Clinical Guidelines to
Manual PAP Titrations in
Adults & Pediatrics
Glenn Roldan, RPSGT, RST
www.sleepeducators.com
© 2014
Recommendations
• Scope of PAP titration recommendations is restricted to adult (> 12
years) and pediatric (< 12 years) patients with obstructive sleep
apnea.
• These recommendations do not apply to patients with conditions
such as neuromuscular disease or intrinsic lung disease.
• The optimal setting for the titration on CPAP or BPAP is in an AASM
accredited sleep center or lab, with the titration protocol
implemented by registered polysomnographic technologists and
review of the titration study by a board certified sleep specialist.
• The recommendations for the minimum and maximum PAP may be
constrained by the specific PAP device used during the titration
protocol.
• These recommendations should not be followed in a “cook book”
manner but techs and clinicians should use their experience and
judgment with application of these recommendations to attain the
best possible titration in any given patient.
General Recommendations
• All potential PAP Titration Candidates should
receive:
– adequate PAP education
– hands-on demonstration
– careful mask fitting
– acclimatization prior to titration
• Recording the airflow signal generated by the PAP
device or estimating airflow by measurement of the
pressure difference between the mask and the
outlet of the machine using a pressure transducer:
with or without square root transformation of the
signal, are acceptable methods for detecting
apneas or hypopneas.
General Recommendations
• Nasal Airflow obtained from a Thermistor or
Thermocouple placed under the PAP mask is NOT
an acceptable method of detecting apneas or
hypopneas.
• Respiratory Effort-Related Arousals may be
estimated by flattening of the inspiratory airflow
profile associated with an arousal when airflow
changes do not meet criteria for apneas or
hypopneas.
• Sawtooth patterns in the unfiltered airflow or mask
pressure tracings and/or detection of vibration by
Piezoelectric transducers or microphones applied
to the neck are acceptable methods for detecting
snoring.
Recommendations for Conducting CPAP
studies in Peds or Adults with OSA
• CPAP should be increased until the
following obstructive respiratory
events are eliminated (no specific
order) or the recommended maximum
CPAP is reached:
– Apneas
– Hypopneas
– RERAs
– Snoring
Recommendations for Conducting CPAP
studies in PEDS or Adults with OSA
• Starting at a higher CPAP may be
selected for patients with an
elevated body mass index and for
retitration studies.
• CPAP should be increased by 1 cm
H20 with an interval no shorter than
5 minutes, with the goal of
eliminating obstructive respiratory
events.
PAP Titrations for Adults & PEDS
(> 12 years) (< 12 years)
• The recommended • The recommended maximum
maximum should be 20.0 should be 15.0 cm H20.
cm H20. • Increase CPAP if at least 1
• Increase CPAP if at least 2 obstructive apnea is observed.
obstructive apneas is • Increase CPAP if at least 1
observed. hypopnea is observed.
• Increase CPAP if at least 3 • Increase CPAP if at least 3
hypopneas are observed. RERAs are observed.
• Increase CPAP if at least 5 • Increase CPAP if at least 1
RERAs are observed. minute of loud or unambiguous
• Increase CPAP if at least 3 snoring is observed.
minutes of loud or
unambiguous snoring is
observed.
General Recommendations
• “Exploration” of CPAP above the pressure at
which control of abnormalities in respiratory
parameters is achieved should not exceed 5 cm
H20.
• If the patient awakens and complains that the
pressure is too high, the pressure should be
restarted at a lower pressure, chosen as one
that the patient reports comfortable enough to
allow to return to sleep.
• “Down” titration is not required but may be
considered as an option.
General Recommendations
• The titration algorithm for split-night CPAP titration
studies should be identical to that of full-night
CPAP titration studies.
• If the patient is uncomfortable or intolerant of high
pressures on CPAP, the patient may be tried on
BPAP. If there are continued obstructive
respiratory events at 15 cm H20 of CPAP during
the titration study, the patient may be switched to
BPAP.
General Recommendations
• BPAP (IPAP and/or EPAP) should be increased
until the following events are eliminated (no
specific order) or the recommended maximum
IPAP is reached:
– Apneas
– Hypopneas
– RERAs
– Snoring
• Starting at higher IPAP or EPAP may be
selected for patients with an elevated BMI and
for retitration studies.
• The recommended maximum IPAP should be
20.0 cm H20.
General Recommendations
• The recommended minimum IPAP-EPAP
differential is 4 cm H20 and the recommended
maximum IPAP-EPAP differential is 10 cm
H20.
• IPAP and/or EPAP should be increased by at
least 1 cm H20 apiece with an interval no shorter
than 5 minutes, with the goal of eliminating
obstructive respiratory events.
• The recommended minimum starting IPAP and
EPAP should be 8 cm H20 and 4 cm H20 in
pediatric and adult patients.
BPAP Titrations for Adults & PEDS
(> 12 years) (<12 years)
• IPAP and EPAP • IPAP and EPAP should
should be increased if be increased if at least 1
at least 2 obstructive obstructive apnea is
apneas are observed. observed.
• IPAP should be • IPAP should be increased
increased if at least 3 if at least 1 hypopnea is
hypopnea is observed. observed.
• IPAP should be • IPAP should be increased
increased if at least 5 if at least 3 RERAs are
RERAs are observed. observed.
• IPAP may be • IPAP may be increased if
increased if at least 3 at least 1 minute of loud
minutes of loud or or unambiguous snoring
unambiguous snoring is observed.
is observed.
General Recommendations
• “Exploration” of IPAP above the pressure at
which control of abnormalities in respiratory
parameters is achieved should not exceed 5 cm
H20.
• If the patient awakens and complains that the
pressure is too high, the pressure should be
restarted at a lower IPAP, chosen as one that
the patient reports is comfortable enough to
allow return to sleep.
General Recommendations
• A decrease in IPAP or setting BPAP in
spontaneous-timed (ST) mode with backup rate
may be helpful if treatment-emergent central
apneas (i.e., complex sleep apnea) are observed
during the titration study.
• “Down” titration is not required but may be
considered as an option.
• The titration algorithm for split-night BPAP
titration studies should be identical to that of full-
night BPAP titration studies.
Acceptable PAP Titration Study
• The CPAP or BPAP selected for patient use
following the titration study should:
– reflect control of the patient’s obstructive
respiratory by a low (preferably <5/hr) RDI at
the selected pressure
– a minimum sea level SpO2 above 90% at the
pressure
– a leak within acceptable parameters at the
pressure.
Grading System
• Optimal titration reduces RDI 5/hr for at least 15-min
duration and should include supine REM sleep at the
selected pressure that is not continually interrupted by
spontaneous arousals or awakenings.
• Good titration reduces the RDI < 10/hr or by 50% if
the baseline RDI <15/hr and should include supine
REM sleep that is not continually interrupted by
spontaneous arousals or awakenings at the selected
pressure.
• Adequate titration is one that does not reduce the RDI
< 10/hr but does reduce the RDI by 75% from baseline
(especially in severe OSA patients), or one in which the
titration grading criteria for optimal or good are met with
the exception that supine REM sleep did not occur at
the selected pressure.
Grading System
• Unacceptable titration is one that does not meet
any one of the above grades.
• Repeat PAP titration should be considered if the
initial titration does not achieve a grade of optimal or
good and, if it is a split-night PSG study, it fails to
meet AASM criteria.
Leak & Comfort
• PAP mask refit or readjustment should be performed
whenever any significant unintentional leak is
observed.
• There is insufficient evidence for what constitutes a
clinically significant leak given mask fit and other
factors. An unacceptable leak for PAP is one that is
substantially higher than the leak recorded at a
given pressure from a well-fitted, applied, and
secured interface. The acceptable leak will always
exceed intentional leak, which depends on the
applied pressure and interface type.
Leak & Comfort
• Pressure waveform modification technology may
improve patient comfort and adherence with PAP.
• Ideally, the patient should be recorded in supine
REM sleep for at least 15 min at the designated
optimal pressure during the PAP titration study. If
the patient is in REM but not supine, the patient may
be awakened and instructed to lie in the supine
position.
Supplemental Oxygen
• Should be added during the PAP titration when,
prior to PAP titration, the patient’s awake supine
SpO2 while breathing room air is < 88% for > 5
minutes in the absence of obstructive respiratory
events.
• In both instances, supplemental O2 should be
introduced at 1 L/min and titrated upwards to
achieve an SpO2 between 88% and 94%.
Supplemental Oxygen
• The minimum starting O2 rate should be 1 L/min
(both pediatrics and adults).
• O2 rate should be increased by 1 L/min with an
interval no shorter than 15 min, until SpO2 is
between 88 and 94%.
• Optimally, supplemental O2 should be connected
to the PAP device outlet (using a T-connector).
• “Weaning” down of O2 supplementation by
employing BPAP or by further increasing IPAP and
if the patient tolerates the higher inspiratory
pressure can be attempted.
Adaptive Servoventilation (ASV)
• May be considered if the patient is
observed to have Cheyne-Stokes
respiration or if treatment emergent
central sleep apnea (i.e., complex
sleep apnea) during the titration study
is not eliminated by down titration of
pressure.
Follow-up After PAP Titration Study
• PAP usage should be objectively monitored to
help assure utilization.
• Troubleshooting of problems encountered while
on PAP management of side effects, and
methods to increase adherence should be a part
of the close follow-up of the patient on PAP.
Reference
Clinical Guidelines for the Manual Titration of
Positive Airway Pressure in Patients with
Obstructive Sleep Apnea. Task Force
Members: Clete A. Kushida, M.D., Ph.D.,
RPSGT, Alejandro Chediak, M.D., Richard B.
Berry, M.D., Lee K. Brown, M.D., David Gozal,
M.D., Conrad Iber, M.D., Sairam Parthasarathy,
M.D., Stuart F. Quan, M.D., James A. Rowley,
M.D. Journal of Clinical Sleep Medicine, 157-
171, 2008.
