What are typical Continuous Positive Airway Pressure (CPAP) settings for adults with obstructive sleep apnea?

Typical CPAP Settings for Adults with Obstructive Sleep Apnea

The standard CPAP settings for adults with obstructive sleep apnea begin at 4 cm H2O with a maximum of 20 cm H2O, with pressure titrated upward in increments of at least 1 cm H2O every 5 minutes until respiratory events are eliminated. 1, 2

Initial CPAP Settings

• Starting pressure: 4 cm H2O for both adults and children 1, 2
• Maximum pressure:
  • Adults (≥12 years): 20 cm H2O 1, 2
  • Children (<12 years): 15 cm H2O 1

Titration Protocol

Pressure Adjustment Algorithm

• Increase CPAP by at least 1 cm H2O at intervals no shorter than 5 minutes 1, 2
• Continue titration until respiratory events are eliminated 1
• Criteria for pressure increases in adults:
  • ≥2 obstructive apneas
  • ≥3 hypopneas
  • ≥5 RERAs (Respiratory Effort-Related Arousals)
  • ≥3 minutes of loud or unambiguous snoring 1, 2

Optimal Titration Endpoint

• At least 30 minutes without breathing events 2
• At least 15 minutes in supine REM sleep (when respiratory events are most likely to occur) 2
• After eliminating respiratory events, an additional "exploration" of up to 5 cm H2O above the controlling pressure may be performed to reduce residual high airway resistance 1, 2

Managing Pressure Intolerance

• If patient awakens complaining of high pressure, restart at a lower, more comfortable pressure 1, 2
• Consider switching to BPAP if:
  • Patient is uncomfortable with high CPAP pressures
  • Continued obstructive events occur at 15 cm H2O 1, 2

BPAP Settings (When CPAP Is Not Tolerated)

• Initial IPAP: 8 cm H2O 1, 2
• Initial EPAP: 4 cm H2O 1, 2
• IPAP-EPAP differential: Minimum 4 cm H2O, maximum 10 cm H2O 1, 2
• Maximum IPAP for adults: 30 cm H2O 1

Special Considerations

• Higher starting pressures may be appropriate for patients with elevated BMI 1
• Patients with higher BMI (>32.3 kg/m²) may prefer auto-adjusting CPAP (APAP) over fixed CPAP 3
• Male sex, higher baseline AHI, higher pressure requirements, and increased mask leak are predictors of suboptimal CPAP titration 4
• Early studies found that even low levels of CPAP (4.5-10 cm H2O) can completely prevent upper airway occlusion 5

Common Pitfalls to Avoid

• Inadequate titration time (ensure sufficient time in REM sleep and supine position)
• Failure to address mask leaks, which can lead to suboptimal titration 4
• Not considering BPAP when patients cannot tolerate effective CPAP pressures
• Neglecting to explore additional pressure (up to +5 cm H2O) after respiratory events are eliminated, which may help reduce residual high airway resistance 1, 2