An Effective Titration Study Is an Interplay Between Patient, Sleep Technician, Interface and Optimal Pressure

Abstract

INTRODUCTION: PAP therapy in children may interfere with mid-face development presumably due to pressure of head gear and mask in the opposite direction of sutural growth. Some children may require protraction therapy to correct midface hypoplasia and improve midface aesthetics. Such changes do not occur in adult population. However, full face mask can cause retroclination of mandible, which may interfere with PAP effectiveness. CASE PRESENTATION:We present a 71-year-old Caucasian gentleman, with medical history of atrial fibrillation, hypertension and dyslipidemia, was evaluated for snoring, non-restorative sleep and abnormal overnight oximetry, suggestive of moderate sleep disordered breathing. Physical examination was significant for a crowded oropharynx with Friedman class 3 tongue position and mild overbite. We proceeded with in-lab attended polysomnography (PSG) in a split night fashion. PSG revealed moderate obstructive sleep apnea with an Apnea Hypopnea Index (AHI) of 28. His mean oxygen saturation was 92.5 %. The therapeutic portion of the study employed a CPAP and BiPAP titration, using a medium-sized ResMed Air-Touch F20 mask. CPAP pressures were titrated from 5 to 10 cm of water with persistence of obstructive events and some treatment emergent central events. Due to patient intolerance to higher pressures, he was transitioned to BiPAP-S, which was titrated from IPAP/EPAP of 12/9 to 16/11 cmH20. He continued to show residual obstructive and treatment emergent central events at highest tested BiPAP pressure. The mean saturation during PAP therapy was 93.4%.Patient returned for repeat PAP titration study. We requested that BiPAP-S be initiated at IPAP/EPAP of 16/11 cmH20 and titrate up. Patient advised the technician of his intolerance to PAP, he experienced during his prior study. BiPAP-S was started at a lower pressure; IPAP/EPAP of 10/5 and titrated up to 12/7cmH20. The final pressure was effective in controlling obstructive events without emergence of central events. A N30 nasal mask was used during this titration. DISCUSSION: Our patient required lower PAP pressures, when a nasal mask was used in place of a full-face mask. There was no leak with either interface. We postulate that a full-face mask or an oronasal mask may have caused some worsening of the sleep disordered breathing due to downward and backward pressure on the mandible. Previous literature has documented effect on the tongue with an oronasal mask (Andrade, 2014), as well as the need for higher pressures with full face mask (Dibra, 2020). CONCLUSIONS: Our case highlights the importance of effective communication between the patient and technician and initiative taking by sleep technician to find the optimal interface and pressure, essential for an effective study.