How to start Continuous Positive Airway Pressure (CPAP) machine therapy without a titration study?

Starting CPAP Therapy Without a Titration Study

When initiating CPAP therapy without a formal titration study, start with a minimum pressure of 4 cm H₂O for adults and gradually increase by 1 cm H₂O increments at intervals of at least 5 minutes until respiratory events are eliminated, not exceeding 20 cm H₂O for adults. 1

Initial Setup and Starting Pressures

• Begin with the following evidence-based starting parameters:

  • Adults (≥12 years): Start at 4 cm H₂O CPAP 1, 2
  • Children (<12 years): Start at 4 cm H₂O CPAP 1
  • Maximum recommended pressure: 20 cm H₂O for adults, 15 cm H₂O for children 1, 2

• For BPAP (if CPAP is not tolerated):

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

Pressure Adjustment Algorithm

1. Start at minimum pressure (4 cm H₂O for CPAP) 1

2. Increase pressure by 1 cm H₂O at intervals no shorter than 5 minutes when the following are observed 1, 2:

   • ≥2 obstructive apneas (adults) or ≥1 (children)
   • ≥3 hypopneas (adults) or ≥1 (children)
   • ≥5 RERAs (adults) or ≥3 (children)
   • ≥3 minutes of loud/unambiguous snoring (adults) or ≥1 minute (children)

3. Continue titration until respiratory events are eliminated or maximum pressure is reached 1

4. Consider "exploration" of up to 5 cm H₂O above the pressure that controls respiratory events to reduce residual high airway resistance 1, 2

5. Switch to BPAP if patient cannot tolerate CPAP at 15 cm H₂O or if respiratory events persist at this pressure 1

Monitoring and Adjustment

• Use auto-CPAP devices when available, as they can help determine effective pressure levels without manual titration 3, 4, 5

• Monitor for:

  • Persistent apneas/hypopneas
  • Snoring
  • Patient comfort and tolerance
  • Mask leaks

• If the patient awakens complaining of high pressure, restart at a lower pressure that allows return to sleep, then resume gradual titration 1, 2

Safety Considerations

• Avoid unattended auto-titration in patients with underlying cardiorespiratory disorders, as this may lead to complications 6
• Monitor for central apneas that may develop during titration, which may require pressure reduction 1
• For patients with COPD, be aware that EPAP levels >5 cm H₂O are rarely tolerated despite potential benefits 2

Follow-up

• Schedule a follow-up evaluation after 2-6 weeks of therapy to assess:

  • Symptom improvement (daytime sleepiness)
  • Compliance with therapy
  • Need for pressure adjustments 3, 5

• Consider a formal sleep study if symptoms persist despite therapy or if there are concerns about efficacy 1

While a full-night, attended polysomnography with titration is the preferred approach, this algorithm provides a structured method for initiating CPAP therapy when a titration study is not available, balancing efficacy and patient comfort to improve morbidity, mortality, and quality of life outcomes.