- Deshpande S, Joosten S, Turton A, et al. Oronasal Masks Require a Higher Pressure than Nasal and Nasal Pillow Masks for the Treatment of Obstructive Sleep Apnea. J Clin Sleep Med 2016; 12:1263.
- Edinger JD, Radtke RA. Use of in vivo desensitization to treat a patient's claustrophobic response to nasal CPAP. Sleep 1993; 16:678.
- Strollo PJ, Sanders MH, Stiller RA. Continuous and bi-level positive airway pressure therapy in sleep-disordered breathing. Atlas Oral and Maxillofac Surg Clin North Am 1995; 7:221.
- Prosise GL, Berry RB. Oral-nasal continuous positive airway pressure as a treatment for obstructive sleep apnea. Chest 1994; 106:180.
- Sanders MH, Kern NB, Stiller RA, et al. CPAP therapy via oronasal mask for obstructive sleep apnea. Chest 1994; 106:774.
- Mortimore IL, Whittle AT, Douglas NJ. Comparison of nose and face mask CPAP therapy for sleep apnoea. Thorax 1998; 53:290.
- Bakker JP, Marshall NS. Flexible pressure delivery modification of continuous positive airway pressure for obstructive sleep apnea does not improve compliance with therapy: systematic review and meta-analysis. Chest 2011; 139:1322.
- Kushida CA, Berry RB, Blau A, et al. Positive airway pressure initiation: a randomized controlled trial to assess the impact of therapy mode and titration process on efficacy, adherence, and outcomes. Sleep 2011; 34:1083.
- Chervin RD, Theut S, Bassetti C, Aldrich MS. Compliance with nasal CPAP can be improved by simple interventions. Sleep 1997; 20:284.
- Collard P, Pieters T, Aubert G, et al. Compliance with nasal CPAP in obstructive sleep apnea patients. Sleep Med Rev 1997; 1:33.
- Hayes MJ, McGregor FB, Roberts DN, et al. Continuous nasal positive airway pressure with a mouth leak: effect on nasal mucosal blood flux and nasal geometry. Thorax 1995; 50:1179.
- Richards GN, Cistulli PA, Ungar RG, et al. Mouth leak with nasal continuous positive airway pressure increases nasal airway resistance. Am J Respir Crit Care Med 1996; 154:182.
- Wiest GH, Harsch IA, Fuchs FS, et al. Initiation of CPAP therapy for OSA: does prophylactic humidification during CPAP pressure titration improve initial patient acceptance and comfort? Respiration 2002; 69:406.
- Mador MJ, Krauza M, Pervez A, et al. Effect of heated humidification on compliance and quality of life in patients with sleep apnea using nasal continuous positive airway pressure. Chest 2005; 128:2151.
- Rakotonanahary D, Pelletier-Fleury N, Gagnadoux F, Fleury B. Predictive factors for the need for additional humidification during nasal continuous positive airway pressure therapy. Chest 2001; 119:460.
- Pressman MR, Peterson DD, Meyer TJ, et al. Ramp abuse. A novel form of patient noncompliance to administration of nasal continuous positive airway pressure for treatment of obstructive sleep apnea. Am J Respir Crit Care Med 1995; 151:1632.
- Fromm RE Jr, Varon J, Lechin AE, Hirshkowitz M. CPAP machine performance and altitude. Chest 1995; 108:1577.
- MODES OF POSITIVE AIRWAY PRESSURE
- Selecting the mode
- Continuous positive airway pressure (CPAP)
- - Fixed CPAP
- - Auto-titrating CPAP
- - Choosing between fixed and auto-titrating CPAP
- Bilevel positive airway pressure (BPAP)
- DETERMINING THE AMOUNT OF POSITIVE AIRWAY PRESSURE
- Selecting the pressure settings
- - Fixed CPAP
- - Auto-titrating CPAP
- - BPAP
- Titration modality
- - Full-night studies
- - Split-night studies
- - In-home titration
- PATIENT-DEVICE INTERFACE
- ACCESSORY FEATURES
- Pressure relief
- Pressure ramp
- Altitude compensation
- EARLY PATIENT EXPERIENCE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS