What is the treatment process for obstructive sleep apnea using Continuous Positive Airway Pressure (CPAP) therapy?

Treatment Process for Obstructive Sleep Apnea Using CPAP Therapy

Continuous Positive Airway Pressure (CPAP) therapy is the gold standard treatment for obstructive sleep apnea (OSA), delivering pressurized air through a mask to maintain airway patency during sleep. 1, 2

Initial Diagnosis and Assessment

• CPAP therapy should only be initiated after a diagnosis of OSA is established through objective testing, either via home sleep apnea test or in-laboratory polysomnography 1
• CPAP is indicated for:
  • Moderate to severe OSA (AHI ≥15 events/hour), regardless of symptoms 2
  • Mild OSA (AHI 5-15 events/hour) with symptoms such as excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia 2
  • OSA with comorbid conditions including hypertension, coronary artery disease, or history of stroke 2, 3

Pre-Titration Preparation

• All potential CPAP candidates should receive:
  • Adequate education about OSA and CPAP therapy
  • Hands-on demonstration of equipment
  • Careful mask fitting to ensure proper seal and comfort
  • Acclimatization to the device prior to titration 1

CPAP Titration Process

• Manual titration is performed during attended polysomnography to determine optimal pressure settings 1
• The recommended minimum starting CPAP pressure is 4 cm H2O for both pediatric and adult patients 1
• CPAP pressure is gradually increased until:
  • Obstructive respiratory events are eliminated (apneas, hypopneas, respiratory effort-related arousals, and snoring)
  • Or the recommended maximum CPAP pressure is reached 1
• If the patient is uncomfortable or intolerant of high pressures (typically at 15 cm H2O or higher), switching to bilevel positive airway pressure (BPAP) may be considered 1
• For BPAP, the recommended minimum starting inspiratory positive airway pressure (IPAP) is 8 cm H2O and expiratory positive airway pressure (EPAP) is 4 cm H2O 1

Equipment Selection and Setup

• CPAP devices deliver a single, fixed pressure throughout the night 1, 4
• Alternative PAP options include:
  • Bilevel positive airway pressure (BPAP): delivers higher inspiratory pressure than expiratory pressure
  • Auto-titrating positive airway pressure (APAP): automatically adjusts pressure as needed throughout the night
  • Adaptive servoventilation (ASV): used primarily for central sleep apnea or complex sleep apnea 4, 5
• Interface options include nasal masks, nasal pillows, and full-face masks, with selection based on patient comfort, facial structure, and breathing patterns 4, 6

Follow-up and Monitoring

• Close monitoring during the initial weeks to months after CPAP initiation is essential to promote adherence and assess treatment response 1
• Objective monitoring of CPAP usage should be performed as patients often overestimate their use 1
• Minimum effective CPAP usage is generally considered to be at least 4 hours per night on 70% of nights, though benefits can be seen even with 2 hours of use 2
• After initial follow-up, yearly evaluation is reasonable for stable patients, while those with persistent issues require more frequent monitoring 1
• CPAP pressure requirements may change over time, requiring periodic reassessment 1

Adherence Optimization

• Early identification and addressing of difficulties with CPAP use is critical, as early adherence predicts long-term use 1
• Factors associated with better CPAP adherence include:
  • Higher AHI and ESS (Epworth Sleepiness Scale) scores
  • Lower CPAP pressure settings
  • Early intervention for CPAP intolerance issues 2
• Common adherence strategies include:
  • Addressing mask fit issues and air leaks
  • Managing side effects (nasal congestion, skin irritation)
  • Behavioral modification therapy, especially for pediatric patients or those with developmental delays
  • Telemonitoring to improve adherence 1, 2

Special Considerations for Pediatric Patients

• CPAP should be managed by clinicians with expertise in its use in children 1
• Behavioral modification therapy may be required for young children or those with developmental delays 1
• Children who have had adenotonsillectomy but have residual OSA may require CPAP therapy 1
• High-risk pediatric patients should be reevaluated after adenotonsillectomy for persistent OSA 1

Alternative and Adjunctive Treatments

• Weight loss has been shown to improve OSA but should be used as an adjunct rather than replacement for CPAP in most cases 1, 2
• Mandibular advancement devices can be considered for patients who cannot tolerate CPAP 2, 5
• Intranasal corticosteroids may be prescribed for children with mild OSA when adenotonsillectomy is contraindicated or for mild postoperative OSA 1