From the Guidelines
The patient requires a CPAP to BiPAP titration study due to significant discomfort and inability to tolerate CPAP, despite a moderate OSA diagnosis and persistently elevated AHI of 13.0 on compliance reports. To justify this need, document the patient's inadequate response to CPAP therapy, as evidenced by the elevated AHI, and specify symptoms like pressure intolerance, mask discomfort, or aerophagia that affect compliance and treatment efficacy. According to the American Academy of Sleep Medicine clinical practice guideline 1, a trial of BiPAP may be offered for patients who are unable to tolerate CPAP or APAP due to high pressure requirements, despite the use of modified pressure profiles.
The patient's significant discomfort and inability to tolerate CPAP, as well as the persistently elevated AHI, support the need for a BiPAP titration study. BiPAP may provide better comfort and efficacy by delivering different inspiratory and expiratory pressures, potentially improving both the patient's AHI and treatment adherence. Key points to document include:
- Moderate OSA diagnosis by HST
- Inadequate response to CPAP therapy, as evidenced by a persistently elevated AHI of 13.0
- Significant discomfort and inability to tolerate CPAP
- Symptoms affecting compliance and treatment efficacy, such as pressure intolerance or mask discomfort
- Potential benefits of BiPAP's dual-pressure support for comorbidities like COPD or obesity hypoventilation syndrome. As noted in the clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea 1, if the patient is uncomfortable or intolerant of high pressures on CPAP, the patient may be tried on BPAP.
From the Research
Patient Eligibility for CPAP BiPAP Titration
The patient's significant discomfort when using CPAP and inability to tolerate it, despite having an AHI of 13.0 on a recent compliance report, suggests the need for a CPAP BiPAP titration study. This is supported by the following points:
- Issues with tolerability and side effects can decrease CPAP device usage and the benefits of therapy, as seen in the study by 2.
- Bilevel positive airway pressure (BPAP) may alleviate some of the issues associated with CPAP, such as pressure tolerance issues or persistent side effects/discomfort, as noted in the study by 3.
- The patient's high AHI on CPAP therapy indicates that the current treatment is not effective, and a titration study may be necessary to determine the optimal settings for BPAP therapy.
Benefits of CPAP BiPAP Titration
The benefits of switching to BPAP therapy include:
- Significant reductions in expiratory PAP, 95th percentile pressure, and leak, as seen in the study by 2.
- Improvements in sleep quality, daytime sleepiness, fatigue, and therapy-related side effects, as noted in the study by 2.
- Increased patient satisfaction and preference for BPAP over CPAP, as reported in the study by 2.
Supporting Evidence
The need for a CPAP BiPAP titration study is further supported by the following evidence:
- A study by 4 found that suboptimal CPAP adherence can lead to decreased effectiveness of therapy, highlighting the need for alternative treatments such as BPAP.
- A study by 5 compared the effectiveness of continuous and bilevel positive airway pressure for obstructive sleep apnea, and found that bilevel therapy may be beneficial for patients who experience discomfort during expiration.
- A study by 6 characterized patients who were unable to tolerate CPAP treatment, and found that older patients with less severe OSAS were more likely to discontinue CPAP treatment due to nasal and pharyngeal side-effects.