Auto-titrating CPAP for the treatment of obstructive sleep apnea in children: APAP and CPAP pressures were not that close.

Abstract

Free AccessLetters to the EditorAuto-titrating CPAP for the treatment of obstructive sleep apnea in children: APAP and CPAP pressures were not that close R. Bart Sangal, MD R. Bart Sangal, MD Search for more papers by this author Published Online:October 15, 2020https://doi.org/10.5664/jcsm.8680Cited by:1SectionsAbstractPDF ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutABSTRACTCitation:Sangal RB. Auto-titrating CPAP for the treatment of obstructive sleep apnea in children: APAP and CPAP pressures were not that close. J Clin Sleep Med. 2020;16(10):1823.INTRODUCTIONKhaytin et al1 compared the pressures attained during continuous positive airway pressure (CPAP) titration with those attained during auto-titrating positive airway pressure (APAP) use. They reported that PPEAKMEAN and P90 during APAP use were not significantly different from the optimal CPAP titration pressure PPSG.Sixty-six of 110 (60%) patients started on APAP were excluded from the study because they did not or could not use their APAP within 90 days of CPAP titration (or because they did not have an adequate CPAP titration). Were there many APAP failures because patients were unable to tolerate and use it? That would not be entirely surprising because pressure changes during APAP use cause arousals,2 which may negatively affect its use. Improvement in adherence has been reported in patients who are having adverse effects or inadequate response on APAP upon being switched to CPAP.3 In evaluating whether APAP can replace CPAP in children, patients unable to use APAP should be considered a failure of APAP pressures to be equivalent to PPSG rather than being excluded.Lower and upper limits of APAP pressures were chosen based on clinical experience and any available prior titration data. Use of prior titration data introduces a bias in favor of APAP pressures being similar to PPSG. Despite that, P90 was within 1 cm of PPSG in only 38% and within 3 cm in 68% of participants. PPEAKMEAN was within 1 cm of PPSG in only 25% and within 3 cm in 68% of participants. Within 3 cm (−3 to +3) is a substantial range of 6 cm of water. Such a range is wide enough potentially to include unacceptable pressure at one extreme, through optimal pressure, to a pressure that results in treatment emergent central apneas in susceptible individuals at the other extreme. APAP use in one third of participants resulted in pressures that were not even within 3 cm of PPSG, despite excluding patients who could not use APAP.Their Figure 2 [comparison of titration pressure (PPSG) and autoCPAP PMEAN, PPEAKMEAN, and P90 pressures] suggests that 50% of patients had a PPSG between 7 and 11 cm. A pressure of 9 cm for every patient may well be as close to PPSG as PPEAKMEAN and P90, yielding results as close to PPSG as APAP determined pressures.Considering that PPSG is the optimal pressure, the finding that most APAP pressures, even after excluding APAP failures, were not within 1 cm of the PPSG may not inspire confidence in the use of APAP in children.DISCLOSURE STATEMENTThe author reports no conflict of interest. The author has received funding within the past five years from Shire, Jazz Pharmaceuticals, Eisai, Balance Therapeutics, Arbor Pharmaceuticals, and Suven Life Sciences.REFERENCES1. Khaytin I, Tapia IE, Xanthopoulos MS, et al.. Auto-titrating CPAP for the treatment of obstructive sleep apnea in children. J Clin Sleep Med. 2020;16(6):871–878. https://doi.org/10.5664/jcsm.8348 LinkGoogle Scholar2. Fuchs FS, Wiest GH, Frank M, Harsch IA, Schahin SP, Hahn EG, Ficker JH. Auto-CPAP therapy for obstructive sleep apnea: induction of microarousals by automatic variations of CPAP pressure? Sleep. 2002;25(5):514–518. https://doi.org/10.1093/sleep/25.5.512 CrossrefGoogle Scholar3. Sangal RB, Sudan N. Baseline lighter sleep and lower saturation are associated with improved sleepiness and adherence on continuous rather than autotitrating positive airway pressure. Clin EEG Neurosci. 2020;51(3):174–179. https://doi.org/10.1177/1550059419892759 CrossrefGoogle Scholar Previous article Next article FiguresReferencesRelatedDetailsCited byAuto-titrating CPAP for the treatment of obstructive sleep apnea in children: a good beginningKhaytin I, Tapia I and Beck S Journal of Clinical Sleep Medicine, Vol. 16, No. 10, (1825-1826), Online publication date: 15-Oct-2020. Volume 16 • Issue 10 • October 15, 2020ISSN (print): 1550-9389ISSN (online): 1550-9397Frequency: Monthly Metrics History Submitted for publicationJune 19, 2020Submitted in final revised formJune 29, 2020Accepted for publicationJune 30, 2020Published onlineOctober 15, 2020 Information© 2020 American Academy of Sleep Medicine