Alternative Procedure to Individual Nasal Pressure Titration for Sleep Apnea

Abstract

In the treatment of obstructive sleep apnea (OSA), the current standard of “CPAP titration” in the laboratory or at home is a resource demanding and costly approach that, in developed economies, markedly augments healthcare costs and in low resource economies precludes access to care altogether. Here, we discuss that current guidelines for titration of CPAP could be obviated by taking a different route that in many ways is similar to the institution of treatment in many other medical conditions. To this effect, we present novel population based data from 16,780 patients, showing that after individualized and labor-intensive and expensive CPAP titration, 86.4% of OSA patients are treated with nasal pressure settings within the range of 9 ± 2 cmH2O, and review the literature to justify the potential adoption of a standard therapeutic CPAP setting as the initial intervention which would be subsequently followed by any necessary adjustments in only a minority of patients who would not derive the necessary benefit from such standardized intervention. Assuming an 80–85% success rate as derived from our analyses, our personal view if extensively adopted could radically reduce healthcare costs and enable markedly improve access to diagnostics.

Different Continuous Positive Airway Pressure Titration Modalities in Obstructive Sleep Apnea Syndrome Patients

“…With the global obesity epidemic and the aging of the population, this challenge will continue to escalate in the coming years. 18 Also, long waiting lists lead to delay in initiation of treatment, which is associated with increased morbidity and mortality risks, especially in severe OSAS patients. 3 According to AASM guidelines, manual titration is the gold standard for measurement for appropriate CPAP treatment, and APAP devices should be used only for patients with uncomplicated moderate to severe OSAS, and in the presence of limited resources.…”

“…Recently, several studies, especially after the COVID-19 pandemic, assessed the efficacy of alternative titration modalities by comparing the standard method with the same alternative methods used in our study and reported near-similar results or compared it with other methods. 18,[21][22][23][24] Demographic and resource features of our region make it very difficult to use self-adjusting home therapeutic strategies as a calibration or therapeutic option.…”

New Predictive Equation for Optimal Continuous Positive Airway Pressure in Adult Patients with Obstructive Sleep Apnea

“…25,26 Moreover, recent data have supported that pressures differing by only a few cm H 2 O from the standard titrated level may be reasonably effective in reducing respiratory events and somnolence. [25][26][27][28][29][30] However, an inappropriate CPAP pressure can cause undesirable side effects and affect treatment adherence. Thus, long-term CPAP compliance and clinical consequences should be further studied in patients using this pressure-derived formula.…”

Costs of sleep apnoea treatment can be reduced

“…Whereas, individual titration is certainly required for some more complex patients, it has been recently proposed that conventional titration can be avoided for the majority of patients. [5] Indeed, epidemiological data on the treatment of 16 780 patients showed that after completing the proccess of individualising labour-intensive and expensive CPAP titrations, 86.4% of sleep apnoea patients were ultimately prescribed and treated with CPAP settings within the range of 7 - 11 cmH 2 O. Accordingly, we proposed that in case that personalised CPAP titration may impede or substantially delay treatment, pressure should be initially prescribed at 9 cmH 2 O for all recently diagnosed obstructive sleep apnoea patients eligible for CPAP, and that in the relatively infrequent case when the patient still manifests residual symptoms, then a visit to the healthcare staff would be needed to modify the CPAP settings.…”

“…Accordingly, we proposed that in case that personalised CPAP titration may impede or substantially delay treatment, pressure should be initially prescribed at 9 cmH 2 O for all recently diagnosed obstructive sleep apnoea patients eligible for CPAP, and that in the relatively infrequent case when the patient still manifests residual symptoms, then a visit to the healthcare staff would be needed to modify the CPAP settings. [5] We think that focusing on steps consisting of affordable CPAP device availability and streamlined clinical management approaches (Fig. 1) could radically reduce healthcare costs and markedly improve access to diagnostics and therapy for sleep apnoea in African countries.…”