Is it reasonable to switch to Bi-Level Positive Airway Pressure (BPAP) or Bi-Level Positive Airway Pressure with Spontaneous Timed (BPAP ST) mode during desensitization for Positive Airway Pressure (PAP) therapy if a patient is experiencing discomfort?

Switching to BPAP or BPAP ST During PAP Therapy Desensitization

Yes, it is reasonable and recommended to switch to BPAP or BPAP ST mode during PAP therapy desensitization if a patient is experiencing discomfort with CPAP. 1, 2

Indications for Switching to BPAP

• Patient discomfort with CPAP: The American Academy of Sleep Medicine explicitly states that "if the patient is uncomfortable or intolerant of high pressures on CPAP, the patient may be tried on BPAP" 1
• Continued obstructive events: If there are continued obstructive respiratory events at 15 cm H₂O of CPAP during titration 1
• Pressure intolerance: BPAP should be considered for patients who are nonadherent to CPAP therapy because of pressure intolerance 3
• Bloating symptoms: Patients experiencing persistent bloating on CPAP may benefit from switching to BPAP 2

When to Consider BPAP ST Mode

• Treatment-emergent central apneas: A decrease in IPAP or setting BPAP in spontaneous-timed (ST) mode with backup rate may be helpful if treatment-emergent central apneas (complex sleep apnea) are observed during titration 1
• Specific patient populations: A backup rate (ST mode) should be used in all patients with:
  • Central hypoventilation
  • Significant number of central apneas
  • Inappropriately low respiratory rate
  • Unreliable triggering of IPAP/EPAP cycles due to muscle weakness 1

Initial BPAP Settings During Desensitization

• Starting IPAP: 8 cm H₂O 1, 2
• Starting EPAP: 4 cm H₂O 1, 2
• IPAP-EPAP differential: Maintain minimum of 4 cm H₂O and maximum of 10 cm H₂O 1
• Pressure adjustments: Increase IPAP and/or EPAP by at least 1 cm H₂O with intervals no shorter than 5 minutes 1

BPAP ST Settings (When Needed)

• Starting backup rate: Equal to or slightly less than the spontaneous sleeping respiratory rate (minimum of 10 breaths per minute) 1
• Adjustments: Increase backup rate in 1-2 breaths per minute increments every 10 minutes if goals not attained 1
• Inspiratory time: Set between 30-40% of the cycle time (60/respiratory rate) 1

Improving Patient Comfort During Desensitization

• Pressure reduction for comfort: If the patient awakens and complains that pressure is too high, restart at a lower pressure that the patient reports is comfortable enough to allow return to sleep 1
• Device parameters: Adjust pressure relief, rise time, and maximum/minimum IPAP durations to optimize patient comfort and synchrony 1
• Mask considerations: Perform mask refit, adjustment, or change in mask type whenever significant unintentional leak is observed or patient complains of mask discomfort 1
• Humidification: Add heated humidification if patient complains of dryness or significant nasal congestion 1

Clinical Benefits of Switching to BPAP

• Improved adherence: Patients who fail CPAP therapy due to pressure intolerance can achieve better adherence with BPAP (7.0 vs 2.5 hours/night) 4
• Better symptom control: BPAP can provide better control of sleep-disordered breathing symptoms compared to failed CPAP therapy 4
• Lower expiratory pressures: BPAP allows for lower expiratory pressures compared to equivalent CPAP (10 vs 16.8 cm H₂O) 4

Monitoring and Follow-up

• Regular monitoring: Ensure adequate treatment of the underlying sleep disorder while minimizing discomfort symptoms 2
• Objective data: Monitor residual AHI, device usage, and symptom improvement 2
• Close follow-up: After initiation of BPAP by appropriately trained healthcare providers to establish effective utilization patterns and remediate side effects 1

By following these guidelines for switching to BPAP or BPAP ST during PAP desensitization, clinicians can improve patient comfort, adherence, and ultimately treatment outcomes for patients with sleep-disordered breathing.