Performing a PAP Titration
Performing a PAP Titration
LEARNING OBJECTIVES
1. Understand how PAP therapy is used in the treatment of sleep-related
breathing disorders.
2. Discover the different types of PAP equipment.
3. Understand the goals of a titration.
4. Know when to use bi-level PAP.
5. Learn how to titrate O2.
Performing a PAP Titration
> PAP Therapy
● Positive airway pressure (PAP) therapy remains the preferred and most widely
used therapy for the treatment of sleep-related breathing disorders (SRBDs).
● PAP therapy is noninvasive and includes three main equipment components: a
blower unit, corrugated tubing, and an interface.
● The therapy works by pulling in and filtering normal room air (21% oxygen) and
applying it to a blower.
● The blower sends air through the tubing to an interface, most commonly a nasal
mask, at a set pressure that is measured in centimeters of water pressure
(cm2HO).
● The air pressure that is delivered can be adjusted to act as a mechanical splint to
hold the patient’s airway open, assist with ventilating the patient while the
patient sleeps, or both.
Performing a PAP Titration
Performing a PAP Titration
> CPAP
● CPAP remains the preferred and most widely used
therapy for obstructive sleep apnea (OSA).
● Obstructive sleep apnea is characterized by a
complete or partial obstruction in the upper airway
during sleep that results in frequent arousals, among
other deleterious consequences.
Performing a PAP Titration
Bi-Level
>
● Bi-level therapy is characterized by two separate pressures corresponding
with inhalation and exhalation.
● The EPAP and IPAP settings serve different purposes.
● Like CPAP, EPAP acts to maintain the patency of the airway.
● IPAP provides a means to provide ventilatory support and increased tidal
volumes.
● Bi-level therapy is used to treat patients with complex SRBDs, like
hypoventilation disorders or Cheyne–Stokes respiration, and those who have
difficulty tolerating high CPAP pressures.
● Providing a lower EPAP allows the patient to exhale more easily without
having to push as hard against the incoming positive pressure.
● Conversely, providing an increased IPAP allows the patient to inhale larger
volumes of air with greater ease.
Performing a PAP Titration
> PAP Devices
● Pressures are measured in centimeters of water (cmH2O).
● PAP levels can be verified by a device called a water column
manometer.
● Diagnostic units typically include options for remote monitoring and
controlling, live output data for recording on the polysomnograph, leak
measurements, and the ability to switch modes among CPAP, bi-level
PAP, and auto positive airway pressure (auto PAP).
● Auto PAP mode automatically adjusts CPAP as needed, based on
detected airflow and vibrations from the upper airway. If the system
detects vibrations in the upper airway from snoring or a decrease or
absence of airflow, then the pressure increases.
● After a period of time without detected vibrations or changes in airflow,
the pressure decreases.
Performing a PAP Titration
● Bi-level units include settings for backup respiratory rates and timing of
the respiratory cycle.
● A timed bilevel mode does not detect the changes in patient
respirations but switches between IPAP and EPAP on a specific time base
as defined by the user.
● A spontaneous bi-level mode automatically shifts between IPAP and
EPAP when it detects a change in the patient’s respirations.
● A third option available on many bi-level machines is a spontaneous
mode with a timed backup. This allows the patient to determine the
change of respirations but with the safety of a timed backup in case the
patient does not breathe on his or her own.
Performing a PAP Titration
● As noted previously, advanced forms of bi-level therapies have been
developed to address more complex SRBDs.
● ASV is a positive pressure mode of ventilation that can automatically
adjust respiratory rate, tidal volume, and inspiratory time based on the
patient’s requirements.
● It collected information on a breath-by-breath basis and adjusts pressure
support to optimize a patient’s breathing pattern.
● ASV machines are used to treat central sleep apnea, mixed sleep apnea,
and Cheynes–Stokes respiration, an abnormal waxing and waning
breathing with central apneic events.
Performing a PAP Titration
● AVAPS - Average Volume-Assured Pressure Support
● is a positive pressure mode of ventilation that automatically adapts the
pressure support (IPAP) a patient needs to maintain an average tidal
volume.
● AVAPS uses an algorithm to estimate tidal volume at each breath,
compares it to the target volume, and adjusts IPAP accordingly.
● These units are commonly used to treat patients with complex SRBDs
such as obesity hypoventilation syndrome and chronic obstructive
pulmonary disease. The prescribed settings would include the target
tidal volume and IPAP limits.
Performing a PAP Titration
● Home units are typically much simpler and easier to use.
● The pressure on these units cannot be changed without an interface
device or a combination of key entries on the machine.
● Many home PAP devices include memory cards, data storage, or Wi-Fi
capabilities with downloadable data, for use at patient follow-ups.
● Many have pressure reliefs at the end of inhalation and the beginning of
exhalation to allow for a more comfortable transition. Many patients
find this option much more comfortable and tolerable.
Performing a PAP Titration
> Humidification
● A common side effect of PAP therapy is nasal and upper airway
dryness.
● Adjustments in humidity levels and temperature can be
tailored to improve patient comfort.
● Many PAP machines have integrated heated humidifiers,
whereas others use external humidifiers.
● When heated humidification is used, water sometimes pools
inside the hose when the room air temperature is significantly
cooler than the hose temperature.
Performing a PAP Titration
> Adverse Effects
● Nasal dryness
● In addition, many patients simply have difficulty tolerating the air
pressure that is delivered.
● Facial soreness at various pressure points can also occur. This is most
appropriately addressed by confirming that the correct size interface is
being used and readjusting the head straps for comfort. If the problem
persists, a different style interface should be considered.
Performing a PAP Titration
> PAP Titration
● Titration refers to the gradual process of adjusting the strength or dose
of a medication or treatment until an acceptable or optimal treatment
level is achieved.
● The hookup procedure for a PAP titration study mirrors that of the
diagnostic study with one exception: The two airflow sensors used in a
PSG are replaced with a PAP mask for the titration.
● The montage selected for these two studies are nearly identical, usually
with the addition of a PAP pressure channel and PAP flow channel. The
PAP flow is detected by the PAP machine rather than, or in addition to, a
thermistor, thermocouple, or pressure transducer.
Performing a PAP Titration
CPAP Titration Protocols
> Increasing CPAP
● During a CPAP titration study, pressure is used as a splint to maintain the
patency of the upper airway.
● Pressures should be titrated upward in ≥1 cm increments over at least
5-minute periods of time in response to the following breathing events:
a. Two or more obstructive apneas
b. Three or more hypopneas
c. Five or more respiratory effort–related arousals (RERAs)
d. Three or more minutes of loud snoring
Performing a PAP Titration
● According to the AASM clinical guidelines for the manual titration of PAP
therapy, an optimal titration is defined as:
a. A respiratory disturbance index (RDI) of less than five events for a
period of 15 minutes
b. SpO > 90%
c. Fewer than five electroencephalogram (EEG) arousals per hour in
supine rapid eye movement (REM)
d. Snoring eliminated
Performing a PAP Titration
> Bi-Level Titration Protocols
● According to the AASM Clinical Guidelines, the recommended minimum
starting IPAP should be 8 cmH2O, whereas EPAP should be set at 4 cmH2O.
● If a patient is uncomfortable or intolerant of high CPAP above 14 cmH20,
then the mode may be switched over from CPAP to bi-level.
● In this case, it is recommended that the EPAP be set at the CPAP whereby
apneic events were eliminated and the IPAP set 4 cmH2O above that. The
recommended minimum IPAP–EPAP differential is 4 cm H2O, while the
maximum differential is 10 cmH2O.
Performing a PAP Titration
● The titration of bi-level therapy should include upward titration of the
IPAP and EPAP by at least 1 cmH2O for apneic events and upward
titration of the IPAP pressure only by at least 1 cm H O in response to
hypopnea, RERAs, or snoring.
● IPAP can also be increased to correct for hypoxemia that persists despite
a patent airway.
● If treatment-emergent central apneas are observed, a decrease in IPAP
or a switch to spontaneously timed mode with backup rate may be
helpful.
● The recommended maximum IPAP pressure is 30 cmH2O for patients 12
years of age and older. An optimal bi-level titration is defined the same
as for a CPAP titration.
Performing a PAP Titration
> Supplemental O2
● Supplemental oxygen is often used in the sleep lab to address hypoxemia.
● Technologists should check the baseline oxygen saturation at the beginning of
the night by using a pulse oximeter (SpO2).
● If a patient demonstrates decreased SpO2 levels, the technologist should
notify the physician to make him or her aware and obtain an order for
supplemental O2.
● For patients with SRBDs that demonstrate decreased SpO2 levels during the
study, it is most often recommended to correct the respiratory events via PAP
therapy first.
● Once the SRBD is addressed, if oxygen desaturation persists, then
supplemental oxygen may be indicated. In this case, supplemental O2 can be
introduced into the PAP circuit by connecting oxygen tubing to one of the
small outlet holes on the PAP interface.
