APAP and Alternative Titration Methods.
PURPOSE OF REVIEW: Positive airway pressure therapy (PAP) is commonly prescribed treatment for obstructive sleep apnea (OSA). Traditionally, the determination of the optimal pressure for treatment of sleep-disordered breathing was made by manual titration of the device by a sleep technician in attendance during polysomnography. However, the advent of alternative methods for determination of optimal PAP - such as auto-titrating PAP (APAP) - has seen tremendous growth over the past decade. The purpose of this review is to improve our understanding of the currently available alternative methods for titration of PAP in patients with sleep-disordered breathing (SDB) with special emphasis on obstructive sleep apnea.  RECENT FINDINGS: Recent prospective-randomized studies of alternative methods of titration suggest that pressure determinations made by such devices are comparable to traditional manual titrations made in the sleep laboratory. Obstacles to the adoption of such alternative modes of titration into day-to-day practice may be attributable to issues surrounding appropriate patient selection, differences between devices, re-imbursement policies of third party payors, consensus amongst sleep experts, and individual physicians' practice patterns and volumes. While newer generations and types of auto-titrating PAP devices are entering the sleep field constantly, providers' knowledge and time availability remain limiting factors.  SUMMARY: There is tremendous growth in the technology and scientific evidence in support of alternative modes of PAP titration for sleep-disordered breathing, but barriers to implementation remain.
Ahmed
Omer
O
Fellow, Pulmonary and Critical Care Medicine, Department of Medicine, University of Arizona, Tucson, AZ.
Parthasarathy
Sairam
S
Sleep Breath. 2007 Mar;11(1):45-51
17089145
Sleep Med. 2007 Nov;8(7-8):695-703
17638595
Sleep Med. 2009 Sep;10(8):898-903
19303811
J Clin Sleep Med. 2005 Jan 15;1(1):27-34
17561612
Sleep. 2008 Oct;31(10):1423-31
18853940
Chest. 2006 Sep;130(3):815-21
16963680
Am J Respir Crit Care Med. 2003 Dec 15;168(12):1506-11
14525804
Am J Respir Crit Care Med. 1996 Dec;154(6 Pt 1):1755-8
8970366
Sleep. 1996 Jul;19(6):497-501
8865508
Eur Respir J. 2000 Jun;15(6):990-5
10885414
Intensive Care Med. 2009 Feb;35(2):306-13
18795255
Chest. 2008 Jul;134(1):61-6
17951617
Eur Respir J. 2009 Apr;33(4):804-11
19129293
Am J Respir Crit Care Med. 2001 Aug 15;164(4):614-9
11520725
Sleep. 2008 Jan;31(1):141-7
18220088
Respir Res. 2008 Jul 24;9:56
18652688
Am J Respir Crit Care Med. 2009 Mar 15;179(6):501-8
19136368
Am J Respir Crit Care Med. 2003 Jan 1;167(1):20-3
12406840
Am J Respir Crit Care Med. 2004 Dec 1;170(11):1218-24
15282204
Ann Intern Med. 2007 Feb 6;146(3):157-66
17283346
Am J Respir Crit Care Med. 2002 Aug 15;166(4):469-73
12186822
Sleep. 1993 Dec;16(8 Suppl):S120-1; discussion S121-3
8177999
Am J Respir Crit Care Med. 1996 Sep;154(3 Pt 1):734-40
8810613
Chest. 2004 Jul;126(1):31-7
15249439
Chest. 2007 May;131(5):1393-9
17494789
Sleep. 2007 Apr;30(4):468-75
17520791
Sleep Breath. 2005 Dec;9(4):167-75
16273421
Sleep. 1993 Oct;16(7):662-7
8290861
Biomed Tech (Berl). 2003 Mar;48(3):68-72
12701337
N Engl J Med. 2010 Apr 1;362(13):1161-3
20335575
N Engl J Med. 2010 Mar 18;362(11):970-3
20164480
Am J Respir Crit Care Med. 2003 Nov 1;168(9):1109-14
12928310
Am J Respir Crit Care Med. 1994 Aug;150(2):486-8
8049834
Sleep. 1993 Dec;16(8 Suppl):S118-9
8177998
Chest. 2006 Aug;130(2):350-61
16899832
J Clin Sleep Med. 2010 Apr 15;6(2):140-5
20411690
Am J Respir Crit Care Med. 2003 Mar 1;167(5):716-22
12598214
Respir Physiol Neurobiol. 2008 Jun 30;162(1):48-54
18499537
Respir Med. 2004 Jul;98(7):619-25
15250227
Chest. 2006 Aug;130(2):343-9
16899831
N Engl J Med. 2009 May 7;360(19):1925-7
19420360
Sleep. 2010 Feb;33(2):267-71
20175411
Sleep Med. 2009 Mar;10(3):337-43
18650127
Respirology. 2008 Jan;13(1):79-86
18197915
Chest. 2006 Aug;130(2):312-4
16899825
Lancet. 1981 Apr 18;1(8225):862-5
6112294