Initial Starting CPAP Settings
Begin CPAP at 4 cm H₂O for both pediatric and adult patients, regardless of age. 1
Starting Pressure
The minimum starting CPAP pressure is 4 cm H₂O for all patients (pediatric and adult), based on consensus from the American Academy of Sleep Medicine and supported by standard-level evidence including multiple Level I and II studies 1
While 4 cm H₂O is the standard starting point, consider beginning at a higher pressure for patients with elevated body mass index (BMI) or those undergoing retitration studies, as CPAP requirements correlate with BMI (ρ = 0.32, p <0.001) 1
Predictive formulas incorporating BMI, neck circumference, and apnea-hypopnea index can estimate optimal pressure to within ±2 cm H₂O in approximately 77% of patients, potentially allowing for a higher starting pressure 2, 3
Maximum Pressure Limits
Maximum CPAP should not exceed 15 cm H₂O for patients <12 years 1
Maximum CPAP should not exceed 20 cm H₂O for patients ≥12 years 1
Titration Algorithm
Increase CPAP by at least 1 cm H₂O increments, waiting a minimum of 5 minutes between adjustments, with the goal of eliminating obstructive respiratory events 1
Specific Indications for Pressure Increases:
Increase pressure if ≥2 obstructive apneas occur in patients ≥12 years (or ≥1 apnea in patients <12 years) 1
Increase pressure if ≥3 hypopneas occur 1
Increase pressure if ≥5 respiratory effort-related arousals (RERAs) occur 1
Increase pressure if ≥3 minutes of loud or unambiguous snoring occurs in patients ≥12 years (or ≥1 minute in patients <12 years) 1
Pressure Exploration:
Once respiratory events are controlled, "exploration" of CPAP above the therapeutic pressure should not exceed 5 cm H₂O 1
This exploration addresses residual upper airway resistance that can be four times normal despite elimination of apneas and hypopneas, potentially causing repetitive arousals 1
Critical Adjustments for Patient Comfort
If the patient awakens complaining pressure is too high, immediately restart at a lower pressure that allows comfortable return to sleep, then resume gradual titration 1
Transition to BiPAP
Switch to BiPAP if obstructive events persist at 15 cm H₂O of CPAP or if the patient is intolerant of high CPAP pressures 1
BiPAP Starting Settings:
Begin with IPAP 8 cm H₂O and EPAP 4 cm H₂O for both pediatric and adult patients 1, 4
Maximum IPAP is 20 cm H₂O for patients <12 years and 30 cm H₂O for patients ≥12 years 1
Common Pitfalls to Avoid
Do not increase CPAP by increments >2.5 cm H₂O, as there is insufficient evidence supporting larger jumps 1
Do not wait <5 minutes between pressure adjustments, as this does not allow adequate time to assess response 1
For split-night studies, consider using larger increments (2 or 2.5 cm H₂O) given the shorter titration duration, though the same algorithm otherwise applies 1
CPAP requirements may decrease within 2 weeks of starting treatment (median reduction 1.5 cm H₂O), so retitration may be warranted if patients report pressure intolerance after initial treatment 5