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

Lee K Brown, MD
Won Lee, MD
Section Editor
Nancy Collop, MD
Deputy Editor
Geraldine Finlay, MD


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 [1]. 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".)


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) [1]. 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 [1]. 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.)

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Literature review current through: Nov 2017. | This topic last updated: May 03, 2017.
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