What are the guidelines for initiating and managing Continuous Positive Airway Pressure (CPAP) therapy?

Guidelines for Initiating and Managing CPAP Therapy

CPAP therapy should be initiated with a minimum starting pressure of 4 cm H2O for both pediatric and adult patients, with pressure adjustments made during attended polysomnography to eliminate obstructive respiratory events including apneas, hypopneas, respiratory effort-related arousals, and snoring. 1

Pre-Titration Requirements

• All potential CPAP candidates should receive adequate education about OSA, PAP therapy benefits, hands-on demonstration, careful mask fitting, and acclimatization prior to titration 1
• Educational interventions before starting CPAP therapy significantly improve adherence and are strongly recommended 1
• Proper mask selection and fitting is critical to prevent leaks and maximize comfort 2

CPAP Titration Protocol

Initial Settings

• Start with 4 cm H2O for both pediatric and adult patients 1, 2
• Maximum recommended CPAP should not exceed 15 cm H2O for patients <12 years and 20 cm H2O for patients ≥12 years 1, 2
• Higher starting pressures may be appropriate for patients with elevated BMI or those undergoing retitration 2

Pressure Adjustment

• Increase CPAP by at least 1 cm H2O with intervals no shorter than 5 minutes 1, 2
• Do not increase CPAP by increments greater than 2.5 cm H2O 1
• Continue titration until obstructive respiratory events are eliminated or maximum recommended pressure is reached 1, 2

When to Increase Pressure

• Increase CPAP when ≥2 obstructive apneas are observed (for patients ≥12 years) or ≥1 obstructive apnea (for patients <12 years) 1, 2
• Increase CPAP when ≥3 hypopneas are observed in patients ≥12 years 2
• Increase CPAP when ≥5 respiratory effort-related arousals (RERAs) are observed 2
• Increase CPAP when ≥3 minutes of loud or unambiguous snoring are observed 1, 2

Determining Optimal Pressure

• The optimal CPAP pressure eliminates apneas, hypopneas, RERAs, and snoring for at least 30 minutes, including time in supine REM sleep 2
• "Exploration" of pressure up to 5 cm H2O above the pressure that controls respiratory events may be performed to ensure optimal control 1, 2

Alternative Approaches

Split-Night Studies

• Split-night diagnostic-titration studies are usually adequate for determining optimal PAP pressure 1
• The titration algorithm for split-night CPAP titration should be identical to full-night titration 1
• It may be prudent to increase CPAP at larger increments (2-2.5 cm H2O) during split-night studies due to shorter titration duration 1

Bilevel PAP (BPAP)

• Consider BPAP if the patient is uncomfortable or intolerant of high CPAP pressures 1
• Switch to BPAP if there are continued obstructive respiratory events at 15 cm H2O of CPAP 1
• Minimum starting IPAP and EPAP should be 8 cm H2O and 4 cm H2O, respectively 1, 2
• Maximum recommended IPAP should be 20 cm H2O for patients <12 years or 30 cm H2O for patients ≥12 years 1
• Maintain a minimum IPAP-EPAP differential of 4 cm H2O and maximum of 10 cm H2O 1

Patient Comfort and Adherence

• If a patient awakens and complains that pressure is too high, reduce to a lower pressure that allows return to sleep, then resume titration 1, 2
• Only about half of patients use CPAP for more than half the night on five or more nights per week 3
• Approximately 4 hours of CPAP therapy per night significantly improves daytime alertness and performance 3
• Add heated humidification to improve CPAP utilization 1, 2
• Implement behavioral and/or troubleshooting interventions during the initial period of PAP therapy 1
• Consider telemonitoring-guided interventions during initial CPAP therapy 1
• CPAP usage should be objectively monitored with time meters to help ensure utilization 1, 4

Follow-up Care

• Initial CPAP follow-up is recommended during the first few weeks to establish utilization pattern and provide remediation if needed 1, 4
• Close follow-up for PAP usage and problems by appropriately trained healthcare providers is essential to establish effective utilization patterns 1
• Longer-term follow-up is recommended yearly or as needed to address mask, machine, or usage problems 4
• After substantial weight loss (≥10% of body weight), a follow-up PSG is indicated to determine if PAP therapy is still needed or if pressure adjustments are necessary 1

Common Pitfalls to Avoid

• Starting with too high a pressure may cause patient discomfort and reduce adherence 2
• Failure to monitor for mask leaks can compromise therapy effectiveness 2
• Using thermal devices or nasal pressure cannulas under the mask for monitoring airflow is not recommended as they may interfere with mask seal 2
• Underestimating the importance of proper mask fitting and patient education before titration 2