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Purpose: To investigate the prevalence of treatment-emergent central sleep apnea (TECSA) in individuals with obstructive sleep apnea syndrome (OSAS) during continuous positive airway pressure (CPAP) titration and assess their polysomnographic characteristics. Methods: A total of 116 patients with OSAS who underwent full-night CPAP titration at the Sleep Laboratory of Adana City Research and Education Hospital from September 2017 to January 2018 were recruited for the study. The patients' polysomnographic data related to respiratory events and sleep stages were reviewed in a retrospective manner. Results: While on CPAP titration, 20 of the 116 patients developed central sleep apnea (CSA). The prevalence of TECSA in the patients with OSAS was 17.2%, being separately determined as 16.3% and 2.2% for the male and female patients, respectively. In the baseline PSG, the groups did not statistically significantly differ in relation to the apnea hypopnea index (AHI), central apnea index (CAI), arousal index (AI), or oxygen desaturation index (ODI). However, the TECSA group had a significantly higher mean oxygen saturation value compared to the non-TECSA group (p = 0.01). The total AHI, CAI, and AI values of the TECSA group were significantly higher during the whole CPAP titration compared to the non-TECSA group. No significant difference was observed in the comparison of the two groups in relation to the titration pressure and ODI. Conclusion: TECSA is a phenomenon that can occur with obstructive sleep apnea treatment and mostly regress spontaneously following appropriate CPAP treatment. TECSA is observed at different rates of prevalence. In this study, the prevalence of TECSA was higher than previously reported. [ABSTRACT FROM AUTHOR]

Purpose: To examine potential clinical, demographic, anthropometric, and polysomnographic predictors of successful auto-adjusting continuous positive airway pressure (CPAP) titration for treatment of obstructive sleep apnea (OSA). Methods: This cross-sectional study was conducted in adults diagnosed with moderate-to-severe OSA (baseline apnea–hypopnea index [AHI] ≥ 15.0/h), who underwent auto-adjusting CPAP titration (S9 or S10 AutoSet ResMed®) in a sleep laboratory setting while wearing a nasal or pillow mask. Participants were then grouped into two groups: optimal CPAP titration (residual AHI < 5.0/h) or suboptimal CPAP titration (residual AHI ≥ 5.0/h). Multivariate logistic regression analysis was used to assess possible independent predictive factors for suboptimal CPAP titration. Results: A total of 1222 adults consisting of 874 subjects with optimal CPAP titration (71.5%) and 348 subjects with suboptimal CPAP titration (28.5%) were evaluated. Multivariate analysis resulted in a model with an adequate calibration (Hosmer–Lemeshow chi-square-test: 7.088; p = 0.527), with male sex, higher values of baseline AHI, therapeutic pressure (95th percentile), and mask leak (95th percentile) emerging as significant and independent predictors for suboptimal CPAP titration: adjusted odds ratio (OR): 1.456 (95% confidence interval [CI] 1.076–1.971; p = 0.015), OR: 1.009 (95% CI 1.002–1.016; p = 0.013), OR: 1.281 (95% CI 1.206–1.361; p < 0.001), and 1.035 (1.026–1.043; p < 0.001), respectively. Conclusions: In a large cohort of adults undergoing auto-adjusting CPAP titration due to moderate-to-severe OSA, male sex, increased values of baseline AHI, pressure requirements, and mask leak were significant predictors for less than optimal CPAP titration. [ABSTRACT FROM AUTHOR]

Objective: To assess the effects of anatomical, clinical parameters, and pulmonary respiratory function on the therapeutic titration pressure of continuous positive airway pressure (CPAP) device in obstructive sleep apnea syndrome (OSAS).Methods: The study comprised 41 OSAS patients whose optimum CPAP titration pressures were measured. Each patient underwent an otorhinolaryngologic and thoracic examination, and data was recorded for height, weight, body mass index, neck-waist circumferences, Mallampati classification, tonsillar hypertrophy, hypopharyngeal collapse, soft palate-tongue base obstruction scores, peak nasal inspiratory flow and acoustic rhinometry measures, and CPAP device therapeutic pressures. Forced vital capacity, forced expiratory volume, FEV1/FVC ratio and peak expiratory flow values were noted.Results: Median CPAP optimal pressure cut-off value was determined as 9 mmH2O. Statistical analysis was made in two groups as CPAP titration optimal pressure ≤9 and >9 mmH2O. In the optimal pressure >9 group, neck and waist circumferences, hypopharyngeal collapse score, retropalatal and retrolingual lateral wall collapse scores were significantly higher (p

Study Objectives: Although the full-night continuous positive airway pressure (CPAP) titration (fnPT) has been recognized as the gold standard for determining an optimal therapeutic pressure for obstructive sleep apnea (OSA) treatment, it is labor-intensive, time-consuming because it requires overnight polysomnography attended by well-experienced sleep technologists. The aim of this study is to develop a practical and feasible alternative titration method. Methods: We assessed demographic data and diagnostic polysomnographic parameters, time spent in CPAP titration, CPAP efficacy and long-term adherence of the two groups of our OSA patients who had received CPAP titration either by fnPT (n = 46) or by afternoon CPAP titration (aPT, n = 22). Main results: Mean total recording time of aPT was significantly shorter than that by fnPT (p < 0.0001). There was no significant difference in mean residual apnea hypopnea index (AHI) on treatment, percent days with device usage, cumulative device usage hours during the 360 days, average device usage hours per day (360 days, days used), and percent of days with device usage = 4 hours during the 360 days after starting CPAP treatment between the two groups. Conclusions: Our study demonstrated that aPT was feasible procedure as an alternative to fnPT. [ABSTRACT FROM AUTHOR]

Purpose: Mask type (nasal versus oronasal) can affect the optimal pressure required to correct the apnea/hypopnea index (AHI) in obstructive sleep apnea (OSA) subjects treated with CPAP. Our objective was to evaluate if mask type influenced CPAP titration outcomes in OSA patients. Methods: A retrospective study of individuals with a baseline AHI ≥ 15.0/h, who received an auto-adjusting CPAP titrating device (S9 AutoSet ResMed®) in a sleep-lab setting. The mask type oronasal (OM) or nasal (NM) was always selected by the patients. Optimal pressure requirements, leak, and residual AHI were compared based on mask type. Results: Overall, 436 patients were included: 283 with NM (64.9%) and 153 with OM (35.1%). At baseline, NM and OM cohorts had similar AHI (p = 0.160). Patients allocated to the OM cohort had a higher 95th percentile pressure, a higher 95th percentile leak, and a higher residual AHI than those with a NM: pressure requirement: 12.9 cm H2O (IQR: 10.6–15.0) versus 10.7 cm H2O (IQR: 9.2–12.3); leak: 21.6 L/min (IQR: 9.6–37.2) versus 9.6 L/min (IQR: 3.6–19.2); and residual AHI: 4.9/h (IQR: 2.4–10.2) versus 2.2/h (IQR: 1.0–4.4), respectively (p < 0.001 for all). Conclusions: CPAP mask type based on individual preferences exerts profound effects on optimal CPAP pressures and efficacy. Patients titrated with OM showed higher pressure requirements, had higher a leak, and higher residual AHI when compared to NM, which may adversely impact treatment adherence and other health outcomes. [ABSTRACT FROM AUTHOR]

Objective: To assess the effects of anatomical, clinical parameters, and pulmonary respiratory function on the therapeutic titration pressure of continuous pos itive airway pressure (CPAP) device in obstructive sleep apnea syndrome (OSAS). Methods: The study comprised 41 OSAS patients whose optimum CPAP titration pressures were measured. Each patient underwent an otorhinolaryngologic and thoracic examination, and data was recorded for height, weight, body mass index, neckwaist circumferences, Mallampati classification, tonsillar hypertrophy, hypopharyngeal collapse, soft palate-tongue base obstruction scores, peak nasal inspiratory flow and acoustic rhinometry measures, and CPAP device therapeutic pressures. Forced vital capacity, forced expiratory volume, FEV1/FVC ratio and peak expiratory flow values were noted. Results: Median CPAP optimal pressure cut-off value was determined as 9 mmH2O. Statistical analysis was made in two groups as CPAP titration optimal pressure ≤9 and >9 mmH2O. In the optimal pressure >9 group, neck and waist circumferences, hypopharyngeal collapse score, retropalatal and retrolingual lateral wall collapse scores were significantly higher (p<0.05). In multivariate and univariate model analysis, neck and waist circumferences, hypopharyngeal collapse score, retropalatal and retrolingual lateral wall collapse scores were observed to be significant in predicting high and low pressures in univariate model. Conclusion: For the prediction of optimal CPAP titration pressure in OSAS treatment, wide neck and waist circumferences, high hypopharyngeal collapse score and retropalatal and retrolingual lateral wall collapse grades may be determinative. [ABSTRACT FROM AUTHOR]

Background: Continuous positive airway pressure (CPAP) is considered the gold standard treatment of obstructive sleep apnea (OSA). However, it can be a challenge in some patients to find an effective CPAP setting that is well tolerated. A lower CPAP setting may improve patient tolerance of the treatment. The objective of this study was to evaluate the effect of approximately 30° torso elevation on minimum effective CPAP for the treatment of OSA. Methods: A retrospective chart review was performed to determine the effective CPAP setting required to treat OSA in patients who underwent CPAP titration with torso elevation using a wedge cushion, after having failed during the same titration study to achieve therapeutic results at CPAP of 20 cm H2O without torso elevation. Results: Thirty-nine patients who underwent CPAP titration with and without torso elevation utilizing a wedge cushion had statistically significant lowering of the minimum effective CPAP setting with torso elevation, with a mean CPAP reduction of 4.7 (p < 0.001) compared to ineffective treatment at CPAP of 20 cm H2O without torso elevation. Apnea hypopnea index (AHI), respiratory disturbance index (RDI), and lowest oxygen saturation (SpO2) were all improved with torso elevation, with a mean AHI difference of 4.4 (p = 0.03), mean RDI difference of 14.2 (p = 0.001), and mean SpO2 difference of 5.9% (p = 0.002). Age and BMI were inversely correlated, and gender had no correlation with therapeutic CPAP settings with use of torso elevation. Conclusion: Torso elevation of approximately 30° resulted in effective CPAP treatment at settings significantly lower than 20 cm H2O in all reviewed OSA patients, who had been ineffectively treated without torso elevation at the maximum tested setting of 20 cm H2O. This intervention may be a useful adjunct during in-lab titration studies for patients who are not effectively treated at or cannot tolerate high CPAP settings. [ABSTRACT FROM AUTHOR]

Introduction: Traditionally, evaluation of obstructive sleep apnea (OSA) has consisted of a diagnostic polysomnogram (PSG), followed by a continuous positive pressure (CPAP) titration. However, to reduce costs, many third-party payers mandate performance of split-night studies (SPL), combining diagnostic and CPAP titration testing. We ascertained the utility of performing SPL for diagnosis and treatment of OSA. Methods: We reviewed the PSG records of 200 patients suspected of having OSA. Using both American Academy of Sleep Medicine (AASM) and Medicare (CMS) criteria for scoring, we calculated the sensitivity, specificity, positive (PPV), and negative predictive value (NPV) of the AHI in the first 2 h of sleep for predicting an overall AHI > 15. Results: For predicting an overall AHI > 15, the sensitivity, specificity, PPV, and NPV of an AHI (AASM criteria) > 40 in the first 2 h were respectively: 0.304, 1.000, 1.000, and 0.335. For an AHI > 20 in the first 2 h, the corresponding values were 0.770, 0.962, 0.983, and 0.595. Corresponding values using CMS criteria were 0.347, 1.0, 1.0, and 0.6 for AHI > 40, and 0.693, 0.99, 0.986, and 0.76 for AHI > 20, respectively. Conclusion: For justification of CPAP (overall AHI > 15), the sensitivity is slightly lower when using an AHI > 40 vs AHI > 20, but the specificity and PPV are much higher. Using AHI > 20 as criteria for SPL as opposed to the guideline criteria of AHI > 40 may be more effective in obtaining CPAP for patients with moderate to severe OSA. [ABSTRACT FROM AUTHOR]

Background: Split-night polysomnography was introduced to obtain diagnosis and determine an effective CPAP on a single night that would be convenient and cost effective. Aim of the study: To evaluate the efficacy of split night CPAP titration in comparison with conventional full night titration in patients with moderate and severe OSAS. Patients and methods: Matched patients for age, sex, body mass index and disease severity were enrolled in the study and classified into two groups either split night or full night group. Results: Sixty matched patients in each group (full night and split night group) were included in the study. Regarding sleep parameters, sleep efficiency (75.9 ± 15.7 vs. 81.5 ± 10.5, p = 0.024) was significantly shorter, stage 1% was significantly higher (22.3 ± 14 vs. 17.9 ± 15.8, p = 0.013) and REM % (23.9 ± 18.7 vs. 31.3 ± 14.8, p = 0.019) was significantly lower during split night CPAP titration compared to full night titration study. Unsuccessful CPAP titration was significantly higher in split night group than the full night group (30 (50%) vs. 16 (35.5%), p = 0.025). Apnea hypopnea index >36.4 during diagnostic part and total sleep time at least 2.45 h during CPAP part of split night titration were identified as the optimum cut off for successful titration with 73.5% sensitivity, 43.3% specificity and 74% sensitivity, 70% specificity respectively. Conclusion: Split night sleep study is more commonly associated with unsuccessful CPAP titration than full night titration but successful titration could be obtained during split night titration in patients with severe AHI >36.5 event/h.

Background: Perceived Health Related Quality of Life (HRQoL) is impaired in obstructive sleep apnea (OSA). This study examines changes in HRQoL aspects occurring immediately after CPAP titration. Furthermore, we analyzed variations in each gender and in patients undergoing home or laboratory-based CPAP titration pathways. Methods: Twohundredfive outpatients (151 M) (56.7 ± 10.3 years) were evaluated, before first visit and nocturnal diagnostic examination (T0), and the morning after CPAP titration (T1). Two self-reported HRQoL questionnaires were administered: Psychological General Well-Being Index (PGWBI), composed by six subscales, and 12-Item Short-Form Health Survey (SF-12), including Physical (PCS) and Mental Component Summaries (MCS). CPAP titration was performed using auto-adjusting CPAP units at patients' home or in the sleep laboratory. Results: PGWBI scores at T1 improved compared to T0 (p < 0.0001). A similar improvement was observed in SF-12 MCS (p = 0.0011), but not in SF-12 PCS. Changes were independent from anthropometric parameters, OSA severity and excessive daytime sleepiness. Gender comparisons showed better HRQoL in males at both times. At T0, patients who received home or laboratory CPAP titration pathways did not show any differences in PGWBI and SF-12 scores. At T1, PGWBI and SF-12 MCS improved in both home and laboratory groups. Conclusions: This study gives evidence that first time CPAP application for titration can lead to a general increase in perceived well-being. Gender comparisons showed better perceived HRQoL with more subscales improvements in males after CPAP titration. The improvement was similar with both home and laboratory CPAP titration pathways. [ABSTRACT FROM AUTHOR]

Purpose To determine whether obstructive sleep apnea syndrome (OSAS) patients with mixed sleep apnea (MSA) have different clinical, polysomnographic, and continuous positive airway pressure (CPAP) titration findings compared to OSAS patients without MSA. Methods We retrospectively reviewed the records of OSAS patients who had undergone CPAP titration and categorized them into pure-OSA and mixed-OSA groups. Demographic features, daytime sleepiness, and apnea severity were compared between the two groups using univariate and multivariate analyses. CPAP titration findings were also compared between the two groups. Results One hundred and ninety-five subjects (n = 126 pure-OSA; n = 69 mixed-OSA) were included in the analysis. Compared to the pure-OSA group, the mixed-OSA group had a higher percentage of males ( p = 0.003) and a higher body mass index ( p = 0.044), Epworth Sleepiness Scale score ( p = 0.028), and apnea–hypopnea index (AHI) ( p < 0.001). In logistic regression analysis, older age, male sex, and higher body mass index were independently associated with mixed-OSA before PSG study. When using AHI as a covariable, the higher AHI with older age, male sex, and daytime sleepiness was independently related to mixed-OSA. The mixed-OSA group had a higher percentage of patients with complex sleep apnea, a lower percentage of patients with optimal titration, and a higher titrated pressure than the pure-OSA group. Conclusions Severe OSA, older age, male sex, obesity, and daytime sleepiness were related to mixed-OSA. Complex sleep apnea, less optimal titration, and a higher titrated CPAP were also associated with MSA in OSAS patients. [ABSTRACT FROM AUTHOR]

Complex sleep apnea ( CompSA) is defined as the development of central events during a continuous positive airway pressure ( CPAP) titration in a patient with obstructive sleep apnea ( OSA). We hypothesized that patients with OSA on chronic opioids would fail a CPAP titration more frequently than patients with OSA not on opioid therapy and that the increased failure rate would be due to a greater prevalence of CompSA. In a retrospective chart review, we identified 58 patients with OSA on opioids and compared them to 150 patients with OSA not on opioids. CPAP titration failure was defined as an apnea-hypopnea index greater than 5/h at all CPAP pressures tested. CompSA was defined as the development of a central apnea index greater than 5/h during the CPAP titration study. Nineteen of the 58 patients (32.8%) with chronic opioid use and 18 of the 150 (12.0%) in the control group had CPAP titration failure ( P-value 0.001). Six of the 49 patients (12.2%) with pure OSA in the opioid group and 5 of the 146 (3.4%) with pure OSA in the control group developed CompSA (odds ratio: 3.93; 95% confidence interval: 1.14-13.52; P-value: 0.03). Logistic regression showed that opiate use still predicted the presence of CompSA after coronary artery disease, hyperlipidemia, antidepressant usage and benzodiazepine use were accounted for. Patients on chronic opioid therapy had a higher percentage of treatment failure, and this was secondary to a higher prevalence of CompSA and persistence of central events seen on the diagnostic sleep study. [ABSTRACT FROM AUTHOR]

BACKGROUND: The Hoffstein formula is the most widely used equation to predict optimal CPAP pressure in patients with obstructive sleep apnea, but it is based on data from white patients. The purpose of this study was to develop an equation for optimal CPAP based on data from Asian patients, and to compare this new formula with the Hoffstein formula. METHODS: We retrospectively reviewed the records of 356 Korean subjects with obstructive sleep apnea who had undergone successful CPAP titration, and randomly divided them into 2 groups, with 178 subjects per group. In group 1 we used stepwise multiple linear regression analysis to develop a predictive equation for optimal CPAP. Then we compared our equation with the Hoffstein equation in group 2. RESULTS: A predictive equation was: predicted pressure (cm H2O) = 6.656 + 0.156 x (body mass index [kg/m2]) - 0.071 x (minimal SpO2 [%]) + 0.041 x (respiratory disturbance index) + 0.094 x (score of Epworth Sleepiness Scale). This equation accounted for 38.9% of the total variance (P < .001). Proportions of optimal estimation of CPAP pressure were 38.8% and 36.5% in this equation and the Hoffstein equation, respectively. The Hoffstein formula significantly underestimated CPAP, compared with our formula. CONCLUSIONS: Although our equation was somewhat better to predict optimal CPAP level in Asian subjects than the Hoffstein equation, the CPAP prediction equation did not accurately predict the prescribed CPAP level. Therefore, the usefulness of the CPAP prediction formula is limited in some clinical settings [ABSTRACT FROM AUTHOR]

Background: There have been reports that optimal CPAP pressure can be predicted from a previously derived formula, with the Hoffstein formula being the most accurate and accepted in the literature so far. However, the validation of this predictive model has not been applied in different clinical settings. Our aim was to compare both the Hoffstein prediction formula and a newly derived formula to the CPAP pressure setting assessed during a formal CPAP titration study. Methods: We prospectively studied 1,111 patients (871 males/240 females) with obstructive sleep apnea hypopnea syndrome (OSAHS) undergoing a CPAP titration procedure. In this large population sample, we tested the Hoffstein formula, utilizing body mass index (BMI), neck circumference and apnea/hypopnea index (AHI), and we compared it with our new formula that included not only AHI and BMI but also smoking history and gender adjustment. Results: We found that using the Hoffstein prediction formula, successful prediction (predicted CPAP pressure within ±2 cm HO compared to the finally assessed optimum CPAP pressure during titration) was accomplished in 873 patients (79%), with significant correlation between CPAP predicted pressure (CPAPpred) and the optimum CPAP pressure (CPAPopt) [ r = 0.364, p < 0.001]. With the new formula, including smoking history and gender adjustment, successful prediction was accomplished in 1,057 patients (95%), with significant correlation between CPAP predicted pressure (CPAPpred) and the CPAPopt ( r = 0.392, p < 0.001). However, there was a highly significant correlation between the two formulas ( r = 0.918, p < 0.001). Conclusions: We conclude that the level of CPAP necessary to abolish sleep apnea can be successfully predicted from both equations, using common clinical measurements and prediction formulas that may be useful in calculating the starting pressure for initiating CPAP titration. It may also be possible to shorten CPAP titration and perhaps in selected cases to combine it with the initial diagnostic study. [ABSTRACT FROM AUTHOR]

Objective: The aim of the study was to investigate the need for pressure change in patients with sleep-disordered breathing (SDB) several weeks after therapy initiation. We prospectively studied 905 consecutive patients (740 men and 165 women) with SDB and therapeutic intervention with continuous positive airway pressure (CPAP)/bilevel PAP. Methods: Several weeks after therapy initiation, patients were restudied for control, and pressure was optimized if it was necessary. The differences in CPAP pressure from initial treatment and control night were assessed. Anthropometric data, polysomnography data, Epworth sleepiness scale, and Berlin questionnaire scores were correlated to pressure differences from the first and control titration nights. Results: Pressure change was needed in 511 patients (58.2%). Pressure increase was more frequent than pressure reduction (41.7% vs. 11.7%). Mean pressure increase in CPAP was 1.3 mbar, and mean decrease, 1.6 mbar. In the bilevel PAP group, the mean increase in inspiratory pressure was 1.2 mbar, and in expiratory pressure, 0.8 mbar; the mean decrease in inspiratory pressure was 1.9 mbar, and in expiratory pressure, 1.4 mbar. No correlation was found between anthropometric data, sleep efficacy, the amount of rapid eye movement sleep per night, or questionnaire scores and pressure change. Conclusion: Our results show that pressure changes are necessary in the majority of patients several weeks after therapy initiation. Therefore, re-evaluation of therapy pressure is useful. [ABSTRACT FROM AUTHOR]

The accepted standard method for titration actually accepted is the conventional polysomnography. It consumes time, qualified personnel and has a high operational cost. Objective: To evaluate the auto adjustable CPAP use for CPAP titration in patients with diagnosis of moderate to severe Obstructive Sleep Apnea (OSA). Material and methods: We report 54 patients with the diagnosis of OSA done by polysomnography (6) and respiratory polygraphy (48). We used the Autoset T (Resmed®) autoadjustable system for titration. All patients received during an office interview the instructions about how to use the equipment before they were taken it home. If results of the first test were not satisfactory, the patient would take it home for a second test. Results: 54 studies were done, one for each patient. In the first test, 8 studies (15%) failed, so they took the equipment home once again. Finally, only in 2 patients (3.7%) the titration failed and they needed a conventional titration with polysomnography. The final pressure to be programmed to the CPAP was defined according to the graphic's visual reading. At the moment we finished the data base, 44 (81%) patients were using the CPAP regularly. Conclusions: We consider that non-conventional titration based on the visual reading of auto adjustable CPAP records is an useful, simple, very cheap CPAP titration method in our country. [ABSTRACT FROM AUTHOR]

Abstract: Background: The duration of automatic computer-controlled continuous positive airway pressure device (autoCPAP) initiation at home varies largely between sleep centers. Our objectives were to evaluate the cost-effectiveness and to find the optimal trial duration. Methods: Of the 206 consecutive CPAP-naive patients with obstructive sleep apnea syndrome, who were referred to our hospital, 166 received autoCPAP for a 5-day trial at home. Results: Of the 166 patients, 89 (15 women) showed a successful 5-day autoCPAP trial (normalized oximetry and mask-on time exceeding 4h/day for at least 4 days). For the first trial day, 88 (53%) patients had normalized oximetry and a mask-on time exceeding 4h. A 1-day autoCPAP trial EUR 668 was less cost-effective than a 5-day trial EUR 653, with no differences in values of efficient CPAP pressure or residual apnea–hypopnea index (AHI). The systematic requirement of oximetry monitoring raised the cost considerably from EUR 481 to EUR 668. Conclusions: In selected patients with obstructive sleep apnea, the optimal duration for initiating CPAP therapy at home by autoCPAP is 5 days. Although a 1-day trial was sufficient to determine the CPAP pressure requirement, it was not cost-effective and had a high rate of failure. [Copyright &y& Elsevier]

Objective: Development of continuous positive airway pressure (CPAP) therapy has become a cornerstone in the treatment of obstructive sleep apnea syndrome (OSAS). Currently, constant pressure CPAP therapy, determined by manual titration during attended second-night polysomnography (PSG), is the standard treatment for OSAS; however, it is expensive and time consuming. It is possible to predict the CPAP pressure by mathematical formula as alternative titration method. In our study, predicted titration pressure (Ppred) and automatic titration pressure (Paut) was compared to reveal any benefit of predetermined CPAP pressure to CPAP therapy. Method: Forty four OSAS patients underwent PSG and automatic CPAP titration. Ppred was calculated with respect to equation which depended on anthropometric features and the apnea hipopnea index of cases as defined in the literature. Results: There was no statistically significant differences between the mean values of Ppred and Paut (P=0.363), correlation was determined between both pressure (r=0.407; p=0.002). In 48% of the cases the Paut value ranges were observed as Ppred ± 1 cm H2O, in 81% as Ppred ± 2 cmH2O, in 88% as Ppred ± 3 cm H2O. Conclusion: It can be concluded that split-night, manual, or automatic CPAP titration with Ppred as the reference value would be a practical method. Ppred may be recalculated according to the changing anthropometric measurements of patients without a control PSG study for readjusting automatic CPAP. [ABSTRACT FROM AUTHOR]

Summary: Flow limitation during sleep occurs when the rise in esophageal pressure is not accompanied by a flow increase which results in a non-rounded inspiratory flow shape. Short periods of flow limitation ending in an arousal or in a fall in SaO2 (hypopnea or upper airway resistance syndrome) are detrimental but the role of prolonged periods of flow limitation (PPFL) has not yet been clarified. This is important not only for diagnosis but also for nasal continuous positive airway pressure (CPAP) titration, especially for the automatic devices that need to be setup. The aim of this study was to analyze the effects of PPFL. We compared the behavior of the mean end-expiratory systemic blood pressure (SBP), end-tidal CO2, esophageal pressure and the pattern of breathing during a period of normal breathing at optimal (CPAP) and during PPFL at suboptimal CPAP in 14 patients with sleep apnea/hypopnea syndrome during a full polysomnography CPAP titration. The mean values of the parameters studied, at optimal and suboptimal CPAP were (1) SBP 92±13 vs. 91±15mmHg (P: ns). At suboptimal CPAP, swings of blood pressure were associated with changes in pleural pressure; (2) SaO2 97.5±1.2 vs. 96.5±1.6 (P: 0.03), (3) end-tidal CO2 43.5±4 vs. 49.5±4 (); (4) oesophageal pressure, 10.5±4 vs. 37.6±15cmH2O () and (5) pattern of breathing: minute ventilation 6.6±1.4 vs. 6.1±1.2L/min (P: ns) and inspiratory time 1.24±0.3 vs. 1.66±0.4s (). It can be concluded that PPFL induces significant physiological changes. Nevertheless, given the scant literature, clinical studies are warranted to elucidate the clinical role of these physiological changes. [Copyright &y& Elsevier]

Increase in upper airway resistance is the main patho-physiological feature in the obstructive breathing disorders during sleep. Upper airway events may be divided into two main groups: static obstruction (apneas) and dynamic obstruction (hypopneas, flow limitation, and snoring). This classification is useful to provide better information about the patho-physiological mechanisms of obstruction and to better define the diagnostic tools necessary for detecting abnormal respiratory events during sleep. Detection of dynamic obstruction requires sensors with a good frequency response. As thermistors have a poor dynamic response, they are not efficient in detecting the dynamic obstruction but are good enough to detect static obstruction. Nasal prongs (NP) connected a to pressure transducer and the impedance signal measured by the forced oscillation technique (FOT) are relatively new tools to noninvasively investigate dynamic upper airflow obstruction during sleep. FOT provides a direct index of the magnitude of airway obstruction and, therefore, of the upper airway patency, even under conditions of no flow (apneas). NP are aimed at assessing flow. Thus, both techniques have a different scope. The main advantages of NP are that they are easy to use and do not require sophisticated technology, while FOT needs a more complex instrumentation. For clinical routine studies NP are probably the best and simplest method for assessing the different respiratory events during sleep. However, FOT would be particularly useful in selected applications such as assessing upper airway patency in some central apneas; interpreting the irregular pattern of breathing during REM sleep; in better characterizing the inspiratory flow-limited breaths classified as intermediate; and in studying upper airway mechanics. [ABSTRACT FROM AUTHOR]

Study Objectives: Attended manual continuous positive airway pressure (CPAP) titration is the standard practice for determining optimal positive airway pressures for obstructive sleep apnea (OSA) treatment. However, an unattended single night auto-titrating positive airway pressure (APAP) titration is an alternative. The goal of this study was to determine whether therapeutic CPAP pressures determined during manual titrations are higher than APAP-generated surrogate pressures., Methods: We conducted a retrospective review of 165 adults with uncomplicated OSA who had full/split-night manual CPAP titrations prior to commencing treatment with APAP. Demographic and clinical data including 30-day APAP compliance data were obtained. We compared the recommended CPAP pressure from manual titrations with the 90th/95th percentile pressure generated from APAP usage over 30 days., Results: The recommended CPAP pressures during the manual titrations were higher than the 90th/95th percentile pressures generated from APAP (11.4 ± 3.4 vs 10.3 ± 2.4 cmH2O; P = .000). Almost half the group (41.9%) had their manually derived titration pressure at least 1.5 cm above the 90th/95th percentile pressure. In multivariate analyses, body mass index was the only variable that predicted higher manual titration pressures. Notably, the average residual apnea-hypopnea index on 30-day APAP data was less than the average residual apnea-hypopnea index observed at the recommended pressure during the manual titration (5.0 ± 4.3 vs 7.2 ± 8.5; P = .006)., Conclusions: Manual CPAP titrations may overestimate pressure requirements, particularly in patients with higher body mass index, and may not be necessary in managing patients with uncomplicated OSA. APAP appears to be at least as effective as single-pressure CPAP, while delivering lower positive airway pressure., Citation: Fashanu OS, Budhiraja R, Batool-Anwar S, Quan SF. Titration studies overestimate continuous positive airway pressure requirements in uncomplicated obstructive sleep apnea. J Clin Sleep Med . 2021;17(9):1859-1863., (© 2021 American Academy of Sleep Medicine.)

Study Objectives: The first-choice therapy for adults with moderate/severe obstructive sleep apnea is continuous positive airway pressure (CPAP). However, studies evaluating whether the therapeutic CPAP level obtained from a titration is affected by sex are surprisingly scarce. Our main objective was to verify if sex influenced the optimal CPAP measurement obtained during a titration., Methods: This cross-sectional study was conducted in adults diagnosed with moderate/severe obstructive sleep apnea [baseline apnea-hypopnea index (AHI) ≥ 15.0 events/h] who underwent auto-adjusting CPAP titration (S9 or S10 AutoSet ResMed) in a sleep laboratory setting. All participants used a nasal mask during the titration. The optimal pressure, leak, and residual AHI values were registered. Multiple linear regression was used to evaluate if clinical and polysomnographic data influenced the therapeutic CPAP level setting (95th percentile pressure)., Results: A total of 1,006 adults were enrolled: 354 women and 652 men. There were no statistically significant sex-related differences in the CPAP requirements and leak values delineated during the titration; all P -values > .005. However, the median residual AHI was significantly higher in males vs females: 2.7 events/h vs 2.2 events/h ( P = .008). Body mass index (β: 0.292, P < .001), baseline AHI (β: 0.167, P < .001), and age (β: 0.065, P = .035) were independent predictors of the therapeutic CPAP level settings., Conclusions: Sex does not significantly influence the therapeutic CPAP settings. However, age, BMI, and baseline AHI emerge as independent predictors of the 95th percentile CPAP requirement during an auto-adjusting CPAP titration., Citation: Duarte RLM, Magalhães-da-Silveira FJ, Gozal D. Are there sex-related differences in therapeutic CPAP levels in adults undergoing in-laboratory titration? J Clin Sleep Med . 2021;17(9):1815-1820., (© 2021 American Academy of Sleep Medicine.)