A Physician’s perspective Navin K Jain, MD PAP Titration A Physician’s perspective Navin K Jain, MD

CONFLICT OF INTEREST None to disclose

OBJECTIVES Learn PAP titration protocols Learn current practices in PAP titration Understand a “good titration

PAP Titration : Survey March 2014 5 Sleep Disorders Centers 20 technicians (1-9 studies) 84 PAP titrations Baseline AHI (5-137/hour) AHI <10 - 15 AHI >60 - 16 PAP Fixed pressure CPAP – 34 Auto Titrating CPAP – 35 Fixed Pressure BPAP – 12 Auto Titrating BPAP – 3 ASV – 3 EPR - 31 Masks Nasal – 12 Nasal Pillows – 9 Full Face – 63

Modes of PAP Titration CPAP - Titrate positive pressure throughout recording to determine single fixed pressure that will eliminate respiratory disturbances during subsequent nightly usage at home BPAP - device may be used when a patient demonstrates difficulty acclimating to high airway pressure during the expiration phase of breathing. BPAP allows the sleep technologist to separately increase inspiratory or expiratory pressures during the polysomnography to arrive at two pressures for subsequent use in the home. Servoventilation device (SV) - a computer-controlled valve to adjust airway pressure breath by breath to maintain steady ventilation. Heplful for patients with periodic breathing abnormalities such as Cheyne Stokes respiration and central apnea seen in heart failure or patients with complex sleep apnea

The goals should be individualized to meet the needs of each patient. Goals of PAP Titration Keep the upper airway open (airway management). Stabilize breathing patterns by monitoring the patient’s response to therapy. Adjust user-set parameters as needed for optimal therapy efficacy and adherence. The goals should be individualized to meet the needs of each patient.

Patient Types for PAP Titration

PAP Titration Study Manual PAP titration during attended PSG is current AASM standard for : Select optimal therapeutic pressure Must be administered by well- trained sleep technologist PAP education Hands on equipment demonstration Careful mask fitting and acclimation to device prior to titration Art and not a cookbook – using clinician’s experience and judgment

Optimal Pressure effective pressure that eliminates SDB events without creating any untoward pressure related side effects Should be effective in all positions and stages of sleep There is a trade off between increasing pressure to yield efficacy in eliminating respiratory events, and decreasing pressure to minimize emergence of pressure related adverse effects

Lower than Optimal Pressures Mouth breathing claustrophobia Higher than Optimal Pressure Air leaks Worsening of nasal congestion Rhinorrhea Exacerbating central apnea Poor tolerance to PAP

Factors influencing Optimal Pressure sleep position, Rapid eye movement (REM) sleep, sleep duration degree of respiratory effort the length of the soft palate. Factors not affecting optimal pressure Severity of AHI BMI

Optimal Titration The Respiratory Disturbance Index (RDI) is < 5 per hour for a period of at least 15 minutes at the selected pressure and within the manufacturer’s acceptable leak limit. The SpO2 is above 90% at the selected pressure. Supine REM sleep at the selected pressure is not continually interrupted by spontaneous arousals or awakenings.

Good Titration The Respiratory Disturbance Index (RDI) is < 10 per hour (or is reduced by 50% if the baseline RDI was <15) for a period of at least 15 minutes at the selected pressure and within the manufacturer’s acceptable leak limit. The SpO2 is above 90% at the selected pressure. Supine REM sleep at the selected pressure is not continually interrupted by spontaneous arousals or awakenings.

Adequate Titration The Respiratory Disturbance Index (RDI) is NOT < 10 per hour, but the RDI is reduced by 75% from baseline. Criteria for optimal or good titration is met but you did NOT get a sample of supine REM at the selected pressure.

Respiratory Parameters during PAP Titration Airflow sensor – airflow signal generated by PAP device (because pressure transducer under nares with mask leads to poor mask seal) – flow signal Respiratory effort sensor – RIP belt Sampling Rate – minimum 25 Hz; prefer 100 Hz (to assess artifacts and cardiogenic oscillations) Filter settings : LFF 0.1 Hz, HFF 15 Hz. Most machines provide a signal reflecting an estimate of leak

Hypopnea during PAP Titration Same definition as during PSG Different signal source Oxygen desaturation criteria – 3%, 4% or none Associated arousal

Educational Program Adequate PAP education, hands-on demonstration, careful mask fitting, and acclimatization Done prior to a diagnostic study with high clinical suspicion of OSA Mask fitting goals Maximizing comfort Compensation for nasal obstruction Minimizing leak Mask interface – nasal, nasal pillow, full face/ oro-nasal Accessories – chin strap, heated humidifier Acclimatization Wearing interface with pressure on prior to lights off

PAP Titration (AASM protocol) Start patient on 5 cm H2O (may start higher pressure for higher BMI or for re-titration studies) Increase pressure until respiratory events are eliminated : apneas, hypopneas, RERAs, and snoring Increase pressure at least 1cm H2O, no sooner than ever 5 minutes (for at least 2 obstructive apneas, or at least 3 hypopneas, or at least 5 RERAs, or at least 3 minutes of loud or unambiguous snoring) Exploration pressure – may increase 2-5 cm to overcome upper airway resistance – to normalize shape of inspiratory flow limitation Down Titration – not necessary If patient still hypoxic after respiratory events are resolved, do not increase pressure Maximum CPAP pressure – 15 cm H2O

PAP Titration – AASM protocol Bi-Level PAP Patient intolerant or uncomfortable of high pressure on CPAP Continued obstructive events at 15 cm H2O CPAP during titration study Not more effective or superior to CPAP TITRATION Starting pressure 8/4; maximum IPAP – 30 cm H2O; minimum difference 4; maximum difference 10

Expiratory Pressure Relief 20% using CPAP complaints of sensation of exhaling against a high pressure Pressure reduction during expiration (EPR, C-flex) on pressure relief CPAP MAY be more comfortable for patients requiring higher CPAP pressure

Adaptive Servo-Ventilation Uses an algorithm that varied Pressure Support to achieve 90% of measured long term minute ventilation Used in management of Central Sleep Apnea, and Complex Sleep Apnea Uses negative feedback loop

Re-Titration Study How often – in stable patient Things to do before Re-Titration Study Clinical evaluation – sleep history Mask fitting and Leak Review of PAP download Auto PAP Trial and adjustment of pressure based on data

PAP NAP Study Previous night sleep restriction 1 – 3 hours of sleep No napping prior to PAP-NAP Mask fitting, desensitization Determine best mask for patient, Full Face vs. Nasal vs. Direct Nasal Pillow Mask fitting for comfort, lack of leak, lack of pressure points Pressure desensitization PAP Therapy Hookup channel hookup is used, including pressure transducer, snore, PAP therapy pressure, mask leak, respiratory effort belts, heart rate, pulse oximetry, video monitoring, and body position S PAP Therapy Testing 60 to 120 minutes spent in bed with PAP device in place Goal is to help patient adapt to PAP therapy sensation Pressure changes for comfort, to improve airflow signal, to increase physiologic exposure, but not to titrate

PAP Titration Deciding factor for therapy Patient – AHI, BMI, gender Technician Sleep Disorders Center Reviewing Physician

Baseline AHI & PAP Titrations What AHI one should not titrate? In survey of SDC – 15/84 – AHI <10 Who should get Split Night studies – 16/84 had AHI >60

EPR 31/84 Technicians SDC Should everyone have EPR 1/9 (minimum) 4/4 (maximum) SDC 2/18 10/11 Should everyone have EPR What Level : 1,2 or 3

PAP Masks Full Face – 63 Technicians (Full Face mask) SDC Quattro – 43 Simplus – 17 Others - 3 Technicians (Full Face mask) 8/9 (maximum) 1/4 (minimum) SDC 16/18 (maximum) 6/11 (minimum) Nasal Pillow- 9 (one technician 3/4) Nasal- 12

PAP Mode of therapy Fixed Pressure Auto Titrating 37/ 42 (maximum) 2/18 (minimum) Auto Titrating 3/42 (minimum) 16/18 (maximum)

PAP Mode of therapy CPAP Bilevel 40/42 Maximum 11/19 Minimum 1/42 minimum (1/9 for technician when >5 studies) 8/19 maximum (one technician 5/9)

PAP Titration Study Should we abandon it?