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

2. CONFLICT OF INTEREST None to disclose

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

4. PAP Titration : Survey March 2014
5 Sleep Disorders Centers
20 technicians (1-9 studies)
84 PAP titrations
Baseline AHI (5-137/hour)
AHI <
AHI >
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

5. 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

6. 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.

7. Patient Types for PAP Titration

8. 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

9. 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

10. 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

11. 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

12. 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.

13. 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.

14. 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.

15. 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

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

17. 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

18. 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

19. 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

20. 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

22. 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

23. 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

24. 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

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

26. 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

27. 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

28. 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

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

30. 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)

31. PAP Titration Study
Should we abandon it?