The prevalence of obstructive sleep apnea (OSA) is increasing requiring easier access to largescale screening and treatment of general population. Autotitrating Positive Airway Pressure (APAP) devices change effective pressure in a feedback circuit based on airflow, pressure changes, or airway resistance changes. This aids in pressure titration process throughout the sleep period. In patients with moderate to severe OSA without co-morbid conditions APAP and Continuous Airway Pressure (CPAP) are similar in affecting change in Apnea hypopnea index, Arousal index, and Sleep efficiency, Time in REM sleep, Quality of life, and adverse events. According to some studies, there has not been a significant difference in blood pressure changes between the APAP and CPAP groups. Current recommendations are to avoid APAP in patients with clinically significant co-morbid conditions including congestive heart failure, severe COPD, central sleep apnea, asthma and other obstructive pulmonary disorders or obesity hypoventilation syndrome and neuromuscular disorders. Further recommendation is to avoid using APAP for the diagnosis of OSA. Careful patient selection, monitoring of APAP data and proper mask fitting and leak control are essential to the success of APAP therapy. This article reviews the current scientific literature and emphasizes the need for more research before APAP can become the most efficacious mode of OSA treatment.
Obstructive sleep apnea (OSA) prevalence is rising owing to many factors. Among these, obesity epidemic is considered a major confounder. Parallel with this increase in OSA, rapidly building public health and public safety burden drives the need for more widespread screening of the at-risk populations. Over the years, a gradual shift favoring “out of center testing” (OCST), popularly known as home sleep test (HST), portable monitoring (PM), and other names, has occurred. Autotitrating continuous positive airway pressure (APAP) was introduced in 1990, mainly for screening patients for nasal continuous positive airway pressure (CPAP) and for those patients whose health prevented visit to sleep laboratory for testing and CPAP titration. The combination of OCST and APAP use has literally eliminated the need for sleep laboratory from the management of OSA in many patients. The versatile technological design of APAP machine offers a wide range of pressures that responds to patient\'s variable breathing patterns and behaviors. The ability to track and monitor the results from these machines makes APAP a reasonable choice in properly selected patients.
Morgenthaler TI, Aurora RN, Brown T, et al.; Standards of Practice Committee of the AASM. Practice parameters for the use of autotitrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome: an update for 2007. An American Academy of Sleep Medicine report. Sleep. 2008;31:141-147.
Trikalinos TA, Ip S, Raman G, et al. Technology Assessment: Home Diagnosis of Obstructive Sleep Apnea Hypopnea Syndrome. Bethesda, MD: Agency for Healthcare Research and Quality, Department of Health and Human Services, 2007.
Rodenstein DO. Automatically controlled continuous positive airway pressure: a bright past, a dubious future. Eur Respir J. 2000; 15:985-987.
Rosen CL, Auckley D, Benca R, et al. A multisite randomized trial of portable sleep studies and positive airway pressure autotitration versus laboratory-based polysomnography for the diagnosis and treatment of obstructive sleep apnea: The HomePAP Study. Sleep. 2012; 35:757-767.
Collen J, Lettieri C, Kelly W, Roop S. Clinical and polysomnographic predictors of short-term continuous positive airway pressure compliance. Chest. 2009; 135:704-709.
Stepnowsky D, Dimsdale JE. Dose-response relationship between CPAP compliance and measures of sleep apnea severity. Sleep Med. 2002; 3:329–334.
Engleman HM, Martin SE, Douglas NJ. Compliance with CPAP therapy in patients with the sleep apnoea/hypopnoea syndrome. Thorax. 1994; 49:263–266.
Smith I, Lasserson TJ. Pressure modification for improving usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea. Cochrane Database Syst Rev. 2009:CD003531.
Ayas NT, Patel SR, Malhotra A, et al. Auto titrating versus continuous positive airway pressure for the treatment of obstructive sleep apnea: results of a meta-analysis. Sleep. 2004; 15:249-253.
Ip S, D'Ambrosio C, Patel K, et al. Auto-titrating versus fixed continuous positive airway pressure for the treatment of obstructive sleep apnea: a systematic review with metaanalyses. Syst Rev. 2012; 1:20.
Sampaio R, Pereira MG, Winck JC. A new characterization of adherence patterns to auto-adjusting positive airway pressure in severe obstructive sleep apnea syndrome: clinical and psychological determinants. Sleep Breath. 2013; 17:1145-1158.
Bastos HN, Castro AS, Pinto T, Marinho A, Sucena M, Drummond M, Winck J. Randomized short-term trial of high span versus low span APAP for the treatment of obstructive sleep apnea. Eur Respir J. 2013; 42(Suppl 57):P3581.
Masa JF, Jimenez A, Duran J, et al. Alternative methods of titrating continuous positive airway pressure: a large multicenter study. Am J Respir Crit Care Med. 2004; 170:1218-1224.
Kushida CA, Chediak A, Berry RB, et al.; Positive Airway Pressure Titration Task Force; American Academy of Sleep Medicine. Clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea. J Clin Sleep Med. 2008; 4:157–171.
Fleetham J, Ayas N, Bradley D, et al; The Canadian Thoracic Society Sleep Disordered Breathing Committee. Canadian Thoracic Society 2011 guideline update: Diagnosis and treatment of sleep disordered breathing. Can Respir J. 2011; 18:25-47.
Berry RB, Parish JM, Hartse KM. The use of auto-titrating continuous positive airway pressure for treatment of adult obstructive sleep apnea. An American Academy of Sleep Medicine review. Sleep. 2002; 25:148–173.
Walsh JK. Enhancement of slow wave sleep: implications for insomnia. J Clin Sleep Med. 2009; 5(2 Suppl):S27– S32.
Dijk DJ, Brunner DP, Beersma DG, Borbély AA. Electroencephalogram power density and slow wave sleep as a function of prior waking and circadian phase. Sleep. 1990; 13:430–440.
Konermann M, Sanner BM, Vyleta M, et al. Use of conventional and self-adjusting nasal continuous positive airway pressure for treatment of severe obstructive sleep apnea syndrome: a comparative study. Chest. 1998; 113:714–718.
Scharf MB, Brannen DE, McDannold MD, Berkowitz DV. Computerized adjustable versus fixed NCPAP treatment of obstructive sleep apnea. Sleep. 1996; 19:491–496.
Brown RE, Basheer R, McKenna JT, Strecker RE, McCarley R. Control of sleep and wakefulness. Physiol Rev. 2012; 92:1087–1187.
Fuchs FS, Wiest GH, Frank M, et al. Auto-CPAP therapy for obstructive sleep apnea: induction of microarousals by automatic variations of CPAP pressure? Sleep. 2002; 25:514–518.
Nguyên XL, Rakotonanahary D, Chaskalovic, Fleury B. Insomnia related to sleep apnoea: effect of long-term autoadjusting positive airway pressure treatment. Eur Respir J. 2013; 41:593–600.
Bertolami A, Gonzaga C, Amodeo C. Cardiac function and hypertension in patients with obstructive sleep apnea. Res Rep Clin Cardiol. 2014; 2014:189–197.
Mehra R, Benjamin EJ, Shahar E, et al. Association of nocturnal arrhythmias with sleep-disordered breathing: the Sleep Heart Health Study. Am J Respir Crit Care Med. 2006; 173:910–916.
Patruno V, Tobaldini E, Bianchi AM, et al. Acute effects of autoadjusting and fixed continuous positive airway pressure treatments on cardiorespiratory coupling in obese patients with obstructive sleep apnea. Eur J Intern Med. 2014; 25:164–168.
Møller DS, Lind P, Strunge B, Pedersen EB. Abnormal vasoactive hormones and 24-hour blood pressure in obstructive sleep apnea. Am J Hypertens. 2003; 16:274– 280.
Marrone O, Salvaggio A, Bue AL, et al. Blood pressure changes after automatic and fixed CPAP in obstructive sleep apnea: relationship with nocturnal sympathetic activity. Clin Exper Hypertens. 2011; 33:373–380.
Pepin JL, Baguet JP, Tamisier R, et al. Fixed pressure (FP) versus auto-adjusting continuous positive airway pressure (autoCPAP): Comparison of efficacy in reducing blood pressure, a randomized controlled trial. Eur Respir J. 2013; 42(Suppl 57):322.
Smith LA, Vennelle M, Gardner RS, et al. Auto-titrating continuous positive airway pressure therapy in patients with chronic heart failure and obstructive sleep apnoea: a randomized placebo-controlled trial. Eur Heart J. 2007; 28:1221–1227.
Davis AP, Billings ME, Longstreth Jr LE, Khot SP. Early diagnosis and treatment of obstructive sleep apnea after stroke: are we neglecting a modifiable stroke risk factor? Neurol Clin Pract. 2013; 3:192–201.
Bravata DM, Concato J, Fried T, et al. Continuous positive airway pressure: evaluation of a novel therapy for patients with acute ischemic stroke. Sleep. 2011; 34:1271–1277.
Mysliwiec V, Gill J, Matsangas P, Baxter T, Barr T, Roth BJ. IGF-1: a potential biomarker for efficacy of sleep improvement with automatic airway pressure therapy for obstructive sleep apnea? Sleep Breath 2015 Feb 28. Epub 2015 Feb 28.
Shah N, Rice T, Tracy D, et al. Sleep and insulin-like growth factors in the cardiovascular health study. J Clin Sleep Med. 2013; 9:1245–1251.
Schussler P, Yassouridis A, Uhr M, et al. Growth hormonereleasing hormone and corticotropin-releasing hormone enhance non-rapid-eye-movement sleep after sleep deprivation. Am J Physiol Endocrinol Metab. 2006; 291:E549–E556.
Drummond M, Winck J, Guimarães J, Santos AC, Almeida J, Marques J. [Long term effect of autoadjusting positive airway pressure on C-reactive protein and interleukin-6 in men with obstructive sleep apnoea syndrome.] Arch Bronconeumol 2009; 45:577–584.
Sériès F, Plante J, Lacasse Y. Reliability of home CPAP titration with different automatic CPAP devices. Respir Res. 2008; 24:56.
Lévy P, Pépin JL. Autoadjusting continuous positive airway pressure: what can we expect? Am J Respir Crit Care Med. 2001; 163:1295–1296.
Farré R, Montserrat JM, Rigau J, Tripat X, Pinto P, Navajas D. Response of automatic continuous positive airway pressure devices to different sleep breathing patterns: a bench study. Am J Respir Crit Care Med. 2002; 166:469–473.
Farney RJ, Walker JM, Boyle KM, Cloward TV, Shilling KC. Adaptive servoventilation (asv) in patients with sleep disordered breathing associated with chronic opioid medications for non-malignant pain. J Clin Sleep Med. 2008; 4:311–319.