1. Titration Guidelines for CPAP, APAP and BiLevel Therapy Know your patient Titrate Successfully
Pamela Minkley RRT, RPSGT, CPFT
Make Sleep a Priority
March 2013

2. Learning objectives List the titration goals for OSA management
Understand the suggested protocols for titrations
Review the titration process for CPAP and Bi-Level therapies
Note: all protocols listed in the presentation are consistent with AASM clinical guidelines.
The learning objectives for today‘s presentation are as follows:
Goals for titration
understanding the protocols
Review the titration process for the different SDB therapies

3. The goals should be individualized to meet the needs of each patient.
Titration Goals
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.
Goals in the sleep lab for titration are:
airway management
stabilizing the breathing patterns by monitoring the response to the therapy
adjusting parameters for the best therapy efficacy and adherence to that therapy

4. Titration protocol Acclimation/To Bed Zone Titration Zone
Prescription Zone
PEARL:
Learn the concepts then apply that knowledge for each patient
Reinforce that they are like other labs
How we came up with Zones
Sleep technicians around the country take very similar steps as you do. As we were evaluating the best practices of sleep technicians and labs, taking into consideration different diagnostic and therapeutic reimbursement scenarios as well as the benefits of C-Flex and Bi-Flex, we began to group the processes that sleep technicians and labs were initiating into 3 main categories or zones. The Acclimation Zone, Titration Zone and the Prescription Zone.

5. Titration Protocol References This protocol is consistent with device validation studies and the following AASM clinical guidelines:
Clinical Guidelines for the Manual Titration of Positive Airway Pressure in Patients with Obstructive Sleep Apnea; J. Clin. Sleep Med 2008, 4(2)
Clinical Guideline for the Evaluation, Management and Long-term Care of Obstructive Sleep Apnea in Adults; J. Clin. Sleep Med 2009, 5(3)
Best Clinical Practices for the Sleep Center Adjustment of Noninvasive Positive Pressure Ventilation (NPPV) in Stable Chronic Alveolar Hypoventilation Syndromes, J.Clin.Sleep Med 2010, 6(5)
The suggested titration protocols are consistent with those from the following studies and the AASM clinical guidelines.

6. CPAP Titration Protocol
Ask audience to tell you what they do. You will later reinforce the concepts that we have in Acclimation Phase and let them know that they do things the way other centers do and the way sleep leaders in the field do.
What steps do you take during the initial part of the night when the patient is still awake?
What are your goals during the actual titration and as the study is coming to a close?
Before we go into detail, I want you to step back for a minute and think about the process that you go through every night as you are performing a titration study, whether it is a full night titration study or a split night titration study.

7. CPAP patient types
The patient types that can be treated by CPAP are the typical OSA patient, that is the majority of the users. But CPAP can also be a treatment for those that have restrictive disorders, OHS, complex SDB, periodic breathing and COPD, especially those that have Overlap Syndrome.

8. Complex Sleep Apnea Components
OSA
Central SDB
Hypoventilation
Obstructive apneas Obstructive hypopneas
Noninvasive Ventilation
Central Apnea
Central Hypopnea
Periodic Breathing
CSR
CPAP
APAP
BiLevel
This is another way to look at matching the right technology with the right patient. By assessing a patient’s breathing patterns, one can determine the best type of device needed then match the specific device to treat the majority of the patient’s breathing pathologies. When multiple pathologies exist, choose the device that will treat the majority of breathing patterns and pathologies. Everything won’t initially get treated but will likely improve over time with adherence to therapy.
Click 1 OSA patients can be treated optimally with CPAP, APAP, BiPAP or BiPAP Auto1
Click 2 Patients with central events and hypoventilation require noninvasive ventilation. Depending on their pathology, BiPAP autoSV Advanced or BiPAP AVAPS may be the best therapy2,3
Click 3 BiPAP AVAPS is FDA approved for patients with chronic respiratory insufficiency. Therefore patients with central apneas (often chronic pain patients on high levels of pain medication) and complex sleep apnea patients whose primary pathology is central apneas (vs periodic breathing and obstructive apneas and hypopneas) benefit from BiPAP AVAPS as well.
Click 4 The FDA has cleared auto SV Advanced for treatment of SDB patients whose primary pathology is periodic breathing such as Cheyne Stokes AND complex sleep apnea patients whose primary central pathology is periodic breathing such as Cheyne Stokes. Note that the algorithm in the BiPAP autoSV Advanced is not intended to treat hypoventilation.
Most sleep technologists have vast experience titration CPAP. Patients’ whose pathology is primarily OSA respond well to therapy and most often can be titrated adequately with excellent therapeutic results by the end of one titration night. Complex sleep apnea patients are not recognized by definition until a titration is in progress so typically need a full night titration that may challenge even the most experienced, brilliant technologist!
Assessment of follow-up data via patient interview and Encore downloads is essential in making the optimal therapeutic match. For some patients, this may be accomplished in steps starting with CPAP/APAP and progressing to other technologies as compliance and efficacy are assessed and underlying breathing patterns are unmasked. A separate presentation is available to cover follow-up in detail.
REFERENCES:
1 AASM guidelines Journal of Clinical Sleep Medicine, Vol.5, No. 3, 2009
2 Flenley DC. Clin. Chest Med. 1985:6(4)
3 McNicholas, W. Chest 2000:117:
Auto Servo Ventilation
Volume Assured Pressure Support with Rate

9. Acclimation zone
Acclimation Zone critical to making great first impression
Need to establish or continue to refine a best practice
Introduce FOSQ to evaluate impact on QOL and Comfort Series
During the Acclimation Zone, the sleep technologist’s interactions with the patient include:
assessing the impact the disease has on the sufferer’s life – we recommend using FOSQ which we will talk about in just a minute
personalizing the education
sizing and fitting the mask: Comfort Series
acclimating the patient to PAP therapy typically to a pressure up to 10 cm H20
helping the patient determine their C-Flex Comfort setting.
The Acclimation Zone is critical to making that great first impression. Be sure that you are evaluating the steps in your acclimation process. Be sure to evaluate what, where, how, when and why for each step in the process. Establish a “best practice” for your lab and monitor how well you are doing and what the impact is based on the changes you have made.

10. Titration zone
Now we will go through the titration zone. Basically you will be observing for apneas and partial airway obstruction and then increase the CPAP level. If a central apnea or hypopnea is observed then the CPAP should be decreased and observed for 20 minutes to see if the centrals go away.
If centrals persist, then BiPAP AutoSV should be considered.

11. Prescription zone
After successful titration then you will be able to move to the prescription zone. This zone is particularly helpful for the more complex devices when a doctor unfamiliar with the device may be responsible for writing the prescription.

12. BiPAP S Titration protocol
We can not move on to titration of the BiPAP S.

13. BiPAP S patient types
The BiPAP S patient types include the OSA , COPD, OHS and restrictive disorders, just like the CPAP patient types, but you might also see the BiPAP S used for neuromuscular disorders, as well.

14. Bi-level S mode Bi-level support with spontaneous mode activated
This mode is commonly used with patients who are able to maintain a constant respiratory rate, but require a pressure difference for comfort or to augment a tidal volume while they sleep.
Can be used with the following patients:
Non compliant CPAP
Non tolerance to CPAP
Obesity hypoventilation
COPD or restrictive thoracic
The Bi-level S mode is a mode in which the patient is able to breathe spontaneously and maintain a consistent rhythm. However, if the patient requires assistance in maintaining a tidal volume or needs to have their tidal volume augmented, the settings required for Bi-Level S mode determine the IPAP setting and EPAP setting. It is also the suggested treatment for patients who have failed CPAP therapy and have an underlying disorder of OSA.

15. BiPAP S acclimation zone
BiPAP S will be for those that can not fall asleep on CPAP, or can not tolerate pressure increases. Acclimate the patient by establishing the initial settings, ensuring the proper mask fit to minimize leaks. Mask fit is best tested with the patient lying down with pressure turned on.

16. BiPAP S titration zone
Moving on to titration with BiPAP S. Since you are titrating both an IPAP and an EPAP, you must be aware of changing both pressures when needed.
Presenter: Go through the decision tree with the audience so they know when to increase IPAP and EPAP.

17. BiPAP S prescription zone
After successful titration, you will be able to write a proper prescription for the DME.

18. Patient follow-up Continuing clinical assessment is essential for:
Compliance
Efficacy
Complex sleep apnea patient may be the most challenging to follow up because they have multiple, changing pathologies requiring therapy
Achieving optimal therapy and meeting patient comfort needs can be a challenge that requires ongoing assessment of therapy device downloads and interviews with the patient
Now that you have gone through the titration, it is good to know that once the patient leaves the sleep lab that they can still be monitored via Encore Data management software to access compliance and efficacy of their therapy.
Encore is addressed in a separate presentation.