title: Continuous positive airway pressure titration for obstructive sleep apnoea: automatic versus manual titration.
abstract: OBJECTIVE
  Manual laboratory continuous positive airway pressure (CPAP) titration for obstructive sleep apnoea (OSA) is costly, time intensive and delays access to treatment. Automatic positive airway pressure (APAP) titration has the potential to reduce cost and improve access to treatment. The aim of this study was to assess the clinical efficacy and costs of APAP titration compared with manual titration in moderate-severe OSA.
  
  
  METHODS
  Patients with moderate-severe OSA (apnoea/hypopnoea index >15 and Epworth Sleepiness Score > or = 8) who were free of co-morbidities that could impair APAP titration were eligible. 249 participants were randomised to manual titration, home APAP or laboratory APAP titration to determine a fixed pressure for CPAP. Clinical and direct cost outcomes were assessed after 4 weeks of treatment.
  
  
  RESULTS
  Average nightly CPAP use, subjective sleepiness, SF36 quality of life, Trails A and B cognitive function and polysomnographic outcomes were similar among the per-protocol groups. Non-hypertensive patients had a lower resting heart rate (and greater reduction in heart rate) at 4 weeks after laboratory APAP titration compared with home APAP titration. Costs per patient were highest in manual (AU$817.84), followed by laboratory (AU$647.56) and home (AU$132.09) APAP titration. An intention-to-treat analysis confirmed the effectiveness of APAP titration compared with manual titration in the standard clinical setting.
  
  
  CONCLUSIONS
  Among patients with moderate-severe OSA without serious co-morbidities, outcomes at 1 month indicate that APAP titration is more cost-effective than manual laboratory titration to determine an appropriate pressure for CPAP for long-term use; with the largest savings occurring in the home APAP patients.
authors.affiliation: University of Western Australia, School of Medicine and Pharmacology, Respiratory Medicine Department, Royal Perth Hospital, Perth 6000, Western Australia. nmcardle@cyllene.uwa.edu
authors.forename: Nigel
authors.initials: N
authors.lastname: McArdle
authors.forename: Bhajan
authors.initials: B
authors.lastname: Singh
authors.forename: Michelle
authors.initials: M
authors.lastname: Murphy
authors.forename: Kevin R
authors.initials: KR
authors.lastname: Gain
authors.forename: Christine
authors.initials: C
authors.lastname: Maguire
authors.forename: Sarah
authors.initials: S
authors.lastname: Mutch
authors.forename: David R
authors.initials: DR
authors.lastname: Hillman
mesh_terms: D000328:Adult; D001794:Blood Pressure / Q000502:physiology; D045422:Continuous Positive Airway Pressure / Q000191:economics / Q000379:methods*; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data; D006339:Heart Rate / Q000502:physiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance; D017286:Polysomnography; D012720:Severity of Illness Index; D020181:Sleep Apnea, Obstructive / Q000191:economics / Q000503:physiopathology / Q000628:therapy*; D016896:Treatment Outcome