title: Reversal of PAP Failure With the REPAP Protocol.
abstract: BACKGROUND
  Re-titrations, an atypical approach to reverse PAP failure, was investigated retrospectively.
  
  
  METHODS
  Application of our re-titration of PAP (REPAP) protocol in subjects with previous PAP failure assessed original technology (masks, modes, and pressures) in 273 subjects, of which 70% reported co-occurring psychiatric conditions. The REPAP protocol emphasized changes in pressure modes and settings to address expiratory pressure intolerance and residual breathing events; mask changes were facilitated. Objective sleep and breathing metrics and subjective post-titration ratings were analyzed in subsequent PAP users and non-users.
  
  
  RESULTS
  Following REPAP protocol (average follow-up = 2 y), 196 of 273 subjects with previous PAP failure were PAP users, and 77 were non-users. Previous PAP failure was attributed to technology factors, including pressure intolerance, mask discomfort, adaptation difficulties, and no benefits. At second opinion re-titration, mask changes resolved discomfort, mouth breathing, or leak (91.2% of sample); pressure mode changes resolved expiratory pressure intolerance (83.5%); and pressure setting changes decreased residual breathing events and improved air flow (96.7%), all of which were associated with renewed PAP use. PAP users showed objective sleep improvements on re-titrations and reported better sleep quality than non-users. Multiple logistic regressions showed 2 subjective, re-initiation predictors: (1) post-re-titration ratings of better sleep quality and (2) less anticipated difficulty in using PAP after initial or multiple re-titrations. User rates were significantly higher for subjects completing multiple (n= 158) versus one (n= 115) re-titration (80% vs 61%,P= .001). In multiple re-titration subjects, PAP users showed significance or a trend for lower apnea-hypopnea index (P= .02, g = 0.48) and respiratory disturbance index (P= .07, g = 0.36) compared with non-users. Available user downloads averaged >5 h/night.
  
  
  CONCLUSIONS
  Technology-related problems due to mask discomfort/leak, pressure intolerance, and residual breathing events were associated with PAP failure in subjects seeking second opinions. Technological solutions (changes in masks, modes, and pressures) were addressed during REPAP protocol, after which 72% of subjects re-initiated PAP use. These technological interventions were associated with improved objective and subjective sleep variables and reversal of PAP failure.
authors.affiliation: Sleep and Human Health Institute, Albuquerque, New Mexico. bkrakow@sleeptreatment.com.|Maimonides Sleep Arts and Sciences, Albuquerque, New Mexico.|Los Alamos Medical Center, Los Alamos, New Mexico.
authors.forename: Barry
authors.initials: B
authors.lastname: Krakow
authors.affiliation: Sleep and Human Health Institute, Albuquerque, New Mexico.|Maimonides Sleep Arts and Sciences, Albuquerque, New Mexico.
authors.forename: Victor A
authors.initials: VA
authors.lastname: Ulibarri
authors.affiliation: Sleep and Human Health Institute, Albuquerque, New Mexico.|Maimonides Sleep Arts and Sciences, Albuquerque, New Mexico.
authors.forename: Natalia D
authors.initials: ND
authors.lastname: McIver
authors.affiliation: Maimonides Sleep Arts and Sciences, Albuquerque, New Mexico.
authors.forename: Carli
authors.initials: C
authors.lastname: Yonemoto
authors.affiliation: Maimonides Sleep Arts and Sciences, Albuquerque, New Mexico.
authors.forename: Alyssa
authors.initials: A
authors.lastname: Tidler
authors.affiliation: Maimonides Sleep Arts and Sciences, Albuquerque, New Mexico.
authors.forename: Jessica
authors.initials: J
authors.lastname: Obando
authors.affiliation: Maimonides Sleep Arts and Sciences, Albuquerque, New Mexico.
authors.forename: Michelle R
authors.initials: MR
authors.lastname: Foley-Shea
authors.affiliation: Maimonides Sleep Arts and Sciences, Albuquerque, New Mexico.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Ornelas
authors.affiliation: Department of Psychology, University of Arizona, Tucson, Arizona.
authors.forename: Spencer
authors.initials: S
authors.lastname: Dawson
mesh_terms: D000328:Adult; D002985:Clinical Protocols; D045422:Continuous Positive Airway Pressure / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods*; D004868:Equipment Failure; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016015:Logistic Models; D008297:Male; D008397:Masks; D017286:Polysomnography; D012189:Retrospective Studies; D012890:Sleep; D020181:Sleep Apnea, Obstructive / Q000503:physiopathology / Q000523:psychology / Q000628:therapy*; D016896:Treatment Outcome
keywords: PAP failure; adaptive servo-ventilation; auto-bi-level; bi-level; expiratory pressure intolerance; obstructive sleep apnea; respiratory effort-related arousals; upper airway resistance