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Mode selection for positive airway pressure titration in adults with obstructive sleep apnea
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Mode selection for positive airway pressure titration in adults with obstructive sleep apnea
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2016. | This topic last updated: Jul 27, 2016.

INTRODUCTION — Positive airway pressure (PAP) is the primary therapy for many patients with obstructive sleep apnea (OSA). Determining the optimal pressure settings for PAP in patients with OSA is of paramount importance to help assure patient adherence to therapy and improve important outcomes. However, in the era of multiple available PAP technologies, the clinician should be aware of the methods of titration relevant to each mode of PAP.

Selecting a titration method to determine the optimal pressure in patients with OSA is discussed in this topic. Detailed discussion of the indications for PAP, the available modes of PAP, titration modules for each mode, and issues that affect adherence to PAP therapy are discussed separately. (See "Management of obstructive sleep apnea in adults", section on 'Indications for treatment' and "Initiation of positive airway pressure therapy for obstructive sleep apnea in adults" and "Adherence with continuous positive airway pressure (CPAP)".)

INDICATIONS FOR POSITIVE AIRWAY PRESSURE (PAP) TITRATION — Devices used to determine the optimal settings for PAP may be the same as or different than those indicated for therapy. Methods include attended in-laboratory polysomnogram (PSG)-based continuous PAP (CPAP) and bilevel PAP (BPAP) titration, and auto-titrating PAP (APAP, auto-BPAP), which can be used in unattended settings and, less commonly, attended settings. Detailed discussion regarding the indications for PAP therapy in patients with OSA is provided separately (algorithm 1). (See "Management of obstructive sleep apnea in adults", section on 'Indications for treatment'.)

OUR APPROACH — Ideally, patients in whom positive airway pressure (PAP) is indicated as a therapy should have their PAP device titrated to determine the optimal settings, since the amount of pressure needed varies among individuals. The optimal method for PAP titration in patients with obstructive sleep apnea (OSA) is unknown with no data demonstrating superior outcomes using one titration method compared with another. While an attended in-laboratory PAP titration is the traditional standard and preferred method of determining an effective continuous PAP (CPAP) setting by many clinicians, some insurers in the United States require that patients receive auto-titrating PAP (APAP) without formal in-laboratory PAP titration. Factors that influence this choice include the following:

OSA-related factors – The type of OSA is a major factor that determines what method is chosen for PAP titration. (See 'Uncomplicated obstructive sleep apnea (OSA)' below and 'Uncomplicated OSA with persistent or new symptoms' below and 'Patients with complicated OSA' below.)

Non OSA-related factors – Other factors that influence the decision include the device used for diagnostic testing, the presence or absence of complicating medical conditions, and the values and preferences of the patient (eg, access to a sleep laboratory), the practices of the institution, the preference of the payer in appropriate patients, as well as previous response to PAP therapy (if known).

The approach described below is consistent with the published literature, our practice, and, where appropriate, the American Academy of Sleep Medicine (AASM) practice guidelines for sleep-disordered breathing [1-3]. (See 'Titration to determine initial settings' below and 'Uncomplicated OSA with persistent or new symptoms' below and 'Assessing adequacy of PAP settings' below and 'Follow-up' below.)

Most recommended approaches are based upon data that are derived from patients with moderate to severe OSA (eg, respiratory events ≥15 per hour), a population in whom PAP therapy is of known benefit. However, since patients with mild OSA (eg, respiratory events between 5 and 14 per hour) who have symptoms are also frequently offered PAP therapy, a similar approach is appropriate in that population. (See "Clinical presentation and diagnosis of obstructive sleep apnea in adults", section on 'Disease spectrum'.)

Uncomplicated obstructive sleep apnea (OSA) — Uncomplicated OSA is defined as OSA that is not associated with chronic lung diseases such as chronic obstructive pulmonary disease and interstitial lung disease, heart failure, or hypoventilation syndromes. Complicated OSA refers to the presence of medical conditions that could potentially affect respiration and create additional respiratory abnormalities over and above OSA. The definition of mild, moderate, and severe OSA is discussed separately. (See "Clinical presentation and diagnosis of obstructive sleep apnea in adults", section on 'Disease spectrum'.)

The optimal mode of PAP titration in uncomplicated OSA is unknown. 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 or adherence between in-laboratory continuous PAP (CPAP) and in-home auto-titrating PAP (APAP) titration strategies [4-8]. This has led to changes in third party payer policies and different practices by experts [9,10]. In-laboratory PAP titration has received the most study, and many experts, including contributors of this topic, utilize it as the ideal first-line mode of PAP titration. However, efficacy data also suggest that a trial of in-home auto-titrating CPAP (APAP) may be suitable for this population such that other experts, including contributors of this topic, utilize APAP as an initial strategy provided no contraindications exist and the threshold to perform an in-laboratory study is low when APAP is suspected to be inadequate. Factors that affect this choice are discussed below. (See 'Choosing in-laboratory CPAP titration or in-home APAP titration' below.)

Strategies for PAP titration in patients with uncomplicated OSA to determine initial settings for fixed level CPAP and PAP titration for patients with uncomplicated OSA who have persistent or new symptoms following CPAP therapy are discussed in the sections below. (See 'Titration to determine initial settings' below and 'Uncomplicated OSA with persistent or new symptoms' below.)

Titration to determine initial settings — To determine a fixed level of 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 device be used. Choosing among these options is discussed below. (See 'Attended in-laboratory CPAP titration' below and 'Unattended auto-titrating CPAP (APAP)' below and 'Choosing in-laboratory CPAP titration or in-home APAP titration' below.)

Bilevel PAP devices are not typically used as the initial approach to the titration of PAP in patients with uncomplicated OSA. These devices are used to treat OSA patients who fail CPAP, have more complicated sleep-disordered breathing, or have central sleep apnea and/or hypoventilation syndromes. (See 'Uncomplicated OSA with persistent or new symptoms' below and 'Patients with complicated OSA' 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. These approaches, if utilized, are typically reserved for experts who manage patients with uncomplicated OSA. (See 'Prediction formulas and empiric titration' below.)

Attended in-laboratory CPAP titration — Fixed level CPAP delivers PAP at a level that remains relatively constant throughout the respiratory cycle.

Titration module – An attended in-laboratory CPAP titration involves a graduated increase in CPAP in a polysomnographic (PSG)-monitored setting. Titration by an attending sleep technologist occurs in the sleep laboratory, thereby requiring an overnight stay. Details regarding a recommended module for in-laboratory CPAP titration and what is considered an optimal response are provided separately. (See "Initiation of positive airway pressure therapy for obstructive sleep apnea in adults", section on 'Fixed CPAP' and "Initiation of positive airway pressure therapy for obstructive sleep apnea in adults", section on 'Titration modality' and 'Assessing adequacy of PAP settings' below.)

Full- versus split-night protocol – A full night of attended in-laboratory CPAP titration is ideal because it provides the most time for the patient to cycle through all sleep stages, although no trials have shown superiority of one over the other. However, a split-night study may be performed in patients with severe OSA during the initial portion of an attended baseline sleep study, provided there is adequate time (minimum of three hours) to perform a proper PAP titration. Additional details regarding split-night studies are provided separately. (See "Initiation of positive airway pressure therapy for obstructive sleep apnea in adults", section on 'Split-night studies'.)

Accessory features – Humidification and expiratory pressure relief are adjunctive comfort measures that can be added to the PAP devices during an attended in-laboratory PAP titration, for the purpose of comfort and symptom relief. Further details on these accessory features including pressure relief, humidification, pressure ramp, and altitude compensation are provided separately. (See "Initiation of positive airway pressure therapy for obstructive sleep apnea in adults", section on 'Accessory features'.)

While an attended in-laboratory CPAP titration is traditionally considered the gold standard for PAP titration, randomized trials have shown that many patients with uncomplicated moderate to severe OSA may be reasonable candidates for in-home auto-titration CPAP therapy. In addition, for patients who cannot access a sleep laboratory, alternate PAP titration modules should be considered. (See 'Unattended auto-titrating CPAP (APAP)' below.)

Unattended auto-titrating CPAP (APAP) — Auto-titrating CPAP (APAP) delivers an amount of PAP that varies during sleep. Auto-titrating positive airway pressure devices utilize proprietary algorithms to resolve obstructive sleep-disordered breathing as detected by the device. They can be used to determine a fixed CPAP setting for patients with uncomplicated OSA, which is discussed in this section [11-15]. However, they can also be used to treat OSA, which is reviewed separately. (See "Initiation of positive airway pressure therapy for obstructive sleep apnea in adults", section on 'Auto-titrating CPAP'.)

Titration module – A fixed level of CPAP can be determined by utilizing device-derived data. However, the optimal method for unattended APAP titration is not clear as many studies have used different approaches to determine a fixed CPAP setting. Variations in APAP titration protocols include different durations of time (eg, 3 to 14 days) using the APAP to determine an optimal pressure, different APAP ranges, and different definitions of trial success. We typically perform 7 to 14 days of APAP titration to determine a starting fixed CPAP pressure. However, in the absence of consensus, shorter or longer periods can also be tried. There is also no consensus on the appropriate initial APAP range, which typically varies from 5 to 20 cm H2O; the range can be further adjusted based on the presence or absence of symptoms and on data calculated from the device. The optimal fixed CPAP setting is typically the level of pressure at or below which obstructive events measured by the APAP device are eliminated for more than 90 or 95 percent of the time ("P90 and P95 pressure") [11,13,16]. However, the P90 and P95 can be affected by several factors including nightly adherence to therapy, pressure range settings, and extent of mask leak. Thus, in clinical practice, the P90 and P95 are typically starting points to determining a fixed CPAP setting with empiric adjustments in CPAP settings being required over time [11,13]. (See 'Assessing adequacy of PAP settings' below.)

Unattended versus attended – APAP devices are more commonly used in an in-home unattended setting (ie, without polysomnographic monitoring), since their main advantage is that they eliminate the need for an overnight stay in a sleep laboratory. Although an attended in-laboratory auto-titration of CPAP is technically feasible, it is only occasionally performed to determine initial settings, or to assess efficacy of auto-titrating CPAP for a given patient. Split-night studies are not practical for unattended in-home settings with auto-titrating devices, as these devices have not been validated for the diagnosis and management of OSA in most patients.

Choosing in-laboratory CPAP titration or in-home APAP titration — 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 or adherence between in-laboratory and in-home APAP titration strategies [4-8].

Choosing among these two options in patients with uncomplicated OSA varies among sleep clinicians and sleep institutions and is dependent upon a number of factors including medical and practical issues that influence success of the chosen titration and/or costs associated with a third party payer. While in-laboratory CPAP titration is ideal, many patients with uncomplicated moderate to severe OSA can be considered for an initial trial of APAP titration. Patients with uncomplicated OSA who may be considered for APAP titration include those in whom access to a sleep laboratory is delayed or not feasible, patients prescribed APAP as a therapy (eg, those with risk factors that may vary pressure requirements including fluctuations in weight and use of alcohol), and those in whom cost is prohibitive. In contrast, patients with uncomplicated OSA in whom in-laboratory CPAP titration is the titration mode of choice include those who fail an in-home APAP titration, those 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. For some patients with severe OSA who have severe nocturnal desaturations and have undergone APAP follow up oximetry is appropriate to ensure that desaturations have been adequately treated. Importantly, for patients with complicated OSA (eg, OSA with co-existent COPD, CHF), in-laboratory CPAP titration should be performed. Detailed discussion of the data that support the use of both of these strategies to titrate CPAP in this population and titration in patients with complicated OSA are discussed separately. (See "Initiation of positive airway pressure therapy for obstructive sleep apnea in adults", section on 'Continuous positive airway pressure (CPAP)' and 'Patients with complicated OSA' below.)

Uncomplicated OSA with persistent or new symptoms

Clinical evaluation — Patients with persistent or new symptoms despite CPAP should be evaluated for explanations including poor adherence, intolerance of pressure, oronasal side effects, and mask leak. For patients with a combination of persistent snoring, an elevated PAP calculated AHI and absence of excessive mask leak, some clinicians at this point may empirically increase the CPAP settings in an attempt to resolve snoring and daytime symptoms as long as the patient has close follow-up. Detailed discussion of this evaluation is provided separately. (See "Initiation of positive airway pressure therapy for obstructive sleep apnea in adults", section on 'Patient-device interface' and "Initiation of positive airway pressure therapy for obstructive sleep apnea in adults", section on 'Early patient experience'.)

Once these issues have been thoroughly addressed, AASM guidelines suggest that bilevel positive airway pressure (BPAP) therapy (usually in the spontaneous mode) be administered in patients with uncomplicated OSA who are intolerant of a given level of CPAP and/or if residual obstructive events or snoring are observed on CPAP therapy at a pressure of ≥15 cm H2O [1]. Once the decision is made to initiate BPAP, the patient must undergo in-laboratory titration with a BPAP device.

Attended in-laboratory bilevel PAP (BPAP) — BPAP delivers PAP at different levels during inspiration (IPAP) and expiration (EPAP). An attended in-laboratory assessment involves a graduated increase in IPAP and EPAP in a polysomnographic (PSG)-monitored setting with the goal of achieving an optimal response. Additional details regarding a recommended module for in-laboratory BPAP titration and what is considered an optimal response are provided separately. (See "Initiation of positive airway pressure therapy for obstructive sleep apnea in adults", section on 'BPAP' and 'Attended in-laboratory assessment' below and 'Clinical assessment' below.)

While a full-night attended in-laboratory BPAP titration is preferred, split-night titration studies may also be feasible in the same select group discussed above, although this is rarely performed [1]. (See 'Attended in-laboratory CPAP titration' above.)

Other — In patients with OSA who have persistent or new symptoms despite CPAP, alternatives to an attended in-laboratory PAP titration may include the following:

APAP – Some patients may benefit from APAP as a pressure-relief strategy, details of which are discussed separately. (See "Initiation of positive airway pressure therapy for obstructive sleep apnea in adults", section on 'Auto-titrating CPAP'.)

Auto-titrating BPAP – The optimal approach and empiric initial settings for auto-titrating BPAP devices are unclear, as there is a paucity of data or validated modules to help guide clinicians with these devices. One reported approach was to arbitrarily set the minimal EPAP at 4 cm H2O, maximal pressure support at 8 cm H2O, and maximal inspiratory pressure at 25 cm H2O on an auto-titrating BPAP device, allowing the device's proprietary algorithms to titrate the pressures to resolve obstructive events [17]. As noted previously, there is no typical or widely accepted approach to this method of PAP treatment, thus close follow-up is necessary to make sure that patients are adequately treated with this approach. There should be a low threshold to send patients to the sleep laboratory for an attended titration if it is not clear that the patient is receiving adequate therapy.

Patients with complicated OSA — "Complicated OSA" as used here refers to patients with OSA who have comorbid diseases such as heart failure, chronic obstructive pulmonary disease, or hypoventilation syndromes, or patients with mixed central and obstructive sleep apnea syndromes (eg, patients with OSA on chronic opioids or who have neuromuscular disease). In this population, regardless of whether CPAP or BPAP is indicated, PAP titration should be performed in an attended sleep laboratory setting with PSG monitoring. Other approaches using auto-titration devices, prediction formulas, or empiric adjustment are not suitable for this population. Choosing between CPAP and BPAP depends on the underlying sleep disorder and is discussed separately. (See 'Attended in-laboratory CPAP titration' above and 'Attended in-laboratory bilevel PAP (BPAP)' above and "Initiation of positive airway pressure therapy for obstructive sleep apnea in adults", section on 'Selecting the mode' and "Mode selection for positive airway pressure titration in adult patients with central sleep apnea syndromes" and "Polysomnography in the evaluation of sleep-disordered breathing in adults".)

TITRATION METHODS — Both continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BPAP) can be titrated in an in-laboratory (attended) and in-home (unattended) setting, which is discussed in this section. Our approach to mode selection is discussed above. (See 'Our approach' above.)

Attended modalities — The major difference between attended and unattended modalities is that attended modalities utilize polysomnography (PSG) to monitor the response to PAP, the advantages of which are discussed separately (see "Overview of polysomnography in adults"). Thus, titration with devices that deliver a fixed level of CPAP and BPAP are best suited to this setting. While auto-titrating devices can technically be used in an attended setting, they are more commonly used in an in-home setting, since they collect useful data that can be used to determine the response to positive airway pressure (PAP). PAP titration in the sleep laboratory may be performed on a separate night, following a diagnostic test for OSA, but it can also be performed during the same night the diagnostic test takes place (eg, split-night protocol). Such protocols are not feasible at home. The indications and specific modules for in-laboratory CPAP and BPAP titration are discussed separately in the following sections:

In-laboratory CPAP titration (see 'Our approach' above and 'Attended in-laboratory CPAP titration' above and "Initiation of positive airway pressure therapy for obstructive sleep apnea in adults", section on 'Fixed CPAP')

In-laboratory BPAP titration (see 'Our approach' above and 'Attended in-laboratory CPAP titration' above and 'Attended in-laboratory bilevel PAP (BPAP)' above and "Initiation of positive airway pressure therapy for obstructive sleep apnea in adults", section on 'BPAP')

Unattended modalities (auto-titration devices) — Auto-titrating devices utilize proprietary algorithms to resolve obstructive sleep-disordered breathing events as detected by the device. Although auto-titration CPAP and BPAP devices can be used in attended and unattended settings, they are mostly used in an unattended setting for in-home titration where the data collected from the device are used to determine optimal PAP settings. The indications and specific module for auto-titrating PAP (APAP) are discussed separately:

Auto-CPAP (see 'Our approach' above and 'Attended in-laboratory CPAP titration' above and "Initiation of positive airway pressure therapy for obstructive sleep apnea in adults", section on 'Fixed CPAP')

Auto-BPAP (see 'Other' above)

Prediction formulas and empiric titration — In general, most clinicians do not use prediction formulas or empiric titration strategies to initiate PAP therapy since they are less well validated than attended in-laboratory or auto-titrating modalities [4,6,11-13,18-20]. However, prediction formula titration may be appropriate in patients who cannot afford or do not have access to an APAP device. Importantly, although such approaches have been shown to have some success in patients with uncomplicated moderate to severe obstructive sleep apnea (OSA), they are not recommended for patients with complicated OSA. In addition, these methods typically offer only a starting pressure for initiating CPAP, and many patients require pressure adjustments based upon symptoms.

While many experts perform repeat re-titration in patients who need adjustments to their PAP, some experts empirically adjust CPAP and BPAP pressures in patients with uncomplicated OSA and residual or new symptoms (snoring or daytime sleepiness). For patients with residual symptoms or new symptoms (snoring or daytime sleepiness) who have an elevated device-calculated apnea-hypopnea index (AHIFlow [21]) and for those who are frequently achieving the set PAP maximum pressure on APAP in absence of excessive mask leak, some experts will empirically increase the CPAP, maximal APAP, or BPAP pressures. Although not well studied, one approach is to empirically increase the CPAP, maximal APAP, or BPAP settings by 2 cm H2O and re-evaluate the patient's symptoms and PAP adherence data in two to four weeks. Additional empiric changes can be made based on the response to the initial titration. However, it should be kept in mind that empiric increases to 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.

Prediction formulas – Several clinical prediction formulas have been developed that typically take into account factors including body mass index (BMI), AHI, oxygen saturation, and/or neck circumference [11,18,19,22].

Small randomized studies have reported that in patients with uncomplicated OSA, a fixed CPAP setting can be determined by a clinical prediction formula using an auto-titrating CPAP device in an unattended home setting [6,19]. However, compared with CPAP settings determined by an attended in-laboratory PSG-based titration, prediction formulas frequently under- or overestimate the optimal initial CPAP pressure required to eliminate obstructive events. Thus, the initial PAP pressure frequently requires some adjustment based upon symptoms (snoring, daytime sleepiness) and PAP adherence data derived from the device.

Self-adjustment – Small randomized studies also report that in a similar population, CPAP therapy may be initiated in an unattended home setting using a self-adjustment titration system targeted at resolving snoring and daytime symptoms [6,18].

The use of home sleep apnea testing (HSAT) is not recommended for the titration of CPAP or other PAP therapies as there are few data evaluating the reliability of HSAT devices for this indication. (See "Home sleep apnea testing for obstructive sleep apnea in adults".)

ASSESSING ADEQUACY OF PAP SETTINGS — The goal of positive airway pressure (PAP) titration is to determine the minimal pressure required to resolve all apneas, hypopneas, snoring, and arousals related to these events, in all stages of sleep and in all sleep positions. Although this is best assessed in an attended in-laboratory setting with polysomnographic (PSG) monitoring, not all patients have PAP initiated in the sleep laboratory (eg, patients titrated with home auto-titrating devices). Thus, in practice, the ability to evaluate the response and the tool(s) used to evaluate it depend upon the modality used for initial titration. (See 'Attended in-laboratory assessment' below and 'Auto-titrating device assessment' below and 'Clinical assessment' below.)

When this goal is met, no further titration is necessary and patients should be started on therapy.

When this goal is not met, we typically perform or repeat an attended in-laboratory PAP titration, most often beginning with the same device.

Once patients are started on PAP therapy, the response should be assessed clinically, typically for the first time in one to eight weeks. (See 'Clinical assessment' below and 'Follow-up' below.)

Attended in-laboratory assessment — For patients who undergo an in-laboratory PSG assessment, PAP titration adequacy is defined by American Academy of Sleep Medicine (AASM) as the following [1]:

Optimal – Reduces the respiratory disturbance index (RDI) <5 for at least 15 minutes; supine rapid eye movement (REM) sleep should not be interrupted by spontaneous arousals or awakenings.

Good – Reduces the RDI ≤10 or by 50 percent if the baseline RDI <15; supine REM sleep should not be interrupted by spontaneous arousals or awakenings.

Adequate – Does not reduce the RDI ≤10 but reduces the RDI by 75 percent from baseline (especially in severe OSA patients), or one in which the titration grading criteria for optimal or good are met with the exception that supine REM sleep did not occur at the selected pressure.

Inadequate – A titration that does not meet any one of the previous grading criteria.

For patients who achieve an adequacy level that is less than good, we typically repeat an attended in-laboratory titration, following an assessment for potential explanations for the poor response (eg, mask leak, oronasal issues, intolerant of pressure). (See "Adherence with continuous positive airway pressure (CPAP)".)

Limited data suggest that many patents do not achieve optimal settings. Post hoc analyses from randomized studies that tested the efficacy of continuous PAP (CPAP) in obstructive sleep apnea (OSA) estimate that only 50 to 60 percent of patients achieve an optimal setting, and 30 to 40 percent achieve an adequate or inadequate setting [23,24]. The reasons for this are unclear but may be due to difficulty achieving an optimal setting from the outset or to an inability of a single study to estimate variable pressure needs over a more prolonged period of use. Thus, clinicians should be aware that many patients on CPAP or BPAP therapy, even those who undergo attended titrations in the sleep laboratory, may be receiving suboptimal pressure settings, such that further titration efforts should be attempted. The efficacy of suboptimal PAP levels is unknown.

Auto-titrating device assessment — In the absence of published guidelines, we define a successful or adequate auto-titrating PAP (APAP) trial as having a combination of a mean nightly use of six hours per night, a device-calculated apnea-hypopnea index (AHIFlow) ≤10 events per hour and a normal leak profile (which is dependent on the individual device manufacturer, mask type, and proprietary algorithm). Symptoms must also be considered in assessment of treatment success, as the AHIFlow is based on proprietary algorithms and has received only limited study.

If residual symptoms of daytime sleepiness and/or snoring persist despite adequate nightly APAP use, the clinician should assess for adequate mask fit, excessive leak, and proper pressure range settings. Attention to the AHIFlow is also worthwhile, with an understanding that various device manufacturers define respiratory events differently and some devices may not reliably differentiate central from obstructive events. For those patients who have residual symptoms and/or snoring, a residual AHIFlow >10 events per hour, a normal leak profile and data to suggest they frequently reach the maximum of the APAP pressure range, we typically empirically increase the top of the pressure range (eg, initial pressure range of 8 to 14 cm H20 would change to 8 to 16 cm H2O) and re-evaluate the patient's symptoms and adherence data in two to four weeks. Issues regarding mask fit and reasons for poor response are also assessed.

For patients with persistent symptoms, an AHIFLow >10 and/or high levels of leak despite empiric changes in pressure and attention to mask fit, a formal attended in-laboratory titration with CPAP or BPAP therapy is recommended with PSG monitoring. (See 'Attended in-laboratory CPAP titration' above and 'Attended in-laboratory bilevel PAP (BPAP)' above.)

There is no standard way to assess the optimal response when auto-titrating bilevel devices (auto-BPAP) are used. The optimal setting is typically the level of pressure that eliminates obstructive events for more than 90 or 95 percent of the time ("P90 and P95 pressure"). Auto-BPAP devices calculate a P90 or P95 for both the expiration (EPAP) and inspiration (IPAP) pressures. All of the outcomes and titration data evaluation of auto-BPAP therapy have been done in an attended setting. In an attended setting, the response can be measured by PSG, while in an unattended setting, the response is assessed on clinical history, the presence or absence of symptoms, snoring and information downloaded from the machine data card (AHI, leak, adherence).

Clinical assessment — For patients who undergo PAP titration on auto-titrating devices or 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. (See 'Prediction formulas and empiric titration' above.)

FOLLOW-UP — In general, following the initiation of positive airway pressure (PAP) therapy 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. Switching to a different mode of PAP therapy necessitates re-titration according to the chosen mode. (See 'Titration methods' above and 'Uncomplicated OSA with persistent or new symptoms' above and 'Patients with complicated OSA' above.)

Treatment of residual symptoms despite multiple attempts to optimize settings is discussed separately. (See 'Titration methods' above and "Evaluation and management of residual sleepiness in obstructive sleep apnea".)

SUMMARY AND RECOMMENDATIONS

Positive airway pressure (PAP) is the primary therapy for patients with obstructive sleep apnea (OSA). Determining the optimal pressure settings for PAP in patients with OSA is of paramount importance to help assure patient adherence to therapy and improve important outcomes. (See 'Introduction' above.)

Devices used to determine the optimal settings for PAP may be the same as or different than those used for therapy. Methods include attended in-laboratory polysomnogram (PSG)-based continuous PAP (CPAP) and bilevel PAP (BPAP) titration, and auto-titrating PAP (APAP, auto-BPAP), which can be used in unattended settings and, less commonly, attended settings. (See 'Indications for positive airway pressure (PAP) titration' above and 'Titration methods' above.)

For patients with uncomplicated OSA in whom fixed-level CPAP therapy is indicated, we suggest that an attended in-laboratory CPAP titration or in select patients an unattended in-home titration using an auto-titrating CPAP (APAP) device be used to determine the initial CPAP setting. Although in-laboratory titration is traditionally considered ideal, in practice, choosing among these two options in this population varies among sleep clinicians and sleep institutions. The choice is frequently dependent upon several factors including medical and practical issues that influence success of the chosen titration and/or costs associated with a third party payer. Bilevel devices, prediction formulas, or empiric strategies are not typically used to titrate PAP in patients with uncomplicated OSA. (See 'Uncomplicated obstructive sleep apnea (OSA)' above and 'Titration to determine initial settings' above.)

For patients with uncomplicated OSA who have persistent or new symptoms in whom poor adherence to fixed level CPAP and reasons for intolerance have been excluded, and in whom BPAP is indicated, we suggest that BPAP titration be performed in an attended PSG-based setting. Unattended approaches are less optimal (APAP, auto-BPAP). (See 'Uncomplicated OSA with persistent or new symptoms' above.)

For patients with complicated OSA, PAP titration should be performed in an attended sleep laboratory setting with PSG-based monitoring. Choosing between CPAP and BPAP in-laboratory titration depends upon the underlying sleep disorder and the indications for each mode of PAP. (See 'Patients with complicated OSA' above.)

The goal of PAP titration is to determine the minimal pressure required to resolve all apneas, hypopneas, snoring, and arousals related to these events, in all stages of sleep and in all sleep positions. When this goal is met, no further titration is necessary and patients should be started on therapy. When this goal is not met, we typically perform or repeat an attended in-laboratory PAP titration, most often beginning with the same device. (See 'Assessing adequacy of PAP settings' above.)

Following the initiation of PAP therapy, most patients are clinically assessed at approximately one to eight weeks for symptoms of daytime sleepiness, snoring, mask tolerance, and oronasal effects. Adjustments can be made accordingly. Switching to a different mode of PAP therapy necessitates re-titrating according to that mode. (See 'Follow-up' above.)

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REFERENCES

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