What are the steps to order Continuous Positive Airway Pressure (CPAP) therapy for a patient with mild sleep apnea?

Ordering CPAP for Mild Sleep Apnea

For patients with mild obstructive sleep apnea (AHI 5-15), CPAP therapy should be ordered when symptoms are present, using either home auto-titration (APAP) or in-laboratory titration, with home APAP being the preferred initial approach due to faster access, lower cost, and equivalent efficacy. 1

Confirming the Diagnosis and Severity

• Mild OSA is defined as an AHI of 5-15 events per hour in adults (or 6-20 per hour by some classifications), typically confirmed by polysomnography or home sleep apnea testing 1, 2
• The sleep laboratory's severity assessment should take precedence over the raw AHI number, as laboratories differ in their detection criteria 1
• Ensure the diagnosis has been established through objective sleep testing before proceeding with PAP therapy 1

Determining Treatment Indication

Not all patients with mild OSA require CPAP therapy. The decision should be based on:

• Presence of symptoms: daytime sleepiness, snoring, restless sleep, irritability, cognitive impairment, or morning headaches 2, 3
• Cardiovascular comorbidities: hypertension, coronary artery disease, heart failure, or stroke risk 2
• Patient preference and motivation: mild OSA patients may have variable symptom improvement with CPAP, and placebo effects can be substantial 3

Important caveat: Research shows that CPAP in mild OSA improves self-reported symptoms (snoring, restless sleep, irritability) but may not significantly improve objective sleepiness measures or blood pressure compared to placebo 3. However, this does not negate treatment for symptomatic patients, as cardiovascular protection remains important 2.

Choosing the Titration Method

The American Academy of Sleep Medicine strongly recommends that PAP therapy can be initiated using either home APAP or in-laboratory titration, with no clinically significant differences in adherence, sleepiness, or quality of life outcomes. 1, 4

Home Auto-Titration (Preferred for Most Patients)

Home APAP should be the first-line approach for most patients with mild OSA without significant comorbidities because:

• Lower cost and faster treatment initiation 1
• No need for overnight facility stay 1
• Equivalent efficacy to in-laboratory titration 1, 5, 6
• Greater convenience and access to care 1

Prerequisites for home APAP initiation:

• Adequate patient education on PAP use by trained staff 1
• Proper mask fitting with or without daytime acclimatization 1
• Absence of significant comorbidities (see exclusions below) 1
• Plan for close follow-up within the first few weeks 1

In-Laboratory Titration (Consider When)

Choose in-laboratory titration for patients with:

• Congestive heart failure 1
• Chronic opiate use 1, 4
• Significant lung disease (COPD, restrictive lung disease) 1
• Neuromuscular disease 1, 4
• History of uvulopalatopharyngoplasty 1, 4
• Nocturnal oxygen requirements or expected desaturation from conditions other than OSA 1
• Central sleep apnea syndromes or hypoventilation syndromes 1, 4
• Anticipated difficulty with PAP treatment based on clinical judgment 1
• Patient preference for supervised titration 1

Writing the CPAP Order

For Home Auto-Titration (APAP):

Order components:

1. Device: Auto-adjusting PAP (APAP) machine 1, 4
2. Pressure range: Typically 4-15 cm H₂O for mild OSA (adjust based on clinical factors like BMI) 1
3. Mask interface: Nasal mask, nasal pillows, or full-face mask based on patient preference and mouth breathing 1
4. Education: Comprehensive PAP education session with trained staff before initiation 1, 4
5. Mask fitting: Professional mask fitting with leak check 1
6. Follow-up: Review usage data and clinical response within 1-2 weeks 1, 4
7. Duration: Initial trial period of 1-2 weeks to determine effective pressure 5

For In-Laboratory Titration:

Order components:

1. Study type: Full-night attended polysomnography with CPAP titration (split-night acceptable if diagnostic portion confirms OSA) 1
2. Starting pressure: 4 cm H₂O minimum 1
3. Titration goal: Reduce AHI to <5 events/hour with supine REM sleep at selected pressure 1
4. Pressure adjustments: Increase by 1 cm H₂O every 5 minutes based on respiratory events 1
5. Maximum pressure: 15 cm H₂O (can go to 20 cm H₂O if needed, but consider BiPAP if events persist at 15 cm H₂O) 1

Ongoing Treatment: CPAP vs APAP

After successful titration, either fixed CPAP or ongoing APAP can be prescribed for long-term treatment, as they show no clinically significant differences in adherence, sleepiness, or quality of life. 1, 4

• Fixed CPAP: Set at the determined effective pressure from titration 1
• Ongoing APAP: Allows automatic adjustment for changes in weight, position, or alcohol use 1
• Choice should be based on: Patient tolerance, individual response, and preference 1

Essential Follow-Up Protocol

Close monitoring is critical for treatment success:

• Within 1-2 weeks: Review objective usage data (hours per night), residual AHI, leak data, and clinical symptom response 1, 4
• Adjust pressure if needed: Based on residual events or inadequate symptom control 1
• Address adherence barriers: Mask discomfort, pressure intolerance, nasal congestion, or claustrophobia 1
• Target adherence: ≥4 hours per night for >70% of nights for clinical benefit 2
• Educational interventions: Strongly recommended at therapy initiation to improve adherence 4
• Telemonitoring: Can be used to guide interventions and improve initial adherence 4

Common Pitfalls to Avoid

• Don't assume all mild OSA requires treatment: Asymptomatic patients with mild OSA may not benefit significantly from CPAP 3
• Don't skip patient education: Inadequate education is a major cause of CPAP failure, especially with home titration 1
• Don't ignore mask fit: Poor mask fit leads to excessive leak and treatment failure 1
• Don't forget early follow-up: Many patients abandon CPAP in the first few weeks without proper support 1
• Don't use home APAP in patients with significant comorbidities: These patients need in-laboratory titration 1, 4
• Don't overlook alternative therapies: For patients who cannot tolerate CPAP, consider mandibular advancement devices, especially in mild-moderate OSA 1, 4

Alternative Considerations for Mild OSA

If CPAP is refused or not tolerated:

• Mandibular advancement devices (MADs): Appropriate for mild-moderate OSA with similar effects on sleepiness and quality of life, though less effective at reducing AHI than CPAP 1, 4
• Weight loss: All overweight/obese patients should be encouraged to lose weight as part of treatment 4
• Positional therapy: Consider if OSA is predominantly supine-position dependent 1