What needs to be documented during the titration portion of a sleep study for a patient with a sleep disorder, including their demographic information, medical history, and response to Continuous Positive Airway Pressure (CPAP) machine pressure settings?

Documentation Requirements During PAP Titration

During the titration portion of a sleep study, you must document the respiratory disturbance index (RDI), oxygen saturation levels, sleep stages (particularly supine REM sleep), pressure settings at each adjustment, presence and type of leak, and any pressure-related side effects or patient complaints. 1

Core Respiratory Parameters

• RDI/AHI tracking: Document the number of apneas, hypopneas, and RERAs per hour of sleep at each pressure level to determine when respiratory events are adequately controlled 1
• Oxygen saturation: Record SpO2 continuously, ensuring it remains above 90% at the selected pressure 1
• Respiratory event types: Distinguish between obstructive apneas, hypopneas, RERAs, and any central events that may emerge during titration 1

Sleep Architecture Documentation

• Supine REM sleep: Specifically document whether supine REM sleep occurred at the selected pressure, as this is critical for grading titration success 1
• Sleep stage distribution: Record time spent in each sleep stage (NREM stages 1-3 and REM) to ensure adequate sleep quality during titration 1
• Arousals and awakenings: Document spontaneous arousals or awakenings that interrupt sleep, particularly during supine REM sleep at the selected pressure 1

Pressure Settings and Adjustments

• Starting pressure: Document the initial CPAP or IPAP/EPAP settings (minimum CPAP 4 cm H2O; minimum IPAP 8 cm H2O and EPAP 4 cm H2O for BiPAP) 1
• Each pressure change: Record every pressure adjustment with the time, reason for change (e.g., ≥2 obstructive apneas, ≥3 hypopneas, ≥5 RERAs, or ≥3 minutes of snoring), and the patient's sleep stage and body position 1
• Duration at each pressure: Note how long the patient remained at each pressure level before adjustment (minimum 5-10 minutes between changes) 1
• Final selected pressure: Document the optimal pressure where RDI <5 per hour was achieved for at least 15 minutes 1

Leak Documentation

• Intentional vs. unintentional leak: Distinguish between controlled leak from the mask port and unintentional leak (mouth leak or mask leak) 1
• Leak magnitude: Record leak levels throughout the night, noting when leak becomes clinically significant enough to warrant mask adjustment 1
• Mask adjustments: Document each time the mask was refitted or readjusted, the type of leak addressed, and whether a chinstrap or different mask interface was required 1

Patient Tolerance and Side Effects

• Patient complaints: Record any complaints of pressure being too high, uncomfortable, or causing difficulty breathing 1
• Pressure-related side effects: Document nasal congestion, oronasal dryness, aerophagia, or other side effects that emerge during titration 1
• Interface changes: Note if the patient required switching between nasal mask, nasal pillows, or full-face/oronasal mask during the night 1, 2
• Use of accessories: Document addition of heated humidifier, chinstrap, or other accessories to address side effects 1

Titration Success Grading

The AASM provides a standardized grading system that should be documented in the final report 1:

• Optimal titration: RDI <5 per hour for at least 15 minutes, including supine REM sleep at the selected pressure without continual arousals 1
• Good titration: RDI ≤10 per hour or 50% reduction if baseline RDI <15, including supine REM sleep at the selected pressure 1
• Adequate titration: RDI reduced by 75% from baseline (especially in severe OSA), or optimal/good criteria met except supine REM sleep did not occur 1

Special Considerations for BiPAP Titration

• IPAP-EPAP differential: Document that the pressure differential remains at least 4 cm H2O throughout titration 1
• Central apnea emergence: Note if central apneas develop during titration, which may require switching to spontaneous-timed (ST) mode with backup rate 3
• Down-titration protocol: If performing down-titration, document at least 30 minutes without respiratory events before decreasing IPAP by 1 cm H2O at intervals no shorter than 10 minutes 3

Common Pitfalls to Avoid

• Insufficient REM sleep documentation: Failure to document whether supine REM sleep occurred at the selected pressure is a critical omission, as this determines whether the titration is optimal versus adequate 1
• Inadequate leak characterization: Not distinguishing between intentional and unintentional leak can lead to inappropriate pressure adjustments 1
• Premature pressure increases: Increasing pressure without waiting at least 5-10 minutes at each level prevents accurate assessment of pressure efficacy 1
• Missing body position data: Not documenting body position during respiratory events makes it impossible to determine if events are position-dependent 1