CPAP Titration Research Articles

Impact of Exclusive Mouth Route and lateral position on the efficacy of oronasal CPAP to treat Obstructive Sleep Apnea in Patients with Obstructive Sleep Apnea Adapted to Oronasal Mask

BackgroundOronasal masks are widely used for treating OSA with CPAP. However, oronasal CPAP is associated with lower effectiveness and lower adherence than nasal CPAP. Research QuestionWhat is the impact of oral route and lateral position in patients well adapted to oronasal CPAP? Can these patients be switched to nasal CPAP? Study Design and MethodsPatients with OSA on oronasal CPAP underwent 2 CPAP polysomnography (PSG) titrations in random order using an oronasal mask with 2 independent sealed compartments connected to two separate pneumotachographs. One study was done with the nasal and oral compartments opened and the other study with only the oral compartment opened. CPAP titration was done in the supine and lateral position. Finally, the patients were offered a nasal mask. A third PSG was performed using nasal CPAP. ResultsTwenty OSA patients (baseline AHI: 52 ± 21 events/h) adapted to oronasal CPAP were studied. Most patients (75%) were oronasal breathers on optimal CPAP. Oral CPAP was less effective to treat OSA than oronasal CPAP, evidenced by a higher residual AHI (2 (1 - 6.0) vs 12.5 (1.8 - 28.3); P = 0.003), despite a significantly higher CPAP level, (10 (9 - 10) vs 11 (10 - 12) cmH20; P = 0.003). The residual AHI was significantly lower in the lateral position for both oronasal and oral CPAP. Finally, patients (75%) agreed to change and preferred to continue on nasal mask, which resulted in lower CPAP and better OSA control. InterpretationThe effectiveness of oronasal CPAP to abolish OSA is significantly decreased when patients are required to breathe exclusively through the mouth. Oronasal CPAP efficacy is significantly better in the lateral position. The transition to nasal mask results in higher CPAP effectiveness to treat OSA.

Formulas to predict continuous positive airway pressure level using a home auto-adjusting device for obstructive sleep apnea treatment.

To develop equations to predict therapeutic continuous positive airway pressure (CPAPT) based on home-based CPAP titration, including the type of interface used. Retrospective study conducted in adult patients with obstructive sleep apnea (OSA) who used home-based autoCPAP titration (AutoSet S10, ResMed®). CPAPT was obtained manually through a visual analysis of autoCPAP data (CPAPV) and automatically using the 95th percentile pressure (CPAPP95). Multiple linear regression and K-fold cross-validation were applied. Independent variables were AHI, neck circumference (NC), BMI, and mask. Two formulas were generated based on mask and the Miljeteig and Hoffstein formula. We included 702 patients (174 women), median age, BMI and AHI of 58 years, 32kg/m2 and 32 ev/h, respectively. Predictors for CPAPv (M1) were BMI, NC, AHI and type of interface (R2: 0.19); and for CPAPP95 (M2), BMI, AHI and mask (R2: 0.09). Error and precision between the formulas and CPAPT were: 0 (CPAPV/CPAPP95), and - 3.2 to 3.2 (CPAPV) and - 4 to 4cm H2O (CPAPP95). CPAPV was higher with oronasal mask (10 vs. 9cm H2O, p < 0.01). Accuracy defined as; a difference ± 2 cm H2O between estimated CPAP and CPAPT was greater in M1 than in M2 (79% vs. 64%, p < 0.01). In both models, calculated error was close to zero. CPAPV (± 3.2cm H2O) showed more precision than CPAPP95 (± 4cm H2O). With M1 (CPAPV), 79% of patients could start CPAP with reasonable accuracy (error of ± 2cm H2O).

0695 Residual Periodic Limb Movement Index After CPAP Titration Is Correlated with Hypoxemia

0695 Residual Periodic Limb Movement Index After CPAP Titration Is Correlated with Hypoxemia

CPAP titration using real time transthoracic echocardiography in a patient with hypoplastic left ventricle and Fontan physiology

CPAP titration using real time transthoracic echocardiography in a patient with hypoplastic left ventricle and Fontan physiology

The Baveno Classification as a Predictor of CPAP Titration Pressure in Obstructive Sleep Apnea Syndrome.

Obstructive sleep apnea syndrome (OSAS) is a clinical condition characterised by repeated periods of partial or full obstruction of airflow throughout sleep, with impairment of the quality of life and increased mortality with socioeconomic impacts. CPAP therapy is a simple and effective treatment option for OSAS patients. To overcome the clinical and prognostic limitations of AHI-as a sole index of OSAS-the Baveno classification was recently set out and introduced into clinical practice. This study aims to analyse the effect of the Baveno classification on the optimum CPAP titration pressure. A retrospective analysis of the records of sleep studies in two centres between 2018 and 2021 was carried out. Patients diagnosed with OSAS and recruited for CPAP titration were included. Based on the Baveno classification, the patients were categorised into four groups (A, B, C, and D). Consequently, 700 patients were analysed and 427 patients were included. A significant positive correlation was detected between the CPAP optimum titration pressure and OSAS severity, neck circumference, the oxygen desaturation index (ODI), mean oxygen saturation, the AHI, the BMI, and cumulative sleep time when the SpO2 was <90% (T90) on the other side (p: <0.0001). A non-significant correlation was seen between the Epworth Sleepiness Scale (ESS), symptom severity, end organ impact, and Baveno classification of the CPAP optimum titration pressure (p: 0.8, 0.4, 0.5, and 0.7, respectively). The Baveno classification is not useful in the prediction of CPAP optimum titration pressure. However, the ODI and neck circumference were significant independent predictors of a higher CPAP titration pressure.

Performance of the NOSE Questionnaire in Mask Selection for Home CPAP Titration.

Introduction Many patients abandon CPAP treatment because they find the mask uncomfortable. Therefore, specialists may benefit from the predictive value of airway assessment tools. Objective To identify nasal ventilation failure through the Nasal Obstruction Symptom Evaluation (NOSE) scale in patients with obstructive sleep apnea (OSA) who undergo home-based auto-adjusting CPAP titration and to determine whether there is a correlation between NOSE score and the type of mask selected. Materials and Methods In this prospective correlational study, the NOSE scale was used in terms of mask selection and titration indicators. Patients were classified based on their NOSE score: > or < 50. Results We included 303 patients; 226 men (74.5%), BMI: 33.2 ± 6.1 kg/m 2 , neck circumference (cm): 42.8 ± 3.6 and Epworth (ESS) score: 9.2 ± 5.6, mild OSA: 12 (3.9%), moderate OSA: 127 (41.9%), and severe OSA: 164 (54.1%). The mean NOSE score was 24.3 ± 22.8 and 42 patients (13.8%) had NOSE scores > 50. Indicators for both groups were: compliance (5.9 ± 1.3 vs. 5.8 ± 1.4 hours) p: 0.41, therapeutic pressure (9.1 ± 2.0 vs. 8.8 ± 1.6 cm of H 2 O) p: 0.23, residual AHI (2.3 ± 1.8 vs. 2.8 ± 2.6 events/hour) p: 0.25, and leaks (20.5 ± 10.6 vs. 21.3 ± 10.7 liters/minute) p: 0.64. According to adjusted multiple regression, a NOSE of > 50 was not a predictor of mask selection. Conclusions A > 50 NOSE score was not a predictor of mask selection, and it was not correlated to titration performance.

P061 CPAP Investigation Results: Physician vs Scientist delivered. Is there a difference in CPAP compliance and uptake?

Abstract Introduction As standard practice in a tertiary public hospital, CPAP titration outcomes and recommendations are provided to patients by Sleep Physicians in a follow up consultation. To free up physician time, a new model of care was introduced where senior scientific staff would provide the results and recommendations after Sleep Physician reporting. The aim of this retrospective review was to determine if there were any differences in CPAP uptake and compliance between results and recommendations provided by Scientists, or Sleep Physicians. Method Retrospective review of uncomplicated CPAP naïve patients attending CPAP titration between 1/07/20 to 30/06/21. CPAP uptake, compliance, and Epworth at 2 and 12 months were compared between the groups receiving physician or scientist recommendations, using Student’s T-Tests for continuous or Chi-Square tests for categorical variables. Results 446 patients (55% Male) received titration outcomes and recommendations, 57% from Scientists and 43% from Physicians. Mean age was 57.6+/-14.5 years, BMI=37.6+/-8.8 kg/m2, Baseline Epworth=10.5+/-5.9 and AHI=37.6+/-26.8 events/hr with no significant differences between groups. CPAP uptake for Scientists=72% and Physician=68% (p=0.403). There was also no difference in either compliance or ESS at 2 month and 12 month follow up. Discussion In this retrospective audit, no differences in CPAP uptake, compliance or ESS were observed between CPAP titration results and recommendations provided by Scientist compared to Sleep Physicians. However patient selection was not randomised and may have influenced results. More robust evidence requires a randomised controlled trial design to confirm findings.

The Influence of CPAP Therapy on Basal Metabolic Rate and Physical Activity in Obese Patients with Obstructive Sleep Apnea.

Energy balance in Obstructive Sleep Apnea (OSA), a disease closely related to obesity, is disturbed, and physical activity levels are impaired. The role of Continuous Positive Airway Pressure treatment (CPAP) in alleviating the disruptions mentioned above is questioned. The objective of this study is to explore changes in energy expenditure (EE) and physical activity (PA) in obese patients with OSA after CPAP treatment. An assessment of Basal Metabolic Rate (BMR) via indirect calorimetry (IC) was performed on 24 obese patients (male in the majority (87.5%), mean age of 52.4 ± 9.8 years), newly diagnosed with moderate-severe OSA by polysomnography, at 4-time points: at baseline, at CPAP titration, at the 1-month and the 3-month follow up. Physical activity levels were subjectively estimated using the International Questionnaire of Physical Activity (IPAQ) before and after 3 months of adherent CPAP application. BMR significantly decreased after CPAP treatment (1926 ± 537.8 kcal/d at baseline, 1790 ± 493.7 kcal/d at CPAP initiation, 1680.3 ± 600.8 kcal/d at 1 month, and 1581.3 ± 478.9 kcal/d at 3 months follow up (p < 0.001)). No significant changes in IPAQ were observed over time: baseline median IPAQ: 3894 (1487.5-11,755.5) total MET·min·wk-1, 3-month median IPAQ: 3900 (1512-11,824.5) total MET·min·wk-1. CPAP has an appreciable time effect on the BMR of obese patients with moderate-severe OSA. However, this change is not accompanied by a significant increase in physical activity levels.

0980 A Child with Achondroplasia, Cervicomedullary Junction Compression, Severe Obstructive Sleep Apnea and Pulmonary Hypertension

Abstract Introduction Achondroplasia is a short stature autosomal dominant skeletal dysplasia. Children with Achondroplasia are at risk for multiple medical comorbidities including sleep disordered breathing due to midface hypoplasia and craniocervical junction compression. Recent guidelines from American Academy of Pediatrics on health supervision of children with achondroplasia recommend routine clinical screening for symptoms of obstructive sleep apnea (OSA) and craniocervical junction compression in which case a polysomnogram should be considered. Report of case(s) The patient is a now 15 month old male who was initially seen in sleep medicine clinic at age 4 months for snoring and respiratory distress while awake. Polysomnogram 2 days later demonstrated severe OSA. The study demonstrated an oAHI of 25.1/hour, O2 nadir of 77%, and TcCO2 with evidence of significant hypoventilation with TcCO2 max of 67mmHg. This was adequately treated with supplemental oxygen. The patient subsequently presented to the emergency department at age 7 months with hypoxemic respiratory failure and signs of right heart failure and was started on CPAP. Echocardiogram demonstrated significant pulmonary hypertension. Subsequent CPAP titration study during admission demonstrated adequate treatment of OSA and his pulmonary hypertension significantly improved with the patient requiring no pulmonary hypertension treatment at discharge. At age 9 months, the patient was again admitted with hypoxemic respiratory failure and subsequent brain MRI demonstrated foramen magnum stenosis requiring subsequent surgical decompression. He was discharged on CPAP, however, was not tolerating this at home. Therefore, repeat polysomnogram was obtained that demonstrated severe OSA that was not responsive to supplemental oxygen. The patient was then started on BPAP therapy which he has since been tolerating well. Conclusion Children with achondroplasia are at increased risk for sleep disordered breathing and craniocervical junction compression. Our patient experienced significant complications from OSA at a young age. His sleep apnea worsened significantly in a short period making it unresponsive to previous treatment recommendations. There is a need for further studies to determine better screening guidelines for craniocervical junction narrowing and OSA. This case highlights the dynamic nature of sleep disordered breathing in achondroplasia and need for close follow up and monitoring of symptoms at all clinical encounters. Support (if any)

0982 Atrial fibrillation diagnosed from a home-based sleep study in a patient with REM behavior disorder

Abstract Introduction Atrial fibrillation (A-Fib) is the most common form of cardiac arrhythmia and is a major cause of stroke. Obstructive sleep apnea (OSA) is an established risk factor of A-Fib, but sleep disruption with frequent awakenings was recently identified as another risk factor, independent from OSA. Home sleep apnea test (HSAT) is widely used to diagnose OSA with low cost and short wait time, and HSAT that uses peripheral arterial tonometry (PAT) can reveal cardiac arrhythmia. Here we report a case of A-Fib detected by PAT-based HSAT in a patient with REM sleep disorder. Report of case(s) A 60-year-old man with hypertension, depression, anxiety, tobacco and alcohol use disorders presented to sleep clinic for frightening vivid dreams and violent dream enactments that gradually developed over the last two years. A diagnostic polysomnography study showed mild OSA, normal heart rhythm, and no epoch of REM sleep without atonia (RSWA). In the following four years, he used CPAP therapy, imagery rehearsal therapy, high-dose melatonin, doxepin and hydroxyzine. However, the frightening dreams and dream enactments persisted despite full adherence to CPAP. To reassess OSA, the patient took a PAT-based HSAT, which showed not only mild OSA, but one episode of irregularly irregular PAT-derived pulsation variations that lasted three hours and started and stopped abruptly. We therefore ordered longitudinal cardiac monitoring, which showed multiple asymptomatic episodes of A-Fib during nighttime. After treatments for A-Fib were started, a polysomnography study with effective CPAP titration showed one episode of A-Fib with rapid ventricular response that lasted 2.5 hours during non-REM sleep, and multiple epochs of RSWA. The diagnosis of REM sleep behavior disorder (RBD) was thus established. Conclusion We reported concurrent developments of RBD and asymptomatic paroxysmal A-Fib in a man in his early sixties. Our case suggests a potential association between RBD and A-Fib, which has not been studied but is conceivable, given that RBD causes frequent awakenings with surges of sympathetic activity. Our case also highlights the advantage of PAT in capturing not only OSA but cardiac arrhythmia. Clinical interpreters of PAT-based HSAT can seize the opportunity to diagnose A-Fib and prevent stroke. Support (if any)

1019 New onset OSA after long term Vagus Nerve Stimulator implantation in a patient with Lennox-Gastaut syndrome: A case report

Abstract Introduction Implantable vagus nerve stimulation (VNS) is an established treatment for drug resistant epilepsy. New onset obstructive sleep apnea (OSA) is a rare side effect of VNS. There are few studies describing VNS induced sleep apnea in adults. [1-2] A study of 16 patients with drug-refractory epilepsy found 5 patients with normal AHI develop mild OSA after VNS treatment for 3 months. [2] However, no literature exists regarding OSA after long term VNS implantation. Untreated OSA in patients with epilepsy can impact epilepsy outcomes. We report a case of new onset OSA after long term VNS implantation, refractory to PAP therapy. Report of case(s) A 36 year-old man with Lennox-Gastaut syndrome presented with gasping during sleep and daytime hypersomnolence. He underwent VNS implantation at the age of 12. A prior PSG in 2018 showed no sleep apnea. Repeat PSG showed VNS-induced OSA (AHI 10.1/hour). After failed CPAP titration, BPAP-S at 25/16 cm H2O improved OSA. Review of therapy data on follow up showed AHI of 13.7/hour and CAI of 10.9/hour, which is concerning for treatment induced central sleep apnea on BPAP. Diagnostic study with VNS turned off revealed mild OSA (AHI 5.8/hour). A multidisciplinary approach involving ENT for drug-induced sleep endoscopy to optimize VNS stimulation parameters along with neurology and sleep involvement is planned. The optimized VNS setting could be used during planned sleep times using a VNS device with dual-programming capability. Conclusion To our knowledge, there is no literature on development of sleep apnea after long term VNS implantation. Although the exact mechanism is unknown, VNS can cause sleep apnea or worsen sleep apnea in patients with a preexisting diagnosis. [1] This case demonstrates need for continuous monitoring and screening for sleep apnea in patients who have been implanted with VNS, even if baseline and follow up PGSs are normal. Current literature suggests discontinuation of VNS to resolve VNS-induced OSA, but we describe a case here where VNS is needed for ongoing management of epilepsy. Further studies are needed to identify treatment options for patients that cannot discontinue VNS therapy who also cannot be successfully treated with PAP if they develop VNS-induced OSA. Support (if any)

0494 Early Feasibility Study on Use of Noninvasive Temporal Interference Stimulation of the Hypoglossal Nerve in the Treatment of OSA

Abstract Introduction Hypoglossal nerve stimulation has proven effective as an alternative to Positive Airway Pressure (PAP) machines in treating obstructive sleep apnea (OSA). The only currently FDA-approved hypoglossal nerve stimulator requires surgical implantation. Somnial Inc. is developing a noninvasive nerve stimulator based on temporal interference (TI), such that multiple supra-kHz-modulating electrical fields overlap to create a hyper-localized field modulating at a lower, nerve-stimulating frequency equal to the offset between the original fields. Bilateral stimulation reduces lateral movement of the tongue and requires less energy applied to the individual nerves. In early studies, transcutaneous, bilateral TI stimulation showed strong forward and central tongue movement with long-term tolerability. Methods To determine the clinical impact of TI on the treatment of OSA, 11 patients recently diagnosed with moderate to severe OSA (AHI 15-50/hour) based on in-lab polysomnography (PSG) and BMI &amp;lt; 35 were subjected to bilateral TI stimulation of the hypoglossal nerves during another PSG. Two pairs of electrodes were placed on either side, medial to the inferior aspect of the mandible overlying the genioglossus muscle. The frequencies were modulated in a 4-second-on, 2-second-off pattern. Initial power settings were determined as sufficient to move the tongue without discomfort and were increased throughout the night in an approach similar to a CPAP titration study. Results 5 of the 11 patients analyzed in the study, including 4 out of 4 women, responded to the therapy (AHI reduction from baseline by &amp;gt;50% and an AHI of &amp;lt; 20/hour). Patient questionnaires indicate the treatment was well tolerated throughout the night. Conclusion These promising proof of concept results after a single night indicate the potential for the use of TI in the treatment of OSA. Transcutaneous application of stimulation energy via TI energy could be used to determine the efficacious does required to reduce AHI events in the at-home healthcare setting. This justifies future research in long-term, chronic-treatment studies with TI stimulation and the advancement of a home-based device. Support (if any)

Factors Associated with the Underestimation of Manual CPAP Titration Pressure.

During the SARS-CoV-2 pandemic, the use of in-laboratory positive airway pressure (PAP) titration studies was not routinely suggested. PAP pressure prediction calculations are emerging as alternative methods for the treatment of these patients. The underestimation of PAP titration pressure usually leads to unsatisfactory results for PAP therapy. This study aimed to evaluate the factors associated with the underestimation of PAP titration pressure when using PAP pressure prediction equations. Estimated PAP pressure formulas based on body mass index (BMI) and apnea-hypopnea index (AHI) were chosen to validate the accuracy of equations in the successful prediction of titration pressure. Among 341 adult patients diagnosed with obstructive sleep apnea (OSA) by overnight polysomnography (PSG) and who received overnight PAP titration in order to select a successful pressure, the mean age of the total subjects was 55.4 years old and 78.9% of patients were male. The average BMI and AHI scores were 27.1 ± 4.8 and 37 ± 21.7, respectively. After multivariate stepwise regression analysis, the odds ratio of participants with a pretitration AHI was 1.017 (95% CI: 1.005-1.030). Only the severity of OSA was significantly different between the underestimated group and the adequately assessed group. In conclusion, a high AHI, but not BMI, is associated with an underestimated CPAP titration pressure in adult patients with OSA.

0988 Vagal Nerve Stimulation and OSA

Abstract Introduction We present a case of obstructive sleep apnea (OSA) worsened by implantation of a vagal nerve stimulator (VNS). A 22-year-old M with PMH of autism and refractory epilepsy s/p VNS implantation was diagnosed with moderate OSA. His parents noted that his sleep-disordered breathing worsened after VNS implantation. He was started on APAP 4-12 cm H2O. Review of adherence data revealed an elevated residual apnea-hypopnea index (AHI) despite nightly usage. PAP titration study was obtained with improvement of AHI on 16 cm H2O. Despite consequent use of determined pressure settings, residual AHI remained elevated. In consultation with the patient’s neurologist, VNS settings were gradually down titrated. Residual AHI improved and remained low as CPAP settings were subsequently weaned. Report of case(s) The vagus nerve is part of the parasympathetic nervous system. Afferent fibers project to cortical regions involved in seizure activity. Vagal nerve activation leads to desynchrony, thereby decreasing seizure activity.3 VNS, an adjunctive non-pharmacologic treatment of refractory epilepsy, consists of a generator with multiple adjustable settings and a lead connected to the left vagus nerve.1 VNS activation, in conjuction with medical therapy, can lead to decreased seizures. However, VNS may cause complications such as vocal cord dysfunction, laryngeal spasm, and dyspnea.2 In this case, VNS was noted to cause OSA due to increased airway obstruction, though the pathophysiological mechanism behind this has not been clearly delineated. 3 Conclusion Based on current evidence of precipitation or worsening OSA with VNS activation, screening and diagnostic testing for OSA in patients under evaluation for VNS placement should be considered. A multidisciplinary approach between Sleep Medicine and Neurology in conjunction with patient goals can lead to a balanced optimization of both epilepsy and OSA management via adjustments of VNS settings, anti-epileptics, and CPAP. Support (if any) 1. VNS therapy epilepsy. Epilepsy Foundation. https://www.epilepsy.com/sites/default/files/atoms/files/516VNS_VNS_FINAL.pdf. December 20, 2022. 2. Ebben MR, Sethi NK, Conte M, Pollak CP, Labar D. Vagus nerve stimulation, sleep apnea, and CPAP titration. J ClinSleepMed. 2008 Oct 15;4(5):471-3. PMID: 18853706. 3. Parhizgar F, Nugent K, Raj R. Obstructive sleep apnea and respiratory complications associated with vagus nerve stimulators. J ClinSleepMed. 2011 Aug 15;7(4):401-7. doi: 10.5664/JCSM.1204. PMID: 21897779.

0976 Central Sleep Apnea (CSA) following treatment with Non-Positive Airway Pressure (PAP) Modalities

Abstract Introduction Emergence or worsening of CSA following non- PAP therapies has not been well studied. We present two cases of CSA following treatment of OSA; one with mandibular advancing device (MAD) and other with hypoglossal nerve stimulation (HGNS). Report of case(s) Case 1: A78 y/o male presented with CPAP intolerance and seeking HGNS for OSA treatment. His AHI was 25 with an O2 nadir of 76%. Following a comprehensive evaluation including sleep endoscopy, he was deemed a good candidate for HGNS. Per protocol, his HGNS was activated, PSG done after an interval period during which his stimulation was titrated from 0-2.3V. His AHI remained elevated (50 – 163) at all voltage settings with emergence of CSA at 2.3 &amp; 2.4 V. Due to tongue discomfort, his stimulation parameters were changed and HSAT was done to re-assess his breathing. Home study showed persistent severe sleep apnea- central &amp; obstructive with periodic breathing and desaturations to 70s. Case 2: A 28-y/o male with OSA AHI of 20.2 and O2 nadir of 82%. He was intolerant of CPAP; hence MAD was pursued. PSG done showed MAD was ineffective as his AHI was elevated at 26.8 with elevated CAI (associated with desaturations). A repeat study at home was done following adjustments to the MAD showed a higher index with pAHI of 37.7, predominantly central in nature with periodic breathing. Patient is awaiting a CPAP titration but has returned back to PAP therapy with good tolerance and resolution of his residual symptoms including daytime hypersomnolence. Conclusion These two cases highlight that CSA can be associated with non-PAP therapies and symptomatic improvement alone may not be an effective approach. Testing following initiation of treatment would allow for more effective management especially when patient is symptomatic or treatment is suspected to be ineffective. Support (if any)

Relationship between level CPAP titration, anthropometric variables, and drug-induced sleep endoscopy DISE.

Subjects with palatal obstruction alone vs. multilevel obstruction on DISE had better outcomes after palate surgery. We asked ourselves if the therapeutic level positive airway pressure (PAP) titration could predict the level of airway obstruction and its complexity. The aim of this study was to identify possible relationships between therapeutic level of positive airway pressure initial titration and levels of collapse in drug-induced sleep endoscopy (DISE). A secondary objective wasto establish the relationship the other variables and DISE. We analyzed retrospective clinical histories between March 2020 to March 2022 of 37 patients with polysomnography or cardiorespiratory polygraphy studies and PAP initial titration who were taken to drug-induced sleep endoscopy. Sleep study data, anthropometric variables, and patterns of airway collapse during DISE were analyzed with PAP initial titration levels. Most of the patients with complex collapse had concentric velum collapse (p < 0.006). A significant association was found between the apnea-hypopnea index (AHI) and oropharyngeal collapse; (p < 0.0030) and finally we demonstrated relationship between neck circumference and gender with epiglottis collapse (p < 0.046), (p < 0.037), respectively. Our findings show a strong relationship between that complex collapses and concentric velum collapse; patients with greater oropharyngeal collapse have a higher mean AHI. Patients without epiglottic collapse have a higher mean neck circumference. An association between mean pressure initial titration and complex collapse could not be established.

P088 Sleep study report checking on night shift: Does it have an impact on the quality of the night study

Abstract Introduction The aim of this study is to determine if the process of sleep study report-checking by the sleep scientist during an overnight shift affects the quality of sleep study acquisition performed during that shift. Methods In this unit one sleep scientist performs 3 sleep studies per night on a 10 or 12 hour shift. All studies are assessed at the time of scoring for quality of acquisition as ‘excellent’, ‘average’, ‘poor’ or ‘failed’. Scored studies are checked by another sleep scientist for accuracy in regard to patient demographics, study date, referring doctor, and sleep parameters. Between October 2021 and May 2022 two senior sleep scientists performed 87 sleep studies (both diagnostic and CPAP titration) and checked an average of 5 (SD 3.2) reports per night. The quality of their study acquisition was compared with 127 historical controls by the same scientists during the previous year. The proportions of ‘excellent’ and ‘average’ quality acquisitions in cases and controls were compared using the McNemar test (MedCalc 2012). Results There were no ‘poor’ or ‘failed’ studies. The percentages of ‘excellent’ study acquisition in cases (93.1%) and controls (89.7%), and ‘average’ cases (6%) and controls (11%) were not statistically different (p=0.58, 95% CI -5.7 to 11.2) . Discussion Results of this study demonstrate the process of report-checking on an overnight shift does not impact on the quality of the study acquisition, in our unit.

Abstract 14324: Improving Rates of Uncontrolled Atrial Fibrillation Through Obstructive Sleep Apnea Screening and Management: Preliminary Data From the OFIB Institutional Quality Initiative

Introduction: Untreated obstructive sleep apnea (OSA) is a major cause of uncontrolled atrial fibrillation (AF). It represents a high prevalence and incidence, as well as significant cause of mortality. Uncontrolled AF with recurrent emergency department (ED) visits and inpatient admissions poses a burden to patient quality of life and increased risk of cardiovascular events, in addition to healthcare costs. Hypothesis: We aim to reduce ED visits and hospitalizations for General Internal Medicine resident clinic patients with OSA and uncontrolled AF over the next year by 10%. Methods: We identified approximately 382 patients with inclusion criteria of age 18-70 years with a history of both AF and OSA without documented CPAP use. Interventions included a week long educational session to all residents starting March 2022, standardizing CPAP device ordering/monitoring, and patient education. A protocol for sleep study ordering and CPAP titration was implemented across clinics. The next phase is inpatient screening and referrals. Results: Prior to our intervention date, 14.7% of our study population presented with uncontrolled AF in the past year. Since our interventions, 2.4% have presented with uncontrolled AF. Conclusions: Our preliminary interventions have shown a numerical trend towards decreasing rates of uncontrolled AF in patients with OSA at our institution. Our interventions are ongoing with periodic evaluation of outcomes. Our findings support the need for a comprehensive approach targeting both providers and patients.

Telemedicine home CPAP titration and follow-up in the COVID-19 scenario.

IntroductionContinuous positive airway pressure (CPAP) titration was dramatically affected by the coronavirus disease 2019 (COVID-19) pandemic due to increased biological risk. This study aimed to compare successful CPAP adaptation and compliance with home telemedicine CPAP titration with the usual method based on face-to-face visits.MethodologyA prospective cohort using telemedicine home CPAP titration and follow-up during the COVID-19 pandemic (TC) was compared with a retrospective cohort receiving face-to-face pre-pandemic home titration (RC). The TC included a subgroup with a smartphone application (TC-APP). Successful CPAP adaptation and compliance at 1 month of follow-up were the main endpoints, while patient satisfaction and costs were secondary endpoints.Results210 consecutive patients were evaluated (80 RC and 130 TC). 36 patients were in the TC-APP subgroup. CPAP titration was successful in 90% in RC versus 95% in TC and 100% in TC-APP. No compliance differences between groups were found at 1 month (4.79 h·night−1 RC, 4.33 h·night−1 TC and 4.59 h·night−1 TC-APP). Mean±sd patient satisfaction out of 10 was 7.69±2.05 in RC versus 9.02±0.64 in TC (p<0.001). 64% of the TC-APP subgroup reported that their telemedicine strategy influenced an increase in CPAP use (p=0.011). CPAP adaptation with follow-up had an estimated direct staff cost per patient of EUR 19.61±8.61 in TC with no smartphone application used versus EUR 23.79±9.94 in TC-APP (p=0.048).ConclusionsTelemedicine in CPAP titration and early follow-up is equivalent to the usual care in terms of successful adaptation and compliance, while achieving greater patient satisfaction.

Results of CPAP Titration and Short-Term Adherence Rates in Patients with Obesity Hypoventilation Syndrome and Mild/Moderate Obstructive Sleep Apnea

PurposeNo study has assessed the titration success of CPAP therapy in patients with obesity hypoventilation syndrome (OHS) and an apnea-hypopnea index (AHI) <30 event/h. This study aimed to assess the titration success of CPAP therapy under polysomnography and subsequent short-term adherence (1 month) in patients with OHS and an AHI <30 event/h.MethodsConsecutive OHS patients with an AHI <30 events/h between 2010 and 2019 were included (n=54). All OHS patients were first started on CPAP during the therapeutic sleep-study. If the therapeutic-study showed that the SpO2 remained < 90% for 20% of the total sleep time, a second therapeutic study was arranged with bi-level PAP (BPAP). Thirty patients agreed to participate in the 1-month follow-up adherence study. We applied the American-Thoracic-Society criteria for PAP adherence.ResultsThe mean age was 54.8±14.6 years, and the mean BMI was 45.9±12.2 kg/m2. Successful titration on CPAP was attained in 36 (66.7%) patients, and 18 (33.3%) required BPAP. Patients who failed the CPAP trial had a significantly higher PaCO2 and bicarbonate, a more restrictive respiratory pattern on spirometry, and a significantly higher time with SpO2<90% (mins) during sleep. The only independent correlate of CPAP-titration success on the multivariable regression analysis was the desaturation index (OR: 1.33 [1.033–1.712]). More than 80% of the participants were using CPAP therapy after one-month with no differences in adherence between the CPAP and BPAP groups.ConclusionsThe current results suggest that CPAP therapy could be an acceptable alternative therapy to BPAP in patients with OHS without severe OSA.