Special Article

Clinical Guidelines for the Manual Titration of Positive Airway Pressure in Patients
with Obstructive Sleep Apnea
Positive Airway Pressure Titration Task Force of the American Academy of Sleep Medicine
Task Force Members: Clete A. Kushida, M.D., Ph.D., RPSGT (Chair)1; Alejandro Chediak, M.D. (Vice-Chair)2; Richard B. Berry, M.D.3; Lee K. Brown, M.D.4;
David Gozal, M.D.5; Conrad Iber, M.D.6; Sairam Parthasarathy, M.D.7; Stuart F. Quan, M.D.8; James A. Rowley, M.D.9

1
Stanford University Center of Excellence for Sleep Disorders, Stanford, CA; 2Sleep Disorders Center, Mount Sinai Medical Center, Miami Beach,
FL; 3Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida, Gainesville, FL; 4University of New Mexico Health Sciences
Center, Albuquerque, NM; 5Department of Pediatrics, Division of Pediatric Sleep Medicine, University of Louisville, Louisville, KY; 6University
of Minnesota, Minneapolis, MN; 7SAVAHCS and University of Arizona, Tucson, AZ; 8Division of Sleep Medicine, Harvard Medical School,
Boston, MA; 9Department of Internal Medicine, Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Wayne State University School of
Medicine, Detroit, MI

Summary: Positive airway pressure (PAP) devices are used to treat BPAP. (4) The recommended maximum CPAP should be 15 cm H2O
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patients with sleep related breathing disorders (SRBDs), including (or recommended maximum IPAP of 20 cm H2O if on BPAP) for pa-
obstructive sleep apnea (OSA). After a patient is diagnosed with tients <12 years, and 20 cm H2O (or recommended maximum IPAP of
OSA, the current standard of practice involves performing attended 30 cm H2O if on BPAP) for patients ≥12 years. (5) The recommended
polysomnography (PSG), during which positive airway pressure is minimum IPAP-EPAP differential is 4 cm H2O and the recommended
adjusted throughout the recording period to determine the optimal maximum IPAP-EPAP differential is 10 cm H2O (6) CPAP (IPAP and/or
pressure for maintaining upper airway patency. Continuous positive EPAP for patients on BPAP depending on the type of event) should be
airway pressure (CPAP) and bilevel positive airway pressure (BPAP) increased by at least 1 cm H2O with an interval no shorter than 5 min,
represent the two forms of PAP that are manually titrated during PSG with the goal of eliminating obstructive respiratory events. (7) CPAP
to determine the single fixed pressure of CPAP or the fixed inspiratory (IPAP and EPAP for patients on BPAP) should be increased from any
and expiratory positive airway pressures (IPAP and EPAP, respec- CPAP (or IPAP) level if at least 1 obstructive apnea is observed for
tively) of BPAP for subsequent nightly usage. A PAP Titration Task patients <12 years, or if at least 2 obstructive apneas are observed for
Force of the American Academy of Sleep Medicine reviewed the avail- patients ≥12 years. (8) CPAP (IPAP for patients on BPAP) should be
able literature. Based on this review, the Task Force developed these increased from any CPAP (or IPAP) level if at least 1 hypopnea is ob-
recommendations for conducting CPAP and BPAP titrations. Major served for patients <12 years, or if at least 3 hypopneas are observed
Copyright 2023 American Academy of Sleep Medicine. All rights reserved.

recommendations are as follows: (1) All potential PAP titration candi- for patients ≥12 years. (9) CPAP (IPAP for patients on BPAP) should
dates should receive adequate PAP education, hands-on demonstra- be increased from any CPAP (or IPAP) level if at least 3 RERAs are
tion, careful mask fitting, and acclimatization prior to titration. (2) CPAP observed for patients <12 years, or if at least 5 RERAs are observed
(IPAP and/or EPAP for patients on BPAP) should be increased until for patients ≥12 years. (10) CPAP (IPAP for patients on BPAP) may
the following obstructive respiratory events are eliminated (no spe- be increased from any CPAP (or IPAP) level if at least 1 min of loud or
cific order) or the recommended maximum CPAP (IPAP for patients unambiguous snoring is observed for patients <12 years, or if at least
on BPAP) is reached: apneas, hypopneas, respiratory effort-related 3 min of loud or unambiguous snoring are observed for patients ≥12
arousals (RERAs), and snoring. (3) The recommended minimum start- years. (11) The titration algorithm for split-night CPAP or BPAP titration
ing CPAP should be 4 cm H2O for pediatric and adult patients, and studies should be identical to that of full-night CPAP or BPAP titration
the recommended minimum starting IPAP and EPAP should be 8 cm studies, respectively. (12) If the patient is uncomfortable or intolerant
H2O and 4 cm H2O, respectively, for pediatric and adult patients on of high pressures on CPAP, the patient may be tried on BPAP. If there
are continued obstructive respiratory events at 15 cm H2O of CPAP
during the titration study, the patient may be switched to BPAP. (13)
Disclosure Statement
The pressure of CPAP or BPAP selected for patient use following the
This was not an industry supported study. The authors have indicated no
titration study should reflect control of the patient’s obstructive respira-
financial conflicts of interest.
tion by a low (preferably <5 per hour) respiratory disturbance index
Submitted for publication February, 2008 (RDI) at the selected pressure, a minimum sea level SpO2 above 90%
Accepted for publication February, 2008 at the pressure, and with a leak within acceptable parameters at the
Address correspondence to: Clete A. Kushida, MD, PhD, RPSGT, Stan- pressure. (14) An optimal titration reduces RDI <5 for at least a 15-
ford University Center of Excellence for Sleep Disorders, 401 Quarry min duration and should include supine REM sleep at the selected
Road, Suite 3301, Stanford, CA, 94305-5730 pressure that is not continually interrupted by spontaneous arousals
Journal of Clinical Sleep Medicine, Vol. 4, No. 2, 2008 157
 CA Kushida, A Chediak, RB Berry et al

or awakenings. (15) A good titration reduces RDI ≤10 or by 50% if the meet AASM criteria (i.e., titration duration should be >3 hr).
baseline RDI <15 and should include supine REM sleep that is not Keywords: PAP; titration; continuous positive airway pressure; CPAP;
continually interrupted by spontaneous arousals or awakenings at the bilevel positive airway pressure; BPAP; obstructive sleep apnea; sleep
selected pressure. (16) An adequate titration does not reduce the RDI related breathing disorder; sleep disordered breathing
≤10 but reduces the RDI by 75% from baseline (especially in severe Citation: Kushida CA; Chediak A; Berry RB; Brown LK; Gozal D;
OSA patients), or one in which the titration grading criteria for optimal Iber C; Parthasarathy S; Quan SF; Rowley JA; Positive Airway Pres-
or good are met with the exception that supine REM sleep did not oc- sure Titration Task Force of the American Academy of Sleep Medi-
cur at the selected pressure. (17) An unacceptable titration is one that cine. Clinical guidelines for the manual titration of positive airway
does not meet any one of the above grades. (18) A repeat PAP titration pressure in patients with obstructive sleep apnea. J Clin Sleep Med
study should be considered if the initial titration does not achieve a 2008;4(2):157-171.
grade of optimal or good and, if it is a split-night PSG study, it fails to

1.0 INTRODUCTION the utility of PSG for the diagnosis of sleep-related breathing
disorders) and on the indications for CPAP and BPAP in the

P ositive airway pressure (PAP) is a standard treatment for

patients with obstructive sleep apnea (OSA), a sleep related
breathing disorder characterized by full or partial occlusion of
treatment of airway obstruction in OSA.7 Lastly, in 2007, the
AASM published a new scoring manual that defines the abnor-
mal respiratory events (e.g., apneas, hypopneas, RERAs), which
the upper airway during sleep. Standard sleep medicine practice are used for PAP titration.8 The present recommendations add to
involves manual pressure adjustment by a sleep technologist but do not modify any of these previously published guidelines
during attended laboratory polysomnography (PSG) to elimi- and definitions.
nate obstructive respiratory-related events (apneas, hypopneas,
respiratory effort-related arousals [RERAs], and snoring). A 2.0 METHODS
PAP delivery system consists of three main components: a PAP
device; a nasal, oral, or oronasal interface (i.e., nasal mask, na- The AASM Board of Directors approved the development
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sal pillows, full-face mask) held snug to the face by headgear; of PAP titration recommendations in April 2007, and approved
and a flexible hose that connects the device to the interface. the appointments of Task Force members in July 2007. An ini-
A PAP device is basically an air pump (fan-driven or turbine tial literature search was conducted by Drs. Alejandro Chediak
system) that draws in external, filtered air and delivers pressur- and Vincenzo Novara on November 27, 2006 using the key
ized airflow, which is adjustable by varying the pressure valve words: CPAP initiation, CPAP titration, CPAP adjustment, PAP
diameter or fan/turbine speed. PAP devices are divided into titration, bilevel positive pressure titration, bi-level pressure
four basic types depending on their pressure delivery system: titration, BiPAP titration, and BiPAP adjustment. This search
(1) continuous positive airway pressure (CPAP), which delivers yielded 372 results, of which 26 relevant abstracts and articles
a single, fixed pressure to the patient during the night; (2) bi- were obtained and reviewed. Supplemental literature searches
level positive airway pressure (BPAP), which delivers a higher were conducted on June 29, 2007 and December 5, 2007 us-
inspiratory PAP (IPAP) than expiratory PAP (EPAP); (3) auto- ing the same key words as in the original search; an additional
titrating positive airway pressure (APAP), which automatically literature search was conducted on November 30, 2007 using
increases CPAP or BPAP (IPAP/EPAP) as needed to maintain the same key words plus the key word: children. These sup-
airway patency and then decreases the pressure if no abnormal plemental searches yielded an additional 82 results, of which
Copyright 2023 American Academy of Sleep Medicine. All rights reserved.

respiratory events are detected within a set period of time; and 7 additional relevant articles were obtained and reviewed. All
(4) adaptive servoventilation (ASV), which uses a servocon- literature searches were computer-based using PubMed. The
troller that automatically adjusts pressure by breath-by-breath objective was to identify all studies that described PAP titration
analysis to maintain a steady minute ventilation especially in protocols and that were published in English from 1968 up to
heart failure patients with central sleep apnea and/or Cheyne- the date of the searches. Twenty-two additional relevant publi-
Stokes respiration. cations were obtained after reviewing the bibliographies of the
A 2004 national survey of 196 board certified sleep physi- publications collected through the original and supplemental
cians regarding APAP device prescriptions based upon point- searches. Lastly, the Task Force also reviewed PAP titration
prevalence estimates revealed that only 4% of PAP devices protocols developed by industry for background information;
prescribed were APAP and that 30% of board certified sleep however, these protocols were not used to support the recom-
physicians reported having never prescribed APAP devices.1 As mendations.
more validation and reliability studies in diverse settings are All relevant publications were assigned an evidence level
being conducted, it is assumed that sleep medicine specialists based on the classification shown in Table 1.
are gradually becoming more accepting of the use of APAP Potential recommendations reflected evidence for reliability
devices.2-4 Nevertheless, manual titration of CPAP or BPAP is and validity as assessed by the Task Force following literature
currently the gold standard for selection of the optimal (effec- review, or comprised uncertainties in the literature that needed
tive) pressure for CPAP and BPAP (IPAP/EPAP), respectively, resolution by consensus. The Rand/UCLA Appropriateness
and the goal of this report was to develop recommendations that Method10 was selected as the consensus process for use by the
reflect current knowledge and practice of this procedure. Task Force given its use by the AASM Standards of Practice
The American Academy of Sleep Medicine (AASM) has Committee (SPC) and the AASM Scoring Manual Task Forces,
published practice parameters on the indications for PSG5,6 (i.e., and also because the relative paucity of evidence warranted
Journal of Clinical Sleep Medicine, Vol. 4, No. 2, 2008 158
 Manual Titration of Positive Airway Pressure
Table 1—AASM Classification of Evidence Table 2—AASM Levels of Recommendations

Evidence Levels Study Design Term Definition

I Randomized well-designed trials with low Standard This is a generally accepted patient care strategy
alpha and beta error* that reflects a high degree of clinical certainty.
II Randomized trials with high alpha and The term standard generally implies the use of
beta error* level I evidence that directly addresses the clini-
III Nonrandomized concurrently controlled cal issue, or overwhelming level II evidence.
studies Guideline This is a patient care strategy that reflects a
IV Nonrandomized historically controlled moderate degree of clinical certainty. The term
studies guideline implies the use of level II evidence or
V Case series a consensus of level III evidence.
Option Recommendation with less evidence than
Adapted from Sackett9 guideline for which agreement was reached in a
*Alpha error refers to the probability (generally set at 95% or standardized consensus process based on avail-
greater) that a significant outcome (e.g., p < 0.05) is not a result of able information.
chance occurrence. Beta error refers to the probability (generally
set at 80% to 90% or greater) that a nonsignificant result (e.g., p > Adapted from Eddy11 and Iber et al.8
0.05) is the correct conclusion of the study or studies. The estima-
tion of beta error is generally the result of a power analysis. The
in the development of this report are directors or members of
power analysis includes a sample size analysis to project the size
sleep disorders centers, and many have substantial experience
of the study population necessary to ensure that significant differ-
ences will be observed if actually present. with PAP titration. These recommendations should not be con-
sidered inclusive of all proper methods of care or exclusive of
other methods of care reasonably directed to obtaining the same
a formal consensus process. The first conference call of the results. The ultimate judgment regarding the propriety of any
Task Force was held on July 23, 2007 to discuss the consensus specific care must be made by the clinician in light of the indi-
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process and to develop a ballot comprised of possible recom- vidual circumstances presented by the patient and the availabil-
mendations. In order to encourage single recommendations, ity of diagnostic and treatment options and resources.
the ballots were constructed when possible to address mutu- The AASM expects these recommendations to have a positive
ally exclusive options. For balloting, the possible recommenda- impact upon the practice of sleep medicine, patient treatment
tions were rated on a 9-point scale for appropriateness and a outcomes, and health care costs. These recommendations re-
4-letter rank for specifying a judgment regarding whether the flect the state of knowledge at publication and will be reviewed,
decision was being made on evidence vs. opinion. The “classic” updated, and revised as new information becomes available. It
definition of agreement was assessed using definitions from the is important to note that the recommendations published in this
RAND manual: report are not practice parameters, since the majority of these
• Agreement for or against: No more than 2 Task Force mem- recommendations do not achieve the evidence level of typical
bers rate the indication outside the 3-point region (1-3, 4-6, practice parameters. Instead, all recommendations were devel-
7-9) containing the median. oped using the consensus process and the evidence grading was
• Disagreement: At least 3 Task Force members rate the indi- used only to indicate the level of evidence available to sup-
cation in the 1-3 region, and at least 3 Task Force members port the recommendations. AASM levels of recommendations
Copyright 2023 American Academy of Sleep Medicine. All rights reserved.

rate it in the 7-9 region. (Table 2) are indicated in parentheses after recommendations
• Indeterminate: Criteria are not met for agreement or dis- that are based on published practice parameters; those recom-
agreement. mendations that were not based on published parameters are
The first round ballot was distributed to the Task Force on labeled as “(Consensus).”
August 6, 2007 and was completed by September 1, 2007; Task
Force members completed this round of voting individually 3.0 BACKGROUND
without discussion. The first round ballot results were distrib-
uted to the Task Force on September 14, 2007. A conference The manual titration of positive airway pressure has been
call for the second round of voting was held on September 24, conducted for over a quarter of a century,12 yet no standard-
2007, at which time there was discussion of the recommenda- ized protocols exist for this procedure.13 A survey of accredited
tions and the results of the first vote; consensus was achieved sleep centers reviewed titration protocols from 51 accredited
on all recommendations during this second round of voting. centers and found that the procedures described for PAP titra-
The recommendations in section 4.0 were developed based on tion varied widely among the centers; 22% of these centers did
the voting results and were subsequently reviewed by two out- not have a written protocol.14 The lack of standardization re-
side reviewers, the Chair of the AASM Standards of Practice sults in clinicians and technologists from different sleep labo-
Committee, and the AASM Board of Directors. The Executive ratories developing their own protocols15 or relying on proto-
Committee of the AASM Board of Directors approved these cols obtained from industry or other sleep laboratories. When a
recommendations on February 8, 2008. standardized protocol is implemented, the optimal pressure for
All members of the Task Force and the Board of Directors CPAP can be reproducible; one study revealed a Spearman cor-
completed detailed conflict-of-interest statements; none had relation coefficient of 0.89 for the optimal pressure selected for
Level 1 conflicts in the scope of their roles. Most participants 2 consecutive CPAP titration nights in 50 patients with OSA.16
Journal of Clinical Sleep Medicine, Vol. 4, No. 2, 2008 159
 CA Kushida, A Chediak, RB Berry et al

However, very few PAP titration protocols have been published (SRBDs). Other SRBDs are not addressed except when relevant
in the literature, and there is a question as to what one would to adaptive servoventilation treatment. The respiratory distur-
use or measure to advocate or support one particular protocol bance index (RDI) refers to the total of apneas, hypopneas, and
over another. Thus, the goal of this Task Force was the develop- RERAs per hour of sleep, and for this report, this term is not
ment of an evidence- and consensus-based standardized PAP synonymous with the AHI, which refers to the total of apneas
titration protocol, with the underlying concept that a successful and hypopneas per hour of sleep. Mild, moderate and severe
titration is one in which there is an optimized trade-off between OSA are defined according to following criteria in adults: mild,
increasing pressure to yield efficacy in elimination of respira- RDI 5 to ≤15; moderate, RDI 15 to 30; and severe, RDI >30.31
tory events and decreasing pressure to minimize emergence of In children <12 years of age: mild, RDI 1 to <5; moderate, RDI
pressure-related side effects.17 5 to <10; and severe, RDI >10.8,32-34
The optimal pressure selected for an OSA patient during a
PAP titration study is subject to interindividual variability, i.e., 4.0 RECOMMENDATIONS
a pressure that controls the respiratory events of one patient
may inadequately control those of another patient.18 There are The following are recommendations of the PAP Titration
several factors that have been identified as potentially influenc- Task Force and the AASM Board of Directors. The scope of
ing optimal pressure, such as rapid eye movement (REM) sleep these PAP titration recommendations is restricted to adult (≥12
amounts,19 the length of the soft palate,18 and the degree of re- years) and pediatric (<12 years) patients with obstructive sleep
spiratory effort.18 Additionally, one might reason that the level apnea; these recommendations do not apply to patients with
of optimal PAP is correlated with OSA severity and/or obesity; conditions such as neuromuscular disease or intrinsic lung dis-
i.e., higher levels of PAP would be needed to control respiratory ease. Summaries and evidence levels of published PAP titration
events in patients with severe OSA and/or those who are obese. protocols for adult and pediatric patients are listed in Tables 3a
However, this premise has not been consistently supported in the and 3b (see JCSM website: www.aasmnet.org/JCSM), respec-
literature; although there are some studies demonstrating a good tively, and CPAP and BPAP titration algorithms for adult and
correlation between the level of optimal CPAP and the apnea- pediatric patients during full- or split-night titration studies are
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hypopnea index (AHI)20,21 or obesity,21 a significant correlation depicted in Figures 1-4. The optimal setting for the titration of
for optimal CPAP and AHI has been observed only in patients CPAP or BPAP is in an AASM-accredited sleep center or labo-
whose apneas are dependent on body position.22 Mathematical ratory, with the titration protocol implemented by registered
equations incorporating measures of OSA severity (AHI) and polysomnographic technologists and review of the titration
obesity (i.e., body mass index and neck circumference) have study (including pressure selection) by a board certified sleep
been developed to predict the optimal level of CPAP21,23,24 in specialist. Additionally, the definitions, protocols, procedures,
order to theoretically achieve a higher rate of successful CPAP and indications for the diagnosis and management of OSA as
titrations by eliminating the need for multiple pressure changes specified in the AASM practice parameters for polysomnogra-
at low pressure levels and to decrease the risk of insufficient phy5 and PAP,7 and the AASM Manual for the Scoring of Sleep
time to perform an adequate titration study. However, two stud- and Associated Events8 (i.e., respiratory rules) should be fol-
ies have independently failed to confirm the accuracy of these lowed. It is understood that the recommendations for minimum
equations in predicting the prescribed CPAP level,25-27 prompt- and maximum PAP may be constrained by the specific PAP de-
ing the authors of one of these studies to comment that this fail- vice used during the titration protocol. Lastly, the expectation
ure “reaffirms the need for a CPAP titration study to prescribe of the Task Force is that these recommendations should not be
Copyright 2023 American Academy of Sleep Medicine. All rights reserved.

the optimal therapy to the patient.”25 followed in a “cookbook” manner; instead, sleep technologists
Two types of PAP devices (CPAP and BPAP) are included and clinicians should combine their experience and judgment
in these titration recommendations, and BPAP as described in with the application of these recommendations to attain the best
this report refers to BPAP set in spontaneous mode unless oth- possible titration in any given patient.
erwise specified. Data regarding usefulness of other PAP device
types or device features were not reviewed; although specific 4.1 General Recommendations for Conducting PAP Titration
indications for adaptive servoventilation are discussed, a titra- Studies in Pediatric or Adult Patients with Obstructive Sleep
tion protocol for this device is not described since this type of Apnea
ventilation was considered beyond the scope of this report. The
recommendations in this report pertain only to nighttime PAP 4.1.1 All Potential PAP Titration Candidates (Including
titration studies, although there is an emerging body of litera- Those Candidates Prior to a Diagnostic Study Where the
ture that indicates that diurnal and nocturnal titration results in Clinical Suspicion of OSA is High and a Split-Night Study is a
comparable therapeutic pressures, equivalent resolution of sleep Possibility) Should Receive Adequate PAP Education, Hands-On
disordered breathing, and improvement in subjective sleepiness Demonstration, Careful Mask Fitting, and Acclimatization Prior to
after 1-12 weeks of treatment, particularly for patients with se- Titration (Standard).
vere OSA.28-30
This report uses the following terminology. Unless stated This recommendation is based on Standard-Level Recommen-
otherwise OSA is used synonymously with obstructive sleep dation 4.3.4 (“The addition of a systematic educational program
apnea syndrome (OSAS), obstructive sleep apnea-hypopnea is indicated to improve PAP utilization”) in the 2006 practice pa-
syndrome (OSAHS), and obstructive forms of either sleep dis- rameters for the use of PAP devices7 and consensus agreement by
ordered breathing (SDB) or sleep related breathing disorder the PAP Titration Task Force. The Task Force recommends that
Journal of Clinical Sleep Medicine, Vol. 4, No. 2, 2008 160
 Manual Titration of Positive Airway Pressure

the indications, rationale for use, and side effects should be dis- Recommended maximum 15 cm H2O -
cussed in detail with the patient or caregiver preferably prior to The patient may be transitioned to
BPAP if there are continued breathing
the PAP titration study; parts and assembly, optional equipment, events at this pressure**
“Exploration” of pressure
importance of daily/nightly use, adherence issues, necessity of  30 min without
+5 cm
cleaning the equipment, and implications of the purchase/rental

PRESSURE
H2O breathing events Control of breathing events and
≥ 15 min in supine REM sleep
of the equipment (when applicable) should be discussed in detail  1 cm
 1 obstructive apnea, or
 1 hypopnea, or  1 cm
with the patient or caregiver, preferably following the PAP titra- H2O  3 RERAs, or
 (1 min of loud or
H2O

tion study. The patient should be carefully fitted for the interface  5 min
unambiguous snoring)  10 min

(i.e., nasal mask, nasal pillows, full-face/oronasal mask) with the  1 cm

 1 obstructive apnea, or
 1 hypopnea, or If patient awakens and  1 cm
 1 cm H2O
goals of maximizing comfort, compensating for significant nasal H2O  3 RERAs, or complains pressure is too
 (1 min of loud or H2O
high, a lower pressure that
unambiguous snoring) the patient reports is
obstruction, and minimizing leak prior to the PAP titration. There Minimum*
4 cm H2O
 5 min
comfortable enough to allow
Stop if re-emergence
return to sleep should be
should be several different types of PAP interfaces (i.e., nasal chosen, and resume titration of breathing events

mask, nasal pillows, full-face/oronasal mask) and accessories TIME

(chinstrap, heated humidifier) available if the patient encounters Figure 1—CPAP Titration Algorithm for Patients <12 years Dur-
problems (e.g., mouth leak, nasal congestion, or oronasal dry- ing Full- or Split-Night Titration Studies. Note: Upward titration
ness) during the night. The patient should be acclimated to the at ≥ 1-cm increments over ≥ 5-min periods is continued according
PAP equipment (i.e., wearing the interface with the pressure on) to the breathing events observed until ≥ 30 min without breathing
prior to “lights off.”35 For pediatric patients, in addition to the events is achieved.
above, pediatric interfaces should be available36 and behavioral * A higher starting CPAP may be selected for patients with an
elevated BMI and for retitration studies
modification techniques may be implemented to increase the
** The patient should also be tried on BPAP if the patient is un-
tolerability and potential adherence to PAP equipment,37-39 since comfortable or intolerant of high CPAP
children frequently have problems adjusting to PAP.
4.1.4 Respiratory Effort-Related Arousals May Be Estimated by
4.1.2 Recording the Airflow Signal Generated by the PAP Device Flattening of the Inspiratory Airflow Profile Associated with an
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or Estimating Airflow by Measurement of the Pressure Difference Arousal When Airflow Changes Do Not Meet Criteria for apneas
Between the Mask and the Outlet of the Machine Using a Pressure or Hypopneas (Consensus).
Transducer, with or without Square Root Transformation of
the Signal, are Acceptable Methods for Detecting Apneas or This recommendation is based on consensus agreement by
Hypopneas (Consensus). the PAP Titration Task Force. As specified in the AASM Scoring
Manual, a respiratory effort-related arousal (RERA) in adults is
This recommendation is based on consensus agreement by defined as a sequence of breaths lasting at least 10 sec charac-
the PAP Titration Task Force and Consensus-Level Respiratory terized by increasing respiratory effort or flattening of the nasal
Rule 1.B (i.e., a nasal air pressure transducer with or without pressure waveform leading to an arousal from sleep when the
square root transformation of the signal is the preferred sensor sequence of breaths does not meet criteria for an apnea or hypo-
for detection of airflow for identification of a hypopnea dur- pnea.8 The scoring rules for pediatric RERAs when using a na-
ing diagnostic [non-PAP] PSG) in the AASM Scoring Manu- sal pressure sensor requires a discernible fall in the amplitude of
al.8 However, during PAP titrations, the use of a standard nasal the signal from the sensor; a duration of at least 2 breath cycles;
pressure sensor placed under the nares is problematic due to the accompanying snoring, noisy breathing, elevation in the end-
Copyright 2023 American Academy of Sleep Medicine. All rights reserved.

difficulty in obtaining a good PAP mask seal since the tubing tidal CO2, transcutaneous CO2, or visual evidence of increased
has to pass underneath the mask. Thus, estimation of airflow work of breathing; and termination by an arousal.8 The contour
for detection of apneas or hypopneas by one of the two tech- of inspiratory flow tracing from a PAP system can be used to
niques specified above is acceptable; care should be exercised infer the presence of elevated upper airway resistance and flow
to ensure that the signal is accurately recorded. PAP devices de- limitation,40,41 and this contour appears to be the simplest vari-
signed for use in polysomnography generate a flow signal based able that best correlates with the lowest esophageal pressure
on accurate flow sensors within the device and the majority also during PAP titration.42 For the assessment of respiratory effort
provide a signal reflecting an estimate of leak. during PAP titration, esophageal manometry or nasal pressure
plus inductance plethysmography can be used in pediatric and
4.1.3 Nasal Airflow Obtained from a Thermistor or Thermocouple adult patients, although the former technique may be more prob-
Placed Under the PAP Mask is not an Acceptable Method for lematic given partial occlusion of one of the nares and difficulty
Detecting Apneas or Hypopneas (Consensus). obtaining a good PAP mask seal with the esophageal catheter and
poorer adherence in the pediatric population.
This recommendation is based on consensus agreement by
the PAP Titration Task Force. An oronasal thermal sensor is 4.1.5 Sawtooth Patterns in the Unfiltered Airflow or Mask
the preferred primary sensor to detect absence of airflow for Pressure Tracings and/or Detection of Vibration by Piezoelectric
identification of an apnea during diagnostic (non-PAP) PSG.8 Transducers or Microphones Applied to the Neck are Acceptable
However, it is not the preferred sensor to detect airflow for Methods for Detecting Snoring (Consensus).
identification of a hypopnea (see Recommendation 4.1.2) and
the placement of this sensor under a PAP mask for detection of This recommendation is based on consensus agreement by
airflow is not recommended. the PAP Titration Task Force. The output from most PAP de-
Journal of Clinical Sleep Medicine, Vol. 4, No. 2, 2008 161
 CA Kushida, A Chediak, RB Berry et al

V studies40,62 [adult and pediatric patients]). If there are continued

Recommended maximum 20 cm H2O
The patient may be transitioned to
obstructive respiratory events at 15 cm H2O of CPAP for either
BPAP if there are continued
breathing events at 15 cm H2O** adult or pediatric patients during the titration study, the patient
+5 cm
“Exploration” of pressure
 30 min without
may be switched to BPAP (see Recommendation 4.3.1.1)
H2 O breathing events Control of breathing events and
≥ 15 min in supine REM sleep
PRESSURE

 2 obstructive apneas, or 4.2.1.4 Methodology to determine CPAP a priori has insufficient

 3 hypopneas, or
evidence, although a higher starting CPAP may be selected for
 1 cm  1 cm
H2O  5 RERAs, or H2O
 (3 min of loud or
 5 min unambiguous snoring)  10 min
patients with an elevated body mass index and for retitration
 1 cm
 2 obstructive apneas, or
 3 hypopneas, or  1 cm studies (Consensus).
H2O  5 RERAs, or If patient awakens and H2O
 (3 min of loud or complains pressure is too

Minimum*
 5 min unambiguous snoring) high, a lower pressure that
the patient reports is
Stop if re-emergence
This recommendation is based on consensus agreement by
the PAP Titration Task Force and Option-Level evidence (1
4 cm H2O comfortable enough to allow
of breathing events
return to sleep should be
chosen, and resume titration
level III study that found that the amount of CPAP pressure
TIME
was correlated with body mass index at baseline [ρ = 0.32, p
Figure 2—CPAP Titration Algorithm for Patients ≥12 years Dur- <0.001]20 and 1 level V study that indicates that body mass in-
ing Full- or Split-Night Titration Studies. Note: Upward titration dices were significantly higher in patients who required higher
at ≥ 1-cm increments over ≥ 5-min periods is continued according
CPAP levels to abolish their apnea21).
to the breathing events observed until ≥ 30 min without breathing
events is achieved.
* A higher starting CPAP may be selected for patients with an 4.2.2 Full Night CPAP Titration Studies
elevated BMI and for retitration studies
** The patient should also be tried on BPAP if the patient is un- 4.2.2.1 CPAP should be increased by at least 1 cm H2O with
comfortable or intolerant of high CPAP an interval no shorter than 5 min, with the goal of eliminating
obstructive respiratory events (Consensus).
vices while accurate for assessing airflow and flow limitation is
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often too filtered or undersampled to display snoring. This recommendation is based on consensus agree-
ment by the PAP Titration Task Force and Standard-Level
4.2 Recommendations for Conducting CPAP Titration Studies in evidence (2 level I studies,52,63 7 level II studies,43,44,53,54,64-66
Pediatric or Adult Patients with Obstructive Sleep Apnea 8 level III studies,16,46,47,55,56,61,67,68 5 level IV studies,25,35,57,69,70
21 level V studies,18,21,24,42,48,49,51,59,60,62,71-81). The studies re-
4.2.1 General Recommendations for CPAP Titration Studies ported pressure increments of 1-2.5 cm H2O, and 11 of these
studies16,25,26,42,43,52,55,56,59,74,77 specify a time duration ≥5 min.
4.2.1.1 CPAP should be increased until the following obstructive There are insufficient data to recommend increasing CPAP by
respiratory events are eliminated (no specific order) or the increments of more than 2.5 cm H2O.
recommended maximum CPAP is reached: apneas, hypopneas,
RERAs, and snoring (Consensus). 4.2.2.2 CPAP should be increased (according to the criterion
in Recommendation 4.2.2.1) if at least 1 obstructive apnea is
This recommendation is based on consensus agreement by observed for patients <12 years or if at least 2 obstructive apneas
the PAP Titration Task Force and Guideline-Level evidence are observed for patients ≥12 years (Consensus).
Copyright 2023 American Academy of Sleep Medicine. All rights reserved.

(3 level II studies,43-45 2 level III studies,46,47 and 5 level V

studies42,48-51). The Task Force recommends that SaO2 desatura- This recommendation is based on consensus agreement by
tion-resaturation events occurring without associated obstruc- the PAP Titration Task Force. A lower pressure is required to
tive respiratory events should not be considered in the decision treat apneas compared to the pressure required to treat other
to increase CPAP in pediatric and adult patients. respiratory events.82

4.2.1.2 The recommended minimum starting CPAP should be 4 4.2.2.3 CPAP should be increased (according to the criterion in
cm H2O in pediatric and adult patients (Consensus). Recommendation 4.2.2.1) if at least 1 hypopnea is observed for
patients <12 years or if at least 3 hypopneas are observed for
This recommendation is based on consensus agreement by patients ≥12 years (Consensus).
the PAP Titration Task Force and Standard-Level evidence (1
level I study,52 4 level II studies,44,45,53,54 4 level III studies,16,47,55,56 This recommendation is based on consensus agreement by
2 level IV studies,35,57 and 4 level V studies49,58-60). the PAP Titration Task Force.

4.2.1.3 The recommended maximum CPAP should be 15 cm H2O 4.2.2.4 CPAP should be increased (according to the criterion
for patients <12 years and 20 cm H2O for patients ≥12 years Recommendation 4.2.2.1) if at least 3 RERAs are observed for
(Consensus). patients <12 years or if at least 5 RERAs are observed for patients
≥12 years (Consensus).
This recommendation is based on consensus agreement by the
PAP Titration Task Force and Option-Level evidence (1 level II This recommendation is based on consensus agreement by
study53 [adult patients], 1 level III study61 [adult patients], 2 level the PAP Titration Task Force.
Journal of Clinical Sleep Medicine, Vol. 4, No. 2, 2008 162
 Manual Titration of Positive Airway Pressure

4.2.2.5 CPAP may be increased (according to the criterion in

Recommendation 4.2.2.1) if at least 1 min of loud or unambiguous
snoring is observed for patients <12 years or if at least 3 min
Recommended maximum IPAP 20 cm

of loud or unambiguous snoring are observed for patients ≥12

“Exploration” of IPAP
IPAP +5  30 min without

years (Consensus).
cm H2O breathing events Control of breathing events and
≥ 15 min in supine REM sleep
 1 obstructive apnea, or

PRESSURE
IPAP and EPAP  1
cm H2O for apneas,  1 hypopnea, or IPAP  1
IPAP  1 cm for other  3 RERAs, or cm H2O
This recommendation is based on consensus agreement by the events  (1 min of loud or
unambiguous snoring)  10 min
 5 min
PAP Titration Task Force. The utility of titrating CPAP to elimi- IPAP and EPAP  1
cm H2O for apneas,  1 obstructive apnea, or
nate snoring was demonstrated in a limited study of non-apneic IPAP  1 cm for other
events
 1 hypopnea, or
 3 RERAs, or
If patient awakens and
complains pressure is too
IPAP  1
cm H2O

patients. Although a minority of these patients accepted CPAP Minimum*

IPAP 8 /  5 min
 (1 min of loud or
unambiguous snoring)
high, a lower IPAP that the
patient reports is
comfortable enough to allow
use and their subsequent CPAP adherence was poor, 73% of these EPAP 4
cm H2O
return to sleep should be
chosen, and resume
Stop if re-emergence
of breathing events
patients nevertheless reported improvement in their subjective titration

daytime sleepiness after using CPAP for a six-month period.83 TIME

Figure 3—BPAP Titration Algorithm for Patients <12 years Dur-

4.2.2.6 “Exploration” of CPAP above the pressure at which control ing Full- or Split-Night Titration Studies. Note: Upward titration
of abnormalities in respiratory parameters is achieved should not of IPAP and EPAP ≥ 1 cm H2O for apneas and IPAP ≥ 1 cm for
exceed 5 cm H2O (Consensus). other events over ≥ 5-min periods is continued until ≥ 30 min
without breathing events is achieved. A decrease in IPAP or set-
This recommendation is based on consensus agreement by ting BPAP in spontaneous-timed mode with backup rate may be
the PAP Titration Task Force. CPAP exploration does have util- helpful if treatment-emergent central apneas are observed.
* A higher starting IPAP and EPAP may be selected for patients
ity; upper airway resistance can be four times normal despite
with an elevated BMI and for retitration studies. When transition-
selection of a pressure that eliminates apneas and hypopneas,42 ing from CPAP to BPAP, the minimum starting EPAP should be
and this residual high airway resistance can lead to repetitive set at 4 cm H2O or the CPAP level at which obstructive apneas
arousals and insomnia.84 Reduction of this resistance has been
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were eliminated. An optimal minimum IPAP-EPAP differential is

demonstrated by increasing pressure until esophageal pressure 4 cm H2O and an optimal maximum IPAP-EPAP differential is
swings (if measured) or the shape of the inspiratory flow limita- 10 cm H2O.
tion curve are normalized,40,84,85 or by increasing pressure by 2
cm H2O17 but no higher than by 5 cm H2O.
increased by increments of 1 cm H2O to normalize respiration
4.2.2.7 If the patient awakens and complains that the pressure is (Peff2). The pressure obtained after the “down” titration had to
too high, the pressure should be restarted at a lower pressure, be re-increased in 79 patients due to snoring (n = 26), flow limi-
chosen as one that the patient reports is comfortable enough to tations associated with arousals (n = 32), obstructive hypopneas
allow return to sleep (Consensus). (n = 19), and obstructive apneas (n = 2). The Peff2 level was sig-
nificantly lower than Peff1 with a mean difference of 0.6 (1.5)
This recommendation is based on consensus agreement by cm H2O (95% confidence interval, 0.29-0.93).
the PAP Titration Task Force.
4.2.3 Split-Night CPAP Titration Studies
4.2.2.8 “Down” titration is not required but may be considered as
Copyright 2023 American Academy of Sleep Medicine. All rights reserved.

an option (Consensus). 4.2.3.1 The titration algorithm for split-night CPAP titration
studies should be identical to that of full-night CPAP titration
This recommendation is based on consensus agreement by studies (Guideline).
the PAP Titration Task Force and Option-Level evidence (2
level III studies16,47). A “down” titration is recommended due to This recommendation is based on Guideline-Level Recom-
the “hysteresis” phenomenon:40 during upward titration the PAP mendation 4.2.1 (“A full-night, attended polysomnography
level at which flow limitation disappears is 2-5 cm H2O higher performed in the laboratory is the preferred approach for titra-
than the level at which it reappears during downward titration. tion to determine optimal positive airway pressure; however,
If a “down” titration is implemented, the Task Force recom- split-night, diagnostic-titration studies are usually adequate”)
mends at least one “up-down” CPAP titration (1 cycle) should in the 2006 practice parameters for the use of PAP devices7 and
be conducted during the night. It should be conducted when at consensus agreement by the PAP Titration Task Force. Studies
least 30 min has elapsed without obstructive respiratory events. that have compared adequacy of prescribed pressure, CPAP ad-
CPAP should be decreased by more than 1 cm H2O with an in- herence, and patient acceptance have found no significant dif-
terval no shorter than 10 min, until there is reemergence of ob- ferences for adult patients undergoing full-night vs. split-night
structive respiratory events. There is also limited evidence that CPAP titration studies,46,69,86-88 with the possible exception that
an “up-down-up” titration protocol should be considered.49 One pressures determined from split-night studies may be lower for
study with 85 OSA patients used a CPAP protocol in which the patients with mild-to-moderate OSA who may not manifest the
pressure was increased by 1 cm H2O in a stepwise fashion until maximal severity of their condition during the first portion of
respiratory events disappeared (effective pressure 1, Peff1); the the night.25,73 It may be prudent to increase CPAP at larger incre-
pressure level was then decreased by increments of 1 cm H2O ments (i.e., 2 or 2.5 cm H2O) given the shorter CPAP titration
until respiratory abnormalities reappeared. The pressure was re- duration in split-night vs. full-night studies. Of note, there are
Journal of Clinical Sleep Medicine, Vol. 4, No. 2, 2008 163
 CA Kushida, A Chediak, RB Berry et al

level I study52 and 1 level III study46). The Task Force recom-
Recommended maximum IPAP 30 cm H2O mends that SaO2 desaturation-resaturation events occurring
“Exploration” of IPAP without associated obstructive respiratory events should not be
IPAP +5
cm H2O
 30 min without
breathing events Control of breathing events and
≥ 15 min in supine REM sleep
considered in the decision to increase IPAP and/or EPAP in pe-
diatric and adult patients.
PRESSURE

IPAP and EPAP  1  2 obstructive apneas, or

cm H2O for apneas, IPAP  1
 3 hypopneas, or
IPAP  1 cm for other cm H2O
 5 RERAs, or
events
4.3.1.3 The recommended minimum starting IPAP and EPAP
 (3 min of loud or  10 min
 5 min unambiguous snoring)
IPAP and EPAP  1
cm H2O for apneas,  2 obstructive apneas, or IPAP  1 should be 8 cm H2O and 4 cm H2O, respectively, in pediatric and
adult patients (Consensus).
IPAP  1 cm for other  3 hypopneas, or If patient awakens and cm H2O
events  5 RERAs, or complains pressure is too
 (3 min of loud or high, a lower IPAP that the
Minimum*  5 min patient reports is
unambiguous snoring)
IPAP 8 / comfortable enough to allow
EPAP 4 Stop if re-emergence
cm H2O
return to sleep should be
chosen, and resume
of breathing events This recommendation is based on consensus agreement by
titration
the PAP Titration Task Force and Guideline-Level evidence (1
TIME
level I study52 for the minimum starting EPAP in adult patients).
Figure 4—BPAP Titration Algorithm for Patients ≥12 years Dur- In addition, when switching from CPAP to BPAP, the Task
ing Full- or Split-Night Titration Studies. Note: Upward titration Force recommends that the minimum starting EPAP should be
of IPAP and EPAP ≥ 1 cm H2O for apneas and IPAP ≥ 1 cm for set at 4 cm H2O or the CPAP level at which obstructive apneas
other events over ≥ 5-min periods is continued until ≥ 30 min
were eliminated.
without breathing events is achieved. A decrease in IPAP or set-
ting BPAP in spontaneous-timed mode with backup rate may be
helpful if treatment-emergent central apneas are observed. 4.3.1.4 The recommended maximum IPAP should be 20 cm
* A higher starting IPAP and EPAP may be selected for patients H2O for patients <12 years or 30 cm H2O for patients ≥12 years
with an elevated BMI and for retitration studies. When transition- (Consensus).
ing from CPAP to BPAP, the minimum starting EPAP should be
set at 4 cm H2O or the CPAP level at which obstructive apneas This recommendation is based on consensus agreement by
were eliminated. An optimal minimum IPAP-EPAP differential is the PAP Titration Task Force. There is also evidence from the
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4 cm H2O and an optimal maximum IPAP-EPAP differential is critical care literature indicating that an excess of 30 cm H2O of
10 cm H2O.
upper airway pressure may increase the risk for barotrauma and
other morbidities.89,90
insufficient data to make any recommendations for split-night
CPAP titration studies in children <12 years. 4.3.1.5 Methodology to determine IPAP or EPAP a priori has
insufficient evidence, although a higher starting IPAP or EPAP
4.3 Recommendations for Conducting Bilevel PAP (BPAP) may be selected for patients with an elevated BMI and for
Titration Studies in Pediatric or Adult Patients with Obstructive retitration studies (Consensus).
Sleep Apnea
This recommendation is based on consensus agreement by
4.3.1 General Recommendations for BPAP Titration Studies the PAP Titration Task Force. As in the case of CPAP, a higher
starting IPAP or EPAP may be needed for patients with an el-
4.3.1.1 If the patient is uncomfortable or intolerant of high evated BMI (see Recommendation 4.2.1.4).
pressures on CPAP, the patient may be tried on BPAP. If there are
Copyright 2023 American Academy of Sleep Medicine. All rights reserved.

continued obstructive respiratory events at 15 cm H2O of CPAP 4.3.1.6 The recommended minimum IPAP-EPAP differential is 4
during the titration study, the patient may be switched to BPAP cm H2O and the recommended maximum IPAP-EPAP differential
(Consensus). is 10 cm H2O (Consensus).

This recommendation is based on consensus agreement by This recommendation is based on consensus agreement by
the PAP Titration Task Force and Option-Level evidence (1 lev- the PAP Titration Task Force and Guideline-Level evidence (1
el IV study40 and 1 level V study62). However, this recommen- level I study52 for the minimum IPAP-EPAP differential in adult
dation does not imply that BPAP is more effective than CPAP at patients).
maintaining upper airway patency. Additionally, efforts should
be made to explore why the patient is uncomfortable or intol- 4.3.2 Full-Night BPAP Titration Studies
erant of high pressures on CPAP and to remedy the situation
before trying the patient on BPAP. 4.3.2.1 IPAP and/or EPAP (depending on the type of obstructive
respiratory event) should be increased by at least 1 cm H2O apiece
4.3.1.2 BPAP (IPAP and/or EPAP, depending on the type of with an interval no shorter than 5 min, with the goal of eliminating
obstructive respiratory event) should be increased until the obstructive respiratory events (Consensus).
following events are eliminated (no specific order) or the
recommended maximum IPAP is reached: apneas, hypopneas, This recommendation is based on consensus agreement by
RERAs, and snoring (Consensus). the PAP Titration Task Force and Guideline-Level evidence (1
level II study,66 1 level III study,46 and 2 level V studies71,74).
This recommendation is based on consensus agreement by
the PAP Titration Task Force and Guideline-Level evidence (1
Journal of Clinical Sleep Medicine, Vol. 4, No. 2, 2008 164
 Manual Titration of Positive Airway Pressure

4.3.2.2 IPAP and EPAP should be increased (according to the central apneas (i.e., complex sleep apnea) are observed during
criterion in Recommendation 4.3.2.1) if at least 1 obstructive the titration study (Consensus).
apnea is observed for patients <12 years or if at least 2 obstructive
apneas are observed for patients ≥12 years (Consensus). This recommendation is based on consensus agreement by
the PAP Titration Task Force.
This recommendation is based on consensus agreement by
the PAP Titration Task Force. As in the case of CPAP, a lower 4.3.2.9 “Down” titration is not required but may be considered as
pressure is required to treat apneas compared to the pressure an option (Consensus).
required to treat other respiratory events (see Recommenda-
tion 4.2.2.2); however, there is 1 level II study53 and 1 level V This recommendation and the following protocol is based
study71 that used increases in both IPAP and EPAP to eliminate on consensus agreement by the PAP Titration Task Force. As in
apneas. the case of CPAP, a “down” titration is recommended for BPAP
due to the “hysteresis” phenomenon40 (see Recommendation
4.3.2.3 IPAP should be increased (according to the criterion in 4.2.2.8). If a “down” titration is implemented, the Task Force
Recommendation 4.3.2.1) if at least 1 hypopnea is observed for recommends at least one “up-down” BPAP titration (1 cycle)
patients <12 years or if at least 3 hypopneas are observed for should be conducted during the night. “Down” titration of IPAP
patients ≥12 years (Consensus). and EPAP is conducted when at least 30 min has elapsed with-
out obstructive respiratory events. IPAP should be decreased
This recommendation is based on consensus agreement by by at least 1 cm H2O with an interval no shorter than 10 min,
the PAP Titration Task Force. until there is reemergence of obstructive respiratory events.
There is also limited evidence that an “up-down-up” titration
4.3.2.4 IPAP should be increased (according to the criterion in protocol should be considered for CPAP49 (see Recommenda-
Recommendation 4.3.2.1) if at least 3 RERAs are observed for tion 4.2.2.8); an “up-down-up” titration protocol should also be
patients <12 years or if at least 5 RERAs are observed for patients similarly considered for BPAP.
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≥12 years (Consensus).

4.3.3 Split-Night BPAP Titration Studies
This recommendation is based on consensus agreement by
the PAP Titration Task Force. 4.3.3.1 The titration algorithm for split-night BPAP titration
studies should be identical to that of full-night BPAP titration
4.3.2.5 IPAP may be increased (according to the criterion in studies (Consensus).
Recommendation 4.3.2.1) if at least 1 min of loud or unambiguous
snoring is observed for patients <12 years or if at least 3 min This recommendation is based on consensus agreement by
of loud or unambiguous snoring are observed for patients ≥12 the PAP Titration Task Force. A full-night, attended polysom-
years (Consensus). nography performed in the laboratory is the preferred approach
for titration to determine optimal positive airway pressure;
This recommendation is based on consensus agreement by however, split-night, diagnostic-titration studies are usually
the PAP Titration Task Force. As in the case of CPAP, the utility adequate (Recommendation 4.2.1 [Guideline] in the practice
of titrating PAP to treat snoring may be reflected in improve- parameters for the use of CPAP and BPAP devices published
Copyright 2023 American Academy of Sleep Medicine. All rights reserved.

ment in patients’ subjective daytime sleepiness (see Recom- in 2006).91 Unfortunately, studies comparing factors such as
mendation 4.2.2.5). patient acceptance, adequacy of prescribed IPAP/EPAP, and
adherence to BPAP for patients undergoing full-night vs. split-
4.3.2.6 “Exploration” of IPAP above the pressure at which control night BPAP titration studies do not exist. It may be prudent to
of abnormalities in respiratory parameters is achieved should not increase IPAP and EPAP at larger increments (i.e., 2 or 2.5 cm
exceed 5 cm H2O (Consensus). H2O) given the shorter BPAP titration duration in split-night vs.
full-night studies. Of note, there are insufficient data to make
This recommendation is based on consensus agreement by any recommendations for split-night BPAP titration studies in
the PAP Titration Task Force. As in the case of CPAP, IPAP ex- children <12 years.
ploration does have utility (see Recommendation 4.2.2.6).
4.4 Important Considerations for PAP Titration Studies in Pediatric
4.3.2.7 If the patient awakens and complains that the pressure or Adult Patients with Obstructive Sleep Apnea
is too high, the pressure should be restarted at a lower IPAP,
chosen as one that the patient reports is comfortable enough to 4.4.1 Acceptable PAP Titration Study
allow return to sleep (Consensus).
4.4.1.1 The CPAP or BPAP selected for patient use following the
This recommendation is based on consensus agreement by titration study should reflect control of the patient’s obstructive
the PAP Titration Task Force. respiration by a low (preferably <5 per hour) RDI at the selected
pressure, a minimum sea level SpO2 above 90% at the pressure,
4.3.2.8 A decrease in IPAP or setting BPAP in spontaneous-timed and with a leak within acceptable parameters at the pressure
(ST) mode with backup rate may be helpful if treatment-emergent (Consensus).
Journal of Clinical Sleep Medicine, Vol. 4, No. 2, 2008 165
 CA Kushida, A Chediak, RB Berry et al

This recommendation is based on consensus agreement by tory events can worsen as the night progresses). (c) PSG docu-
the PAP Titration Task Force. See Recommendation 4.4.3.2 for ments that CPAP eliminates or nearly eliminates the respiratory
description of leak within acceptable parameters. events during REM and NREM sleep, including REM sleep
with the patient in the supine position. (d) A second full night of
4.4.1.2 Grading system: An optimal titration reduces RDI <5 per PSG for CPAP titration is performed if the diagnosis of a SRBD
hour for at least a 15-min duration and should include supine REM is confirmed but criteria (b) and (c) are not met.
sleep at the selected pressure that is not continually interrupted
by spontaneous arousals or awakenings (Consensus). 4.4.3 Leak and Comfort

This recommendation is based on consensus agreement by 4.4.3.1 PAP mask refit or readjustment should be performed
the PAP Titration Task Force and the grading system proposed whenever any significant unintentional leak is observed
by Hirshkowitz and Sharafkhaneh.91 (Consensus).

4.4.1.3 Grading system: A good titration reduces the overnight This recommendation is based on consensus agreement by
RDI ≤10 per hour or by 50% if the baseline RDI <15 per hour the PAP Titration Task Force. Leakage can occur in several
and should include supine REM sleep that is not continually forms. Intentional leak is the controlled leak from the port on
interrupted by spontaneous arousals or awakenings at the mask interfaces that washes out CO2 and prevents rebreathing.
selected pressure (Consensus). Unintentional leak is characterized as a “mouth leak” (i.e., pres-
surized air escaping via the mouth when a nasal mask is used)
This recommendation is based on consensus agreement by or “mask leak” between the mask and the face (i.e., pressurized
the PAP Titration Task Force and the grading system proposed air escaping between the mask and the face when a nasal mask
by Hirshkowitz and Sharafkhaneh.91 or full-face/oronasal mask is used). Unintentional leak can be
minimized by mask refit or readjustment, and, in the case of
4.4.1.4 Grading system: An adequate titration is one that does “mouth leak”, addition of a chinstrap to reduce mouth opening
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not reduce the overnight RDI ≤10 per hour but does reduce the or switching to a full-face/oronasal mask may be beneficial.92,93
RDI by 75% from baseline (especially in severe OSA patients), or A study examining the effects of mask leak on the efficacy of
one in which the titration grading criteria for optimal or good are BPAP therapy reported that the patients showed improved oxy-
met with the exception that supine REM sleep did not occur at the genation, decreased arousal index, and increased REM sleep
selected pressure (Consensus). when this leak was minimized.94

This recommendation is based on consensus agreement by 4.4.3.2 There is insufficient evidence for what constitutes a
the PAP Titration Task Force and the grading system proposed clinically significant leak given mask fit and other factors;
by Hirshkowitz and Sharafkhaneh.91 however, in general, an unacceptable leak for PAP is one that is
substantially higher than the leak recorded at a given pressure
4.4.1.5 Grading system: An unacceptable titration is one that from a well-fitted, applied, and secured interface. The acceptable
does not meet any one of the above grades (Consensus). leak will always exceed the intentional leak, which depends on
the applied pressure and interface type. The intentional leak vs.
This recommendation is based on consensus agreement by pressure relationship is usually supplied by the manufacturer of
Copyright 2023 American Academy of Sleep Medicine. All rights reserved.

the PAP Titration Task Force and the grading system proposed each interface (Consensus).
by Hirshkowitz and Sharafkhaneh.91
This recommendation is based on consensus agreement by
4.4.2 Repeat PAP Titration Study the PAP Titration Task Force. The intentional leak of all inter-
faces increases as pressure increases. The exact amount of leak
4.4.2.1 A repeat PAP titration study should be considered if also varies with the type of interface. This makes identification
the initial titration does not achieve a grade of optimal or good of what constitutes an unacceptable leak value very difficult.
and, if it is a split-night PSG study, it fails to meet AASM criteria Clinical judgment based on laboratory-specific criteria or the
(Consensus). leak vs. pressure relationship supplied by the manufacturer for
a given interface is recommended. A sudden increase in leak
This recommendation is based on consensus agreement by without a pressure change should alert the technologist to a pos-
the PAP Titration Task Force. As per split-night study criteria sible increase in mask/mouth leak.
in the AASM practice parameters for the indications for PSG5:
(a) an AHI of at least 40 is documented during a minimum of 4.4.3.3 Pressure waveform modification technologies may
2 hours of diagnostic PSG. Split-night studies may sometimes improve patient comfort and adherence with PAP (Consensus).
be considered at an AHI of 20 to 40, based on clinical judgment
(e.g., if there are also repetitive long obstructions and major de- This recommendation is based on consensus agreement by
saturations). However, at AHI values below 40, determination the PAP Titration Task Force. Complaints of a sensation of ex-
of CPAP pressure requirements, based on split-night studies, haling against a high pressure were reported by approximately
may be less accurate than in full-night calibrations. (b) CPAP 20% of patients receiving CPAP,95 and it is possible that the
titration is carried out for more than 3 hours (because respira- pressure reduction during expiration on pressure-relief CPAP is
Journal of Clinical Sleep Medicine, Vol. 4, No. 2, 2008 166
 Manual Titration of Positive Airway Pressure

more comfortable for those patients who require a higher CPAP This recommendation is based on consensus agreement by
pressure. These new technologies have had limited testing but the PAP Titration Task Force.
have potential utility in patient acceptance and utilization of
PAP.43,58,96-99 4.4.5.3 O2 rate should be increased by 1 L/min, with an interval
no shorter than 15 min, until SpO2 is between 88% and 94%
4.4.4 Positional and Sleep Stage Factors (Consensus).

4.4.4.1 Ideally, the patient should be recorded in supine REM This recommendation is based on consensus agreement by
sleep for at least 15 min at the designated optimal pressure during the PAP Titration Task Force. Similar to Recommendation
the PAP titration study. If the patient is in REM sleep but not in 4.4.5.1, a slightly higher goal than 88% (90%-94%) might be
the supine position while at the designated optimal pressure, prudent in some circumstances.
the patient may be awakened and instructed to lie in the supine
position (Consensus). 4.4.5.4 Optimally, supplemental O2 should be connected to the
PAP device outlet (using a T-connector) (Consensus).
This recommendation is based on consensus agreement by
the PAP Titration Task Force. Optimal CPAP has been defined This recommendation is based on consensus agreement by
as the highest pressure obtained during REM sleep with the the PAP Titration Task Force. When O2 is introduced directly
patient having slept in the supine position.55 Since treatment- into a PAP mask, the O2 does not have time or space to mix well
emergent central sleep apnea is more likely to occur in NREM with the high flow coming from the tubing, which leads to high-
sleep, it is also important to evaluate patients at the designated ly variable O2 concentrations inside the mask. However, when
optimal pressure during NREM sleep.100 There is evidence that O2 is introduced into the tubing near the PAP device rather than
the optimal CPAP level in the supine position is greater than 2 directly into the mask, more constant O2 delivery to patients us-
cm H2O higher than the optimal CPAP needed while sleeping ing PAP would be expected.102
in the lateral position, both in REM and NREM sleep, in obese
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and nonobese subjects and in those younger and older than 60 4.4.5.5 “Weaning” down of O2 supplementation by employing
years.50 However, the decision to awaken the patient to obtain a BPAP or by further increasing IPAP (if BPAP was already instituted
PSG sample of supine REM must be carefully considered, since and if the patient tolerates the higher inspiratory pressures) can
it is important that the patient be allowed to obtain adequate be attempted (Consensus).
sleep during the titration study. This point may be supported
by research demonstrating that an increase in sleep efficiency This recommendation is based on consensus agreement by
(SE) during CPAP titration compared to the diagnostic night the PAP Titration Task Force. However, there is evidence from
was found to be the only significant predictor of objectively bench testing and limited human studies that measured O2 con-
measured CPAP adherence after controlling for indices of OSA centration with supplemental O2 is lower with higher CPAP, or
severity and sleep quality during the diagnostic night. Specifi- in the case of BPAP, higher IPAP and EPAP levels, regardless
cally, patients who had their SE increase used their machines an of the difference between IPAP and EPAP levels.93,102 Anything
average of 2 hours more per night than those who did not have that increases machine flow (room air) has the potential to re-
their SE increase.101 duce the effective O2 concentration for a given supplemental
O2 flow.
Copyright 2023 American Academy of Sleep Medicine. All rights reserved.

4.4.5 Supplemental Oxygen

4.4.6 Adaptive Servoventilation
4.4.5.1 Supplemental O2 should be added during the PAP titration
when, prior to the PAP titration, the patient’s awake supine SpO2 4.4.6.1 Adaptive servoventilation may be considered if the patient
while breathing room air is ≤88%. Supplemental O2 may also is observed to have Cheyne-Stokes respiration or if treatment-
be added during the PAP titration when SpO2 is ≤88% for ≥5 emergent central sleep apnea (i.e., complex sleep apnea) during
minutes in the absence of obstructive respiratory events. In both the titration study is not eliminated by down titration of pressure
instances, supplemental O2 should be introduced at 1 L/min and (Consensus).
titrated upwards to achieve a target SpO2 between 88% and 94%
(Consensus). This recommendation is based on consensus agreement by
the PAP Titration Task Force. Adaptive servoventilation is a
This recommendation is based on consensus agreement by the new therapy that provides an expiratory positive airway pres-
PAP Titration Task Force. The above recommendation is made sure and inspiratory pressure support which is servocontrolled,
with the understanding that pulse oximetry can overestimate the based on the detection of Cheyne-Stokes respiration,103 with a
actual arterial oxygen saturation in some circumstances and that backup respiratory rate. There is controversy as to what com-
the effective inspired oxygen concentration can fall if machine plex sleep apnea represents,104,105 but in one study, adaptive
flow increases due to higher leak. A slightly higher goal than 88% servoventilation has been shown to decrease respiratory events
(90%-94%) might be prudent in some circumstances. and improve objective sleep measures in patients with central
sleep apnea/Cheyne-Stokes respiration, mixed sleep apnea, and
4.4.5.2 The minimum starting O2 rate should be 1 L/min (both complex sleep apnea.106
pediatric and adult patients) (Consensus).
Journal of Clinical Sleep Medicine, Vol. 4, No. 2, 2008 167
 CA Kushida, A Chediak, RB Berry et al

4.4.7 Follow-up After the PAP Titration Study nary literature search and review. The Task Force also thanks
the outside reviewers (Drs. Brian Boehlecke, Michael Littner,
4.4.7.1 PAP usage should be objectively monitored to help assure and Timothy Morgenthaler) and the Board of Directors of the
utilization (Standard). American Academy of Sleep Medicine who provided valu-
able comments to the draft of this report. This report could not
This recommendation is based on consensus agreement by have been completed without the administrative support of the
the PAP Titration Task Force, and is a slight modification of American Academy of Sleep Medicine; specifically, Lisa Anti-
Standard-Level Recommendation 4.3.1 in the 2006 practice gnano, Jennifer Markkanen, and Jerry Barrett.
parameters for the use of PAP devices7; the current recommen-
dation reflects objective monitoring of PAP (i.e., CPAP and REFERENCES
BPAP), rather than only CPAP, usage.
1. Parthasarathy S, Habib M, Quan SF. How are automatic positive
airway pressure and related devices prescribed by sleep physi-
4.4.7.2 Troubleshooting of problems encountered while on PAP, cians? A web-based survey. J Clin Sleep Med 2005;1:27-34.
management of side effects, and methods to increase adherence 2. Littner M, Hirshkowitz M, Davila D, et al. Practice parameters
should be a part of the close follow-up of the patient on PAP for the use of auto-titrating continuous positive airway pressure
(Standard). devices for titrating pressures and treating adult patients with ob-
structive sleep apnea syndrome. An American Academy of Sleep
This recommendation is based on consensus agreement by Medicine report. Sleep 2002;25:143-7.
the PAP Titration Task Force, and is a modification of Standard- 3. Berry RB, Parish JM, Hartse KM. The use of auto-titrating con-
tinuous positive airway pressure for treatment of adult obstructive
Level Recommendation 4.4.1 (“Close follow-up for PAP us-
sleep apnea. An American Academy of Sleep Medicine review.
age and problems in patients with OSA by appropriately trained Sleep 2002;25:148-73.
health care providers is indicated to establish effective utiliza- 4. Collop NA, Anderson WM, Boehlecke B, et al. Clinical guide-
tion patterns and remediate problems, if needed. This is espe- lines for the use of unattended portable monitors in the diagno-
cially important during the first few weeks of PAP use.”) in the
Downloaded from jcsm.aasm.org by 129.176.151.29 on March 17, 2023. For personal use only. No other uses without permission.

sis of obstructive sleep apnea in adult patients. J Clin Sleep Med

2006 practice parameters for the use of PAP devices.7 CPAP use 2007;3:1-16.
is improved by contact with health care providers (either clinic 5. Kushida CA, Littner M, Morgenthaler T, et al. Practice param-
physician appointment or specialist nurse home visit).107 How- eters for the indications for polysomnography and related proce-
ever, newer approaches may represent alternatives to current dures: an update for 2005. Sleep 2005;28:499-521.
6. Chesson AL Jr, Ferber RA, Fry JM, et al. The indications for poly-
practices; the use of telemedicine support (i.e., Internet-based
somnography and related procedures. Sleep 1997;20:423-87.
informational support and feedback for problems experienced 7. Kushida CA, Littner MR, Hirshkowitz M, et al. Practice param-
with CPAP use) resulted in equivalent use, functional status, and eters for the use of continuous and bilevel positive airway pres-
patient satisfaction at 30 days compared to traditional follow- sure devices to treat adult patients with sleep-related breathing
up care.108 Skipping the use of CPAP for 2 or more nights within disorders. Sleep 2006;29:375-80.
the first week of treatment signals potential nonadherence and 8. Iber C, Ancoli-Israel S, Chesson A, Quan SF, American Academy
highlights the need for close follow-up during this particularly of Sleep Medicine. The AASM manual for the scoring of sleep
vulnerable period of usage.109 This is especially important since and associated events: rules, terminology and technical specifica-
it is estimated that worldwide 5%-50% of OSA patients recom- tions. 2nd ed. westchester, IL: American Academy of Sleep Medi-
cine; 2007.
mended for CPAP either reject or discontinue its use within the
9. Sackett DL. Rules of evidence and clinical recommendations for
Copyright 2023 American Academy of Sleep Medicine. All rights reserved.

first week.110 the management of patients. Can J Cardiol 1993;9:487-9.

10. Fitch K, Bernstein S, Aguilar M, et al. The RAND/UCLA Ap-
5.0 FUTURE RESEARCH propriateness Method User’s Manual. Santa Monica, CA: RAND
Corporation; 2001.
Additional work is needed with respect to the following: 11. Eddy DM, ed. A manual for assessing health practices and de-
1. Further outcome studies comparing manual PAP titration signing practice policies: the explicit approach. Philadelphia, PA:
studies vs. autotitrating PAP devices with respect to OSA American College of Physicians; 1992.
severity and diverse patient populations. 12. Juhasz J. The fine art of CPAP titration--will it ever become obso-
lete? Sleep Breath 2007;11:65-7.
2. Assessment of the reliability of selection of optimal pressure
13. Stepanski EJ. The need for a standardized CPAP titration protocol
following PAP titration studies and the stability of the select- and follow-up procedures. J Clin Sleep Med 2005;1:311.
ed optimal pressure across successive PAP titration studies is 14. Stepanski EJ, Dull R, Basner RC. CPAP titration protocols among
needed. accredited sleep disorder centers. Sleep Res 1996;25:374.
3. Clinically significant thresholds for unintentional leak from 15. Mokhlesi B, Tulaimat A. Recent advances in obesity hypoventila-
the mouth or mask need to be identified. tion syndrome. Chest 2007;132:1322-36.
4. Finally, advances in the technology for improving patient 16. Wiest GH, Fuchs FS, Harsch IA, et al. Reproducibility of a stan-
comfort and adherence to PAP devices are sorely needed. dardized titration procedure for the initiation of continuous posi-
tive airway pressure therapy in patients with obstructive sleep
apnoea. Respiration 2001;68:145-50.
ACKNOWLEDGMENTS
17. Berthon-Jones M, Lawrence S, Sullivan CE, Grunstein R. Nasal
continuous positive airway pressure treatment: current realities
The Task Force gratefully acknowledges the contribution of and future. Sleep 1996;19(9 Suppl):S131-5.
Dr. Vincenzo Novara, who provided assistance in the prelimi- 18. Sforza E, Krieger J, Bacon W, Petiau C, Zamagni M, Boudewijns
Journal of Clinical Sleep Medicine, Vol. 4, No. 2, 2008 168
 Manual Titration of Positive Airway Pressure

A. Determinants of effective continuous positive airway pressure 38. Kirk VG, O’Donnell AR. Continuous positive airway pressure
in obstructive sleep apnea. Role of respiratory effort. Am J Respir for children: a discussion on how to maximize compliance. Sleep
Crit Care Med 1995;151:1852-6. Med Rev 2006;10:119-27.
19. Sullivan CE, Issa FG, Berthon-Jones M, McCauley VB, Costas 39. Slifer KJ, Kruglak D, Benore E, et al. Behavioral training for
LJ. Home treatment of obstructive sleep apnoea with continuous increasing preschool children’s adherence with positive airway
positive airway pressure applied through a nose-mask. Bull Eur pressure: a preliminary study. Behav Sleep Med 2007;5:147-75.
Physiopathol Respir 1984;20:49-54. 40. Condos R, Norman RG, Krishnasamy I, Peduzzi N, Goldring
20. Nino-Murcia G, McCann CC, Bliwise DL, Guilleminault C, De- RM, Rapoport DM. Flow limitation as a noninvasive assessment
ment WC. Compliance and side effects in sleep apnea patients of residual upper-airway resistance during continuous positive
treated with nasal continuous positive airway pressure. West J airway pressure therapy of obstructive sleep apnea. Am J Respir
Med 1989;150:165-9. Crit Care Med 1994;150:475-80.
21. Miljeteig H, Hoffstein V. Determinants of continuous positive air- 41. Hosselet JJ, Norman RG, Ayappa I, Rapoport DM. Detection of
way pressure level for treatment of obstructive sleep apnea. Am flow limitation with a nasal cannula/pressure transducer system.
Rev Respir Dis 1993;147(6 Pt 1):1526-30. Am J Respir Crit Care Med 1998;157(5 Pt 1):1461-7.
22. Pevernagie DA, Shepard JW Jr. Relations between sleep 42. Montserrat JM, Ballester E, Olivi H, et al. Time-course of step-
stage, posture and effective nasal CPAP levels in OSA. Sleep wise CPAP titration. Behavior of respiratory and neurological
1992;15:162-7. variables. Am J Respir Crit Care Med 1995;152(6 Pt 1):1854-9.
23. Hoheisel GB, Teschler H. Clinical parameters for the prescrip- 43. Nilius G, Happel A, Domanski U, Ruhle KH. Pressure-relief con-
tion of minimally effective CPAP for the treatment of obstructive tinuous positive airway pressure vs constant continuous positive
sleep apnea. Am J Resp Crit Care Med 1994;149:A496. airway pressure: a comparison of efficacy and compliance. Chest
24. Hoffstein V, Mateika S. Predicting nasal continuous positive air- 2006;130:1018-24.
way pressure. Am J Respir Crit Care Med 1994;150:486-8. 44. Montserrat JM, Alarcon A, Lloberes P, Ballester E, Fornas C,
25. Rowley JA, Tarbichi AG, Badr MS. The use of a predicted Rodriguez-Roisin R. Adequacy of prescribing nasal continuous
CPAP equation improves CPAP titration success. Sleep Breath positive airway pressure therapy for the sleep apnoea/hypopnoea
2005;9:26-32. syndrome on the basis of night time respiratory recording vari-
26. Gokcebay N, Iqbal S, Yang K, Zebrak A, Hirshkowitz M. Ac- ables. Thorax 1995;50:969-71.
Downloaded from jcsm.aasm.org by 129.176.151.29 on March 17, 2023. For personal use only. No other uses without permission.

curacy of CPAP predicted from anthropometric and polysomno- 45. Lloberes P, Ballester E, Montserrat JM, et al. Comparison of man-
graphic indices. Sleep 1996;19:600-1. ual and automatic CPAP titration in patients with sleep apnea/
27. Gokcebay N, Hirshkowitz M. Optimal CPAP: Titration vs. for- hypopnea syndrome. Am J Respir Crit Care Med 1996;154(6 Pt
mula. Sleep. 1997;20:237-8. 1):1755-8.
28. Ballester E, Badia JR, Hernandez L, et al. Evidence of the effec- 46. Sanders MH, Kern NB, Costantino JP, et al. Adequacy of pre-
tiveness of continuous positive airway pressure in the treatment scribing positive airway pressure therapy by mask for sleep
of sleep apnea/hypopnea syndrome. Am J Respir Crit Care Med apnea on the basis of a partial-night trial. Am Rev Respir Dis
1999;159:495-501. 1993;147:1169-74.
29. Rosenthal L, Nykamp K, Guido P, et al. Daytime CPAP titration: 47. Jokic R, Klimaszewski A, Sridhar G, Fitzpatrick MF. Continuous
a viable alternative for patients with severe obstructive sleep ap- positive airway pressure requirement during the first month of
nea. Chest 1998;114:1056-60. treatment in patients with severe obstructive sleep apnea. Chest
30. Rudkowski JC, Verschelden P, Kimoff RJ. Efficacy of daytime 1998;114:1061-9.
continuous positive airway pressure titration in severe obstructive 48. Baltzan MA, Kassissia I, Elkholi O, Palayew M, Dabrusin R,
sleep apnoea. Eur Respir J 2001;18:535-41. Wolkove N. Prevalence of persistent sleep apnea in patients treated
31. American Academy of Sleep Medicine Task Force. Sleep-related with continuous positive airway pressure. Sleep 2006;29:557-63.
breathing disorders in adults: recommendations for syndrome 49. Bureau MP, Series F. Comparison of two in-laboratory titration
Copyright 2023 American Academy of Sleep Medicine. All rights reserved.

definition and measurement techniques in clinical research. The methods to determine effective pressure levels in patients with
report of an American Academy of Sleep Medicine task force. obstructive sleep apnoea. Thorax 2000;55:741-5.
Sleep 1999;22:667-89. 50. Oksenberg A, Silverberg DS, Arons E, Radwan H. The sleep su-
32. Montgomery-Downs HE, O’Brien LM, Gulliver TE, Gozal D. pine position has a major effect on optimal nasal continuous posi-
Polysomnographic characteristics in normal preschool and early tive airway pressure: relationship with rapid eye movements and
school-aged children. Pediatrics 2006;117:741-53. non-rapid eye movements sleep, body mass index, respiratory
33. Goodwin JL, Kaemingk KL, Fregosi RF, et al. Clinical outcomes disturbance index, and age. Chest 1999;116:1000-6.
associated with sleep-disordered breathing in Caucasian and His- 51. Berry RB, Patel PB. Effect of zolpidem on the efficacy of contin-
panic children--the Tucson Children’s Assessment of Sleep Ap- uous positive airway pressure as treatment for obstructive sleep
nea study (TuCASA). Sleep 2003;26:587-91. apnea. Sleep 2006;29:1052-6.
34. Kheirandish L, Goldbart AD, Gozal D. Intranasal steroids and 52. Randerath WJ, Galetke W, Ruhle KH. Auto-adjusting CPAP
oral leukotriene modifier therapy in residual sleep-disordered based on impedance versus bilevel pressure in difficult-to-treat
breathing after tonsillectomy and adenoidectomy in children. Pe- sleep apnea syndrome: a prospective randomized crossover study.
diatrics 2006;117:e61-6. Med Sci Monit 2003;9:CR353-8.
35. Silva RS, Truksinas V, de Mello-Fujita L, et al. An orientation ses- 53. Reeves-Hoche MK, Hudgel DW, Meck R, Witteman R, Ross A,
sion improves objective sleep quality and mask acceptance during Zwillich CW. Continuous versus bilevel positive airway pres-
positive airway pressure titration. Sleep Breath 2008;12:85-9. sure for obstructive sleep apnea. Am J Respir Crit Care Med
36. Marcus CL, Ward SL, Mallory GB, et al. Use of nasal continuous 1995;151(2 Pt 1):443-9.
positive airway pressure as treatment of childhood obstructive 54. Behbehani K, Yen FC, Lucas EA, Burk JR. A sleep laboratory
sleep apnea. J Pediatr 1995;127:88-94. evaluation of an automatic positive airway pressure system for
37. Rains JC. Treatment of obstructive sleep apnea in pediatric patients. treatment of obstructive sleep apnea. Sleep 1998;21:485-91.
Behavioral intervention for compliance with nasal continuous posi- 55. Lloberes P, Rodriguez B, Roca A, et al. Comparison of conven-
tive airway pressure. Clin Pediatr (Phila) 1995;34:535-41. tional nighttime with automatic or manual daytime CPAP titra-

Journal of Clinical Sleep Medicine, Vol. 4, No. 2, 2008 169

 CA Kushida, A Chediak, RB Berry et al

tion in unselected sleep apnea patients: study of the usefulness of 74. Resta O, Guido P, Picca V, et al. Prescription of nCPAP and nBI-
daytime titration studies. Respir Med 2004;98:619-25. PAP in obstructive sleep apnoea syndrome: Italian experience
56. Fietze I, Glos M, Moebus I, Witt C, Penzel T, Baumann G. Auto- in 105 subjects. A prospective two centre study. Respir Med
matic pressure titration with APAP is as effective as manual titra- 1998;92:820-7.
tion with CPAP in patients with obstructive sleep apnea. Respira- 75. Berry RB, Desa MM, Light RW. Effect of ethanol on the efficacy
tion 2007;74:279-86. of nasal continuous positive airway pressure as a treatment for
57. Lopez-Campos JL, Garcia Polo C, Leon Jimenez A, Gonzalez- obstructive sleep apnea. Chest 1991;99:339-43.
Moya E, Arnedillo A, Fernandez Berni JJ. CPAP titration: Dif- 76. Hoffstein V, Oliver Z. Comparing pressures required to abolish
ferent methods for similar clinical results. Eur J Intern Med snoring and sleep apnea. Can Respir J 2001;8:427-30.
2007;18:230-4. 77. Fleury B, Rakotonanahary D, Tehindrazanarivelo AD, Hausser-
58. Farre R, Peslin R, Montserrat JM, Rotger M, Navajas D. Flow- Hauw C, Lebeau B. Long-term compliance to continuous posi-
dependent positive airway pressure to maintain airway patency tive airway pressure therapy (nCPAP) set up during a split-night
in sleep apnea-hypopnea syndrome. Am J Respir Crit Care Med polysomnography. Sleep 1994;17:512-5.
1998;157(6 Pt 1):1855-63. 78. Hedner J, Darpo B, Ejnell H, Carlson J, Caidahl K. Reduction
59. Oksenberg A, Arons E, Froom P. Does the severity of obstructive in sympathetic activity after long-term CPAP treatment in sleep
sleep apnea predict patients requiring high continuous positive apnoea: cardiovascular implications. Eur Respir J 1995;8:222-9.
airway pressure? Laryngoscope 2006;116:951-5. 79. Series F, Marc I, Cormier Y, La Forge J. Required levels of nasal
60. Massa F, Gonsalez S, Laverty A, Wallis C, Lane R. The use of na- continuous positive airway pressure during treatment of obstruc-
sal continuous positive airway pressure to treat obstructive sleep tive sleep apnoea. Eur Respir J 1994;7:1776-81.
apnoea. Arch Dis Child 2002;87:438-43. 80. Downey R, 3rd, Perkin RM, MacQuarrie J. Nasal continuous
61. Derderian SS, Bridenbaugh RH, Rajagopal KR. Neuropsycho- positive airway pressure use in children with obstructive sleep
logic symptoms in obstructive sleep apnea improve after treat- apnea younger than 2 years of age. Chest 2000;117:1608-12.
ment with nasal continuous positive airway pressure. Chest 81. McNamara F, Sullivan CE. Obstructive sleep apnea in infants and
1988;94:1023-7. its management with nasal continuous positive airway pressure.
62. Uong EC, Epperson M, Bathon SA, Jeffe DB. Adherence to nasal Chest 1999;116:10-16.
positive airway pressure therapy among school-aged children and 82. Issa FG, Sullivan CE. Upper airway closing pressures in snorers.
Downloaded from jcsm.aasm.org by 129.176.151.29 on March 17, 2023. For personal use only. No other uses without permission.

adolescents with obstructive sleep apnea syndrome. Pediatrics J Appl Physiol 1984;57:528-35.
2007;120:e1203-11. 83. Rauscher H, Formanek D, Zwick H. Nasal continuous positive
63. Gay PC, Herold DL, Olson EJ. A randomized, double-blind clini- airway pressure for nonapneic snoring? Chest 1995;107:58-61.
cal trial comparing continuous positive airway pressure with a 84. Guilleminault C, Stoohs R, Clerk A, Cetel M, Maistros P. A cause
novel bilevel pressure system for treatment of obstructive sleep of excessive daytime sleepiness. The upper airway resistance syn-
apnea syndrome. Sleep 2003;26:864-9. drome. Chest 1993;104:781-7.
64. Lloberes P, Montserrat JM, Ascaso A, et al. Comparison of par- 85. Berthon-Jones M. Feasibility of a self-setting CPAP machine.
tially attended night time respiratory recordings and full poly- Sleep 1993;16(8 Suppl):S120-1; discussion S121-3.
somnography in patients with suspected sleep apnoea/hypopnoea 86. Strollo PJ Jr, Sanders MH, Costantino JP, Walsh SK, Stiller RA,
syndrome. Thorax 1996;51:1043-7. Atwood CW Jr. Split-night studies for the diagnosis and treatment
65. Meurice JC, Paquereau J, Denjean A, Patte F, Series F. Influence of sleep-disordered breathing. Sleep 1996;19(10 Suppl):S255-9.
of correction of flow limitation on continuous positive airway 87. Sanders MH, Kern NB, Costantino JP, et al. Prescription of posi-
pressure efficiency in sleep apnoea/hypopnoea syndrome. Eur tive airway pressure for sleep apnea on the basis of a partial-night
Respir J 1998;11:1121-7. trial. Sleep 1993;16(8 Suppl):S106-107.
66. Marcus CL, Rosen G, Ward SL, et al. Adherence to and effective- 88. McArdle N, Grove A, Devereux G, Mackay-Brown L, Mackay
ness of positive airway pressure therapy in children with obstruc- T, Douglas NJ. Split-night versus full-night studies for sleep ap-
Copyright 2023 American Academy of Sleep Medicine. All rights reserved.

tive sleep apnea. Pediatrics 2006;117:e442-51. noea/hypopnoea syndrome. Eur Respir J 2000;15:670-5.
67. Rajagopal KR, Bennett LL, Dillard TA, Tellis CJ, Tenholder MF. 89. Seegobin RD, van Hasselt GL. Endotracheal cuff pressure and
Overnight nasal CPAP improves hypersomnolence in sleep ap- tracheal mucosal blood flow: endoscopic study of effects of four
nea. Chest 1986;90:172-6. large volume cuffs. Br Med J (Clin Res Ed)1984;288:965-8.
68. Schafer H, Ewig S, Hasper E, Luderitz B. Failure of CPAP ther- 90. International consensus conferences in intensive care medicine:
apy in obstructive sleep apnoea syndrome: predictive factors Ventilator-associated Lung Injury in ARDS. This official confer-
and treatment with bilevel-positive airway pressure. Respir Med ence report was cosponsored by the American Thoracic Society,
1998;92:208-15. The European Society of Intensive Care Medicine, and The So-
69. Sanders MH, Costantino JP, Strollo PJ, Studnicki K, Atwood CW. ciete de Reanimation de Langue Francaise, and was approved by
The impact of split-night polysomnography for diagnosis and the ATS Board of Directors, July 1999. Am J Respir Crit Care
positive pressure therapy titration on treatment acceptance and Med 1999;160:2118-24.
adherence in sleep apnea/hypopnea. Sleep 2000;23:17-24. 91. Hirshkowitz M, Sharafkhaneh A. Positive airway pressure thera-
70. Hers V, Liistro G, Dury M, Collard P, Aubert G, Rodenstein DO. py of OSA. Semin Respir Crit Care Med 2005;26:68-79.
Residual effect of nCPAP applied for part of the night in patients 92. Berry RB. Medical therapy. In: Johnson JT, Gluckman JL, Sand-
with obstructive sleep apnoea. Eur Respir J 1997;10:973-6. ers MH, eds. Obstructive sleep apnea. London: Martin Dunniz;
71. Sanders MH, Kern N. Obstructive sleep apnea treated by inde- 2002:89-118.
pendently adjusted inspiratory and expiratory positive airway 93. Schwartz AR, Kacmarek RM, Hess DR. Factors affecting oxy-
pressures via nasal mask. Physiologic and clinical implications. gen delivery with bi-level positive airway pressure. Respir Care
Chest 1990;98:317-24. 2004;49:270-5.
72. Oliver Z, Hoffstein V. Predicting effective continuous positive 94. Teschler H, Stampa J, Ragette R, Konietzko N, Berthon-Jones
airway pressure. Chest 2000;117:1061-4. M. Effect of mouth leak on effectiveness of nasal bilevel venti-
73. Yamashiro Y, Kryger MH. CPAP titration for sleep apnea using a latory assistance and sleep architecture.[comment]. Eur Respir J
split-night protocol. Chest 1995;107:62-6. 1999;14:1251-7.

Journal of Clinical Sleep Medicine, Vol. 4, No. 2, 2008 170

 Manual Titration of Positive Airway Pressure

95. Engleman HM, Asgari-Jirhandeh N, McLeod AL, Ramsay CF, titration for obstructive sleep apnea syndrome. Am J Respir Crit
Deary IJ, Douglas NJ. Self-reported use of CPAP and benefits of Care Med 1996;154(3 Pt 1):734-40.
CPAP therapy: a patient survey. Chest 1996;109:1470-6. 116. Migliori C, Motta M, Angeli A, Chirico G. Nasal bilevel vs. con-
96. Ruhle KH, Domanski U, Happel A, Nilius G. [Analysis of expira- tinuous positive airway pressure in preterm infants. Pediatr Pul-
tory pressure reduction (C-Flex method) during CPAP therapy]. monol 2005;40:426-30.
Pneumologie 2007;61:86-9. 117. Waters KA, Everett FM, Bruderer JW, Sullivan CE. Obstructive
97. Mulgrew AT, Cheema R, Fleetham J, Ryan CF, Ayas NT. Efficacy sleep apnea: the use of nasal CPAP in 80 children. Am J Respir
and patient satisfaction with autoadjusting CPAP with variable Crit Care Med 1995;152:780-5.
expiratory pressure vs standard CPAP: a two-night randomized
crossover trial. Sleep Breath 2007;11:31-7.
98. Aloia MS, Stanchina M, Arnedt JT, Malhotra A, Millman RP.
Treatment adherence and outcomes in flexible vs standard continu-
ous positive airway pressure therapy. Chest 2005;127:2085-93.
99. Juhasz J, Becker H, Cassel W, Rostig S, Peter JH. Proportional
positive airway pressure: a new concept to treat obstructive sleep
apnoea. Eur Respir J 2001;17:467-73.
100. Gilmartin GS, Daly RW, Thomas RJ. Recognition and manage-
ment of complex sleep-disordered breathing. Curr Opin Pulm
Med 2005;11:485-93.
101. Drake CL, Day R, Hudgel D, et al. Sleep during titration pre-
dicts continuous positive airway pressure compliance. Sleep
2003;26:308-11.
102. Yoder EA, Klann K, Strohl KP. Inspired oxygen concentrations
during positive pressure therapy. Sleep Breath 2004;8:1-5.
103. Teschler H, Dohring J, Wang YM, Berthon-Jones M. Adaptive
pressure support servo-ventilation: a novel treatment for Cheyne-
Downloaded from jcsm.aasm.org by 129.176.151.29 on March 17, 2023. For personal use only. No other uses without permission.

Stokes respiration in heart failure. Am J Respir Crit Care Med

2001;164:614-9.
104. Brown LK, Casey KR. Complex sleep apnea: the hedgehog and
the fox. Curr Opin Pulm Med 2007;13:473-8.
105. Morgenthaler TI, Kagramanov V, Hanak V, Decker PA. Complex
sleep apnea syndrome: is it a unique clinical syndrome? Sleep
2006;29:1203-9.
106. Morgenthaler TI, Gay PC, Gordon N, Brown LK. Adaptive ser-
voventilation versus noninvasive positive pressure ventilation
for central, mixed, and complex sleep apnea syndromes. Sleep
2007;30:468-75.
107. Palmer S, Selvaraj S, Dunn C, et al. Annual review of patients
with sleep apnea/hypopnea syndrome--a pragmatic randomised
trial of nurse home visit versus consultant clinic review. Sleep
Med 2004;5:61-5.
108. Taylor Y, Eliasson A, Andrada T, Kristo D, Howard R. The role
Copyright 2023 American Academy of Sleep Medicine. All rights reserved.

of telemedicine in CPAP compliance for patients with obstructive

sleep apnea syndrome. Sleep Breath 2006;10:132-8.
109. Weaver TE, Kribbs NB, Pack AI, et al. Night-to-night variabil-
ity in CPAP use over the first three months of treatment. Sleep
1997;20:278-83.
110. Engleman HM, Wild MR. Improving CPAP use by patients with
the sleep apnoea/hypopnoea syndrome (SAHS). Sleep Med Rev
2003;7:81-99.
111. McArdle N, Grove A, Devereux G, Mackay-Brown L, Mackay
T, Douglas NJ. Split-night versus full-night studies for sleep ap-
noea/hypopnoea syndrome. Eur Respir J 2000;15:670-5.
112. McEvoy RD, Thornton AT. Treatment of obstructive sleep apnea
syndrome with nasal continuous positive airway pressure. Sleep
1984;7:313-25.
113. Pieters T, Collard P, Aubert G, Dury M, Delguste P, Rodenstein
DO. Acceptance and long-term compliance with nCPAP in pa-
tients with obstructive sleep apnoea syndrome. Eur Respir J
1996;9:939-44.
114. Stradling JR, Barbour C, Pitson DJ, Davies RJ. Automatic nasal
continuous positive airway pressure titration in the laboratory:
patient outcomes. Thorax 1997;52:72-5.
115. Teschler H, Berthon-Jones M, Thompson AB, Henkel A, Henry
J, Konietzko N. Automated continuous positive airway pressure

Journal of Clinical Sleep Medicine, Vol. 4, No. 2, 2008 171