Titration is important to determine the optimal pressure for positive airway pressure (PAP) therapy. Manual titration involves starting at 4 cm for CPAP and gradually increasing pressure until apneas, hypopneas, and snoring are abolished. If high pressure is required or hypoxia occurs, bilevel PAP may be better. Oxygen can be added if needed to target SpO2 of 92-94%. The goal is an optimal or good titration with minimal events and arousals at a pressure the patient can tolerate. Common issues include mask leaks, discomfort, and congestion which may require pressure adjustment or changing the interface.

1. Titration study in OSA & COPD / OSA
overlap
Dr. Zia Hashim
MD Internal Medicine (PGI Chandigarh)
DM Pulmonary & Critical Care (PGI Chandigarh)
FCCP (USA)
Associate Professor
Consultant in charge Sleep Lab
Department of Pulmonary Medicine
SGPGIMS Lucknow

2. Indications for starting PAP
AHI or RDI 15 events/hour
AHI or RDI 5 but <15 events/hour with any one of the
following symptoms:
– Excessive daytime sleepiness
– Neurocognitive impairment
– Hypertension
– Coronary artery disease
– Cardiac arrhythmias
– Pulmonary hypertension
– History of stroke
Pilots and drivers: AHI 5 - 14 even if no symptoms.
RERA > 10 with excessive daytime sleepiness even if AHI < 5

3. Before starting treatment
• Which device to use ?
• At what pressure ?
• Is oxygen also required ?

4. • Pneumatic splint
• Increase in lung volume
• Increase in upper airway size

5. Mechanism of action of PAP

6. After starting CPAP

7. Before doing titration complete
diagnosis is very important
• OSA
• OHS
• CHF
• COPD
• Central apnea
syndromes
• Cheyne stokes
respiration
• Neuromuscular disease
• BMI
• Clinical examination
– History
– Wheeze
– Pedal edema
• Morning awake ABG
• PFT
• Complete In Lab PSG
• ECHO

8. TYPES OF DEVICES

9. Basic devices
• CPAP
• BPAP (S mode)
• Flexible PAP, expiratory
pressure relief
• AutoCPAP
Advanced devises
• Auto BPAP
• BPAP S/T
• Adaptive Servoventilation

10. CPAP
CPAP with pressure relief
BPAP

11. BPAP in OSA
• EPAP eliminates obstructive apnea
• IPAP eliminates
– Hypopnea
– RERA
– Snoring
• IPAP-EPAP provides Tv

12. BPAP
– Patients requiring a CPAP pressure more than 15
cm
– Patients who have barotrauma complications like
ear infections and bloating with high pressure
CPAP
– Patients with hypoventilation
No additional advantage
Compliance similar

13. Autotitrating PAP
• APAP: titrated between maximum and minimum pressure limits to prevent
apnea hypopnea, airflow flattening and snoring
Exemple1 REMstar auto
Sleep Therapy Daily Details
Legend: NR - Non-Responsive Apnea/Hypopnea, OA - Obstructive Apnea, H- Hypopnea, FL- Flow Limitation, VS - Vibratory Snore
09/01/2007 10:08 - 10/01/2007 6:56
Large Leak
0,0 Mins.
0,0% of Night
Average Leak
36,42
Indices
9
90% AutoCPAP
AHI:5,1
7,1
Avg AutoCPAP
Daily Events Per Hour

14. APAP vs CPAP: Evidence
• APAP associated with improved sleep
architecture and continuity compared to fixed
CPAP
Small randomized trials and observational studies:
 Scharf MB, Brannen DE, McDannold MD, Berkowitz DV. Computerized
adjustable versus fixed NCPAP treatment of obstructive sleep apnea.
Sleep 1996;19:491-6.
 Meurice JC, Marc I, Series F. Efficacy of auto-CPAP in the treatment of
obstructive sleep apnea/hypopnea syndrome. American journal of
respiratory and critical care medicine 1996;153:794-8.

15. Metaanalysis
• Four metanalysis (largest incorporating 30
studies totalling 1136 participants)
• Equal improvement of AHI
• Better with APAP
– Adherence
– EDS
– Patient preference

16. APAP vs CPAP
• Randomized crossover trial
• 200 patients with APAP vs CPAP 6 weeks.
• Mean AHI: 33
• No difference in patient preference for a device
• APAP
– Marginally longer duration of use (4.2 versus 4.0 hours per
night)
– Less subjective daytime sleepiness (Epworth Sleepiness
Scale score of 9.5 versus 10.0
• There was also no difference in the QOL, objective
measures of sleepiness, or psychomotor vigilance
testing

17. APAP indications
Factors that have variable pressure requirement
– Use of alcohol
– Episodes of nasal obstruction
– Wide variations in body weight
To improve compliance

18. ADVANCED MODES
• Auto BPAP: Titrates IPAP and EPAP between
EPAPmin and IPAPmax with Psmin =3 PSmax
set by clinician
• BPAP with backup rate: BPAP S/T
• Adaptive servoventilation

19. Airflow
Thor.
Effort
Abd.
Effort
SAO2
ECG
Central Apnea: Patient forgets to take
breath

22. BPAP S/T mode indications
Treatment emergent central sleep apnea
OHS
OSA with
Neuromuscular disorder
Thoracic cage disorder

23. AutoBPAP: IPAPmax 25 EPAP min 6

24. CHF: Cheyne Stokes Respiration
SpO2
HR
Flow
Effort
Position
CSR continues because of
Persistent Instability
CSR continues because of
Persistent Instability

25. ASV in Cheyne Stokes Breathing

26. ASV in Cheyne Stokes Breathing

27. ASV in Cheyne Stokes Breathing

28. ASV in Cheyne Stokes Breathing

29. 1325 patients
LVEF<45%
AHI > 15/hr
predominance
of central
apnea:
•Medical mgt
•ASV
There was reduction in central apnea AHI reduced from 12 to 6.6
•Adaptive Servoventilation group INCREASE in
 All cause mortality
 Cardiovascular mortality

30. TITRATION PROTOCOLS

31. Options available
• In lab full night titration
• Split night study
• Home AutoCPAP titration

32. BASIC RULES OF CPAP AND BIPAP
TITRATION

33. Before titration
• Education about the disease
• Show his PSG report
• Explain the procedure
• About benefits of treatment
• Proper interface selection
• Proper mask fit

34. General titration rule
• The patient must be able to sleep in order for
PAP titration to be successful
• If the patient awakens and complains the
pressure is too high, the pressure should be
reduced to a level at which the patient is able
to return to sleep
• Leaks should be properly addressed
• Pressure relief technology

35. Choosing correct interface
• Full face masks: significant nasal obstruction
• Nasal masks: lighter fit
• Nasal pillow masks: more lightweight offering
a high level of openness and visibility
– Larger masks fit better and minimize leak
– Smaller masks are preferred for those with
claustrophobia and those with lower pressure

36. Manual CPAP titration
Age > 12 years Age < 12 years
Minimum CPAP 4 cm 4 cm
Maximum CPAP 20 cm 15 cm

37. CPAP titration
• Increase pressure by 1 cm
• Maintain for at least 5 minutes
Age > 12 Age < 12
Obstructive apnea 2 1
Hypopnea 3 1
RERA 5 3
Loud unambiguous
snoring (minutes)
3 1

38. CPAP titration
• If all events are abolished then increase
pressure further by 1-2cm increment upto 4
cm
• If treatment emergent central apneas appear
then reduce the pressure further till central
apneas disappear
• If central apneas appear then decrease
pressure till they disappear

39. Example
• 45 year/M
• Non smoker
• EDS Not able to drive, sleeps in meetings
• BMI 29.1 kg/m2
• History of HTN on Amlodipine 5 mg OD
• No history of dyspnea, chest pain
• PFT Normal

40. Overnight in Lab PSG

41. • AHI: 45.6/hr
• RDI: 51.8/hr
• Diagnosis: Severe OSA
• Patient is called next day for InLab titration
• You show him his report and tell him that his
sleep breaks about 45 times per hour which is the
cause of his EDS
• You give him oronasal mask and explain the
procedure

42. CPAP titration

44. Causes of failure of CPAP titration
• Intolerance: Pressure relief technology
• Air leaks:
– Proper mask fit
– Chin strap
– Change mask
• Treatment emergent complex sleep apnea:
– Decrease pressure
– Shift to BPAP S/T

45. When to switch to BPAP
• Patient is uncomfortable or intolerant of high
CPAP
• When CPAP is > 15 cm and respiratory
disturbance continue
• Hypoxia
• Hypercarbia
• OSA with OHS
• OSA with COPD overlap syndrome
• OSA with chronic lung disease

46. BPAP
• Beginning EPAP:
– At 4 cm or
– The CPAP where obstructive apnea was
obliterated
• Beginning IPAP: 4 cm higher

47. BPAP titration
Age > 12 Age < 12
Minimum IPAP 8 8
Minimum EPAP 4 4
Maximum IPAP 30 20
Minimum IPAP EPAP difference 4 4
Maximum IPAP EPAP difference 10 10

48. BPAP titration
• Increase pressure by 1 cm
• NOT LESS THAN 5 MINUTES
Age > 12 Age < 12 Intervention
Obstructive apnea 2 1 Increase both IPAP
and EPAP
Hypopnea 3 1 Increase IPAP
RERA 5 3 Increase IPAP
Loud unambiguous
snoring (minutes)
3 1 Increase IPAP

49. ADDITION OF OXYGEN

50. SpO2 ≤88% for ≥5 minutes in the absence
of obstructive respiratory events

51. Requirement of oxygen
• Increase in CPAP can be tried to eliminate
unrecognized high upper airway resistance
• CPAP can be changed to BPAP
• If patient is already on BPAP PS (IPAP-EPAP)
may be increased

52. Oxygen
• Should be introduced into the PAP device at the
device tubing connection using a T connector,
not at the PAP mask
Rate: 1 L/min
Titrate O2 in 1 L/min increments
Interval = 15 minutes
Target SpO2: 88% and 94%(Preferably 92-94%)

53. Complex sleep apnea
> 50% of the residual respiratory events on PAP
are central apneas or central hypopneas
Central AHI ≥ 5/hr
Total AHI ≥ 5/hr
• To increase CPAP only until the obstructive
apneas and hypopneas are eliminated

54. End of titration
• Patient should be given enough time to sleep
with device comfortably
• Patient’s experience after the device should
be recorded

55. Types of titration
• OPTIMAL
• GOOD
• ACCEPTABLE
• UNACCEPTABLE

56. Optimal Titration
• RDI < 5/h for a period of at least 15 minutes
at the selected pressure
• SpO2 > 90% at the selected pressure
• Supine REM sleep at the selected pressure is
not continually interrupted by spontaneous
arousals or awakenings

57. Good titration
At selected pressure for a period of at least 15
minutes
– RDI < 10/h
OR
– RDI reduced by 50% if the baseline RDI was <15
• SpO2 > 90%
• Supine REM sleep is not continually
interrupted by spontaneous arousals or
awakenings

58. Adequate titration
• Which does not reduces overnight RDI<10 per
hour but reduces RDI >75% of baseline in
severe OSA patients
OR
• Criteria of optimal or good titration are
achieved with exception that supine REM does
not occur at selected pressure

59. Mask Issues
Problem Occurrence Recommended Remedy
Discomfort 30-50% Check fit, adjust straps, change interface
Excessive air leaks 80-100% Realign interface, check strap tension, change to
full face mask
Nasal bridge redness or
ulceration
5-10% Use artificial skin, minimize strap tension, use
spacer, alternate interface
Rashes 5-10% Use skin barrier lotion and/or topical
corticosteroids, change to interface made from a
different material
Claustrophobic reactions 5-10% Reassure, try nasal interface or mouth piece

60. Pressure/Flow Issues
Problem Occurrence Recommended Remedy
Discomfort – too much
pressure
Sinus and ear pain
20-50%
10-20%
Reduce IPAP
Gastric insufflation 30-40% Reduce pressure
Nasal/oral congestion 50% Humidification, topical steroids, decongestants
Nasal/oral dryness 30-50-% Reassure, try nasal interface or mouth piece
Eye irritation 33% Reduce air leakage, adjusting strap tension,
change masks

61. Obesity hypoventilation syndrome
(OHS)
• Obese individual BMI >30kg/m2
• Awake alveolar hypoventilation PaCO2>45
mmHg
• Which cannot be attributed to
– pulmonary disease
– skeletal restriction
– neuromuscular weakness
– untreated hypothyroidism
– pleural pathology

62. Treatment of OHS
• OHS alone: BPAP
• OHS and coexisting OSA: CPAP and then
changed to BPAP if the CPAP is insufficient
• Nocturnal CPAP may improve alveolar
ventilation during sleep while also treating the
OSA

63. Patients who benefit from nocturnal
CPAP
• Higher baseline AHI
• Less restrictive physiology on spirometry
• Less severe oxyhemoglobin desaturation
during baseline polysomnography

64. Overlap syndrome (OSA + COPD)
• Prevalence of OSA in COPD is the same as the
general population
• Predisposes OSA patients to more severe
arterial oxygen desaturation
• Hypercapnia may occur in OLS at FEV1 values
greater than typically associated with
hypercapnia in patients with COPD without
OSA

65. Treatment of overlap syndrome
• PAP (CPAP or BPAP), BPAP may be better
tolerated
• Supplemental oxygen if needed (low awake or
baseline sleeping SaO2)
• Bronchodilator treatment and smoking
cessation
• May be associated with significant
hypercapnia during sleep and worse outcomes

66. Prognosis of overlap syndrome
• OLS patients who adhere to CPAP (in addition to
oxygen if needed) have a better outcome
Machado MCL, Vollmer WM, Togeiro SM, et al: CPAP and survival in moderate to severe obstructive sleep apnea
syndrome and hypoxemic COPD. Eur Respir J 2010;35:132–137
• OLS patients have an increased risk of death and
hospitalization due to severe COPD exacerbations
Treatment with CPAP may improve survival of OLS
patients and decrease hospitalizations
Marin JM, Soriano JB, Carrizo SJ, et al: Outcomes in patients with chronic obstructive pulmonary
disease and obstructive sleep apnea. Am J Respir Crit Care Med 2010;182:325–331

67. Full night vs split night
• A full-night attended PSG performed in the
laboratory is the preferred approach for
titration
• Split-night diagnostic-titration studies are
sometimes adequate
– Less costly
– Reduces the delay in prescribing treatment
– More convenient

68. Split night study
• Diagnostic portion if the AHI is greater than
40/hr and 2 hours of monitoring have
occurred
• Titration: 3 hours of PAP titration is the
minimum acceptable duration
• Increase pressure by 2 cm

69. Disadvantage of split night study
• LOWER CPAP level derived as compared to full-
night studies
• May not allow enough time for an optimal CPAP
titration or for transitioning to BPAP if that
becomes necessary
• Likelihood of observing the patient when the risk
of OSA is highest ie, during REM sleep in the
supine position is reduced
• There are fewer opportunities for patient
education
• Higher degree of technologist skill is required

70. In home AutoCPAP titration
• Patient should have simple OSA
• In patients with known or anticipated variable
pressure requirement
– OSA exacerbated in supine or REM sleep
– Variation in weight
– Use of alcohol
– Intermittent nasal obstruction
• No dates in sleep lab

71. In home AutoCPAP titration
• Residual AHI < 10
• Clinical response
• Favourable adherence
• Outcome:
– Fix pressure to 90-95th percentile derived from
AutoCPAP
– Use auto-CPAP