Auto-adjusting and Advanced Positive Airway Pressure Therapeutic Modalities

 

 Buy Article Permissions and Reprints

Abstract

Continuous positive airway pressure (CPAP) therapy is the first-line treatment for obstructive sleep apnea (OSA). Although the gold standard for the treatment of OSA, CPAP may not be the optimal modality to treat more complex sleep disordered breathing such as Cheyne–Stokes respirations, opioid-induced central apnea, and complex sleep disordered breathing related to chronic hypoventilation syndromes (obesity–hypoventilation syndrome, restrictive thoracic disease due to neuromuscular or thoracic cage disease, chronic obstructive pulmonary disease). Newer generation auto-adjusting PAP devices are increasingly being used to treat OSA. Advanced positive airway pressure modalities have been developed in an effort to improve treatment of the more complex sleep disordered breathing syndromes including automated servo ventilation and volume-targeted pressure-limited ventilation. This article is intended to provide the clinician reader with a description of newer PAP modalities, a review of evidence-supported indications for use, as well as to provide a framework for managing patients with advanced positive airway pressure therapy.

• References

• 1 Sullivan CE, Issa FG, Berthon-Jones M, Eves L. Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares. Lancet 1981; 1 (8225) 862-865
  PubMedGoogle Scholar
• 2 Epstein LJ, Kristo D, Strollo Jr PJ , et al; Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med 2009; 5 (3) 263-276
  PubMedGoogle Scholar
• 3 U.S. Shipments of Auto-PAP Devices for Treatment of Sleep Apnea to Grow 70 Percent by 2017. IHS Inc, 2014 . Available at: http://press.ihs.com/press-release/design-supply-chain/us-shipments-auto-pap-devices-treatment-sleep-apnea-grow-70-percen (Accessed February 13, 2014)
  PubMed
• 4 Morgenthaler TI, Aurora RN, Brown T , et al; Standards of Practice Committee of the AASM. American Academy of Sleep Medicine. 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 (1) 141-147
  PubMedGoogle Scholar
• 5 Kuna ST, Gurubhagavatula I, Maislin G , et al. Noninferiority of functional outcome in ambulatory management of obstructive sleep apnea. Am J Respir Crit Care Med 2011; 183 (9) 1238-1244
  CrossrefPubMedGoogle Scholar
• 6 Respironics Clinical Applications Guide REMstar Auto 2009
  PubMed
• 7 ResMed S9 Series AutoSet Elite H5i Clinical Guide. 2010
  PubMed
• 8 Farré R, Montserrat JM, Rigau J, Trepat 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 (4) 469-473
  CrossrefPubMedGoogle Scholar
• 9 Stepnowsky C, Zamora T, Barker R, Liu L, Sarmiento K. Accuracy of positive airway pressure device-measured apneas and hypopneas: role in treatment followup. Sleep Disord 2013; 2013: 314589
  PubMedGoogle Scholar
• 10 Ikeda Y, Kasai T, Kawana F , et al. Comparison between the apnea-hypopnea indices determined by the REMstar Auto M series and those determined by standard in-laboratory polysomnography in patients with obstructive sleep apnea. Intern Med 2012; 51 (20) 2877-2885
  CrossrefPubMedGoogle Scholar
• 11 Woodson BT, Saurejan A, Brusky LT, Han JK. Nonattended home automated continuous positive airway pressure titration: comparison with polysomnography. Otolaryngol Head Neck Surg 2003; 128 (3) 353-357
  CrossrefPubMedGoogle Scholar
• 12 Desai H, Patel A, Patel P, Grant BJ, Mador MJ. Accuracy of autotitrating CPAP to estimate the residual Apnea-Hypopnea Index in patients with obstructive sleep apnea on treatment with autotitrating CPAP. Sleep Breath 2009; 13 (4) 383-390
  Google Scholar
• 13 Berry RB, Kushida CA, Kryger MH, Soto-Calderon H, Staley B, Kuna ST. Respiratory event detection by a positive airway pressure device. Sleep 2012; 35 (3) 361-367
  PubMedGoogle Scholar
• 14 Huang HC, Hillman DR, McArdle N. Control of OSA during automatic positive airway pressure titration in a clinical case series: predictors and accuracy of device download data. Sleep 2012; 35 (9) 1277-83A
  PubMedGoogle Scholar
• 15 Denotti AL, Wong KK, Dungan II GC, Gilholme JW, Marshall NS, Grunstein RR. Residual sleep-disordered breathing during autotitrating continuous positive airway pressure therapy. Eur Respir J 2012; 39 (6) 1391-1397
  CrossrefPubMedGoogle Scholar
• 16 Coller D, Stanley D, Parthasarathy S. Effect of air leak on the performance of auto-PAP devices: a bench study. Sleep Breath 2005; 9 (4) 167-175
  CrossrefPubMedGoogle Scholar
• 17 Valentin A, Subramanian S, Quan SF, Berry RB, Parthasarathy S. Air leak is associated with poor adherence to autoPAP therapy. Sleep 2011; 34 (6) 801-806
  Google Scholar
• 18 Massie CA, McArdle N, Hart RW , et al. Comparison between automatic and fixed positive airway pressure therapy in the home. Am J Respir Crit Care Med 2003; 167 (1) 20-23
  CrossrefPubMedGoogle Scholar
• 19 Hukins C. Comparative study of autotitrating and fixed-pressure CPAP in the home: a randomized, single-blind crossover trial. Sleep 2004; 27 (8) 1512-1517
  PubMedGoogle Scholar
• 20 Vennelle M, White S, Riha RL, Mackay TW, Engleman HM, Douglas NJ. Randomized controlled trial of variable-pressure versus fixed-pressure continuous positive airway pressure (CPAP) treatment for patients with obstructive sleep apnea/hypopnea syndrome (OSAHS). Sleep 2010; 33 (2) 267-271
  PubMedGoogle Scholar
• 21 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 meta-analyses. Syst Rev 2012; 1: 20
  CrossrefPubMedGoogle Scholar
• 22 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; (4) CD003531
  PubMedGoogle Scholar
• 23 Xu T, Li T, Wei D , et al. Effect of automatic versus fixed continuous positive airway pressure for the treatment of obstructive sleep apnea: an up-to-date meta-analysis. Sleep Breath 2012; 16 (4) 1017-1026
  CrossrefPubMedGoogle Scholar
• 24 Ayas NT, Patel SR, Malhotra A , et al. Auto-titrating versus standard continuous positive airway pressure for the treatment of obstructive sleep apnea: results of a meta-analysis. Sleep 2004; 27 (2) 249-253
  Google Scholar
• 25 Bakker J, Campbell A, Neill A. Randomised controlled trial of auto-adjusting positive airway pressure in morbidly obese patients requiring high therapeutic pressure delivery. J Sleep Res 2011; 20 (1, Pt 2) 233-240
  CrossrefPubMedGoogle Scholar
• 26 Kushida CA, Berry RB, Blau A , et al. Positive airway pressure initiation: a randomized controlled trial to assess the impact of therapy mode and titration process on efficacy, adherence, and outcomes. Sleep 2011; 34 (8) 1083-1092
  PubMedGoogle Scholar
• 27 Noseda A, Kempenaers C, Kerkhofs M, Braun S, Linkowski P, Jann E. Constant vs auto-continuous positive airway pressure in patients with sleep apnea hypopnea syndrome and a high variability in pressure requirement. Chest 2004; 126 (1) 31-37
  CrossrefPubMedGoogle Scholar
• 28 Patruno V, Aiolfi S, Costantino G , et al. Fixed and autoadjusting continuous positive airway pressure treatments are not similar in reducing cardiovascular risk factors in patients with obstructive sleep apnea. Chest 2007; 131 (5) 1393-1399
  CrossrefPubMedGoogle Scholar
• 29 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 (2) 164-168
  CrossrefPubMedGoogle Scholar
• 30 Nolan GM, Ryan S, O'connor TM, McNicholas WT. Comparison of three auto-adjusting positive pressure devices in patients with sleep apnoea. Eur Respir J 2006; 28 (1) 159-164
  CrossrefPubMedGoogle Scholar
• 31 Stammnitz A, Jerrentrup A, Penzel T, Peter JH, Vogelmeier C, Becker HF. Automatic CPAP titration with different self-setting devices in patients with obstructive sleep apnoea. Eur Respir J 2004; 24 (2) 273-278
  CrossrefPubMedGoogle Scholar
• 32 Hertegonne KB, Rombaut B, Houtmeyers P, Van Maele G, Pevernagie DA. Titration efficacy of two auto-adjustable continuous positive airway pressure devices using different flow limitation-based algorithms. Respiration 2008; 75 (1) 48-54
  CrossrefPubMedGoogle Scholar
• 33 Fietze I, Glos M, Moebus I, Witt C, Penzel T, Baumann G. Automatic pressure titration with APAP is as effective as manual titration with CPAP in patients with obstructive sleep apnea. Respiration 2007; 74 (3) 279-286
  CrossrefPubMedGoogle Scholar
• 34 Mulgrew AT, Fox N, Ayas NT, Ryan CF. Diagnosis and initial management of obstructive sleep apnea without polysomnography: a randomized validation study. Ann Intern Med 2007; 146 (3) 157-166
  CrossrefPubMedGoogle Scholar
• 35 Gao W, Jin Y, Wang Y , et al. Is automatic CPAP titration as effective as manual CPAP titration in OSAHS patients? A meta-analysis. Sleep Breath 2012; 16 (2) 329-340
  CrossrefPubMedGoogle Scholar
• 36 Damiani MF, Quaranta VN, Tedeschi E , et al. Titration effectiveness of two autoadjustable continuous positive airway pressure devices driven by different algorithms in patients with obstructive sleep apnoea. Respirology 2013; 18 (6) 968-973
  CrossrefPubMedGoogle Scholar
• 37 Pietzsch JB, Garner A, Cipriano LE, Linehan JH. An integrated health-economic analysis of diagnostic and therapeutic strategies in the treatment of moderate-to-severe obstructive sleep apnea. Sleep 2011; 34 (6) 695-709
  CrossrefPubMedGoogle Scholar
• 38 Masa JF, Corral J, Sanchez de Cos J , et al; Collaborating group. Effectiveness of three sleep apnea management alternatives. Sleep 2013; 36 (12) 1799-1807
  PubMedGoogle Scholar
• 39 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 (6) 757-767
  CrossrefPubMedGoogle Scholar
• 40 Senn O, Brack T, Russi EW, Bloch KE. A continuous positive airway pressure trial as a novel approach to the diagnosis of the obstructive sleep apnea syndrome. Chest 2006; 129 (1) 67-75
  CrossrefPubMedGoogle Scholar
• 41 Drummond F, Doelken P, Ahmed QA , et al. Empiric auto-titrating CPAP in people with suspected obstructive sleep apnea. J Clin Sleep Med 2010; 6 (2) 140-145
  PubMedGoogle Scholar
• 42 Fox N, Hirsch-Allen AJ, Goodfellow E , et al. The impact of a telemedicine monitoring system on positive airway pressure adherence in patients with obstructive sleep apnea: a randomized controlled trial. Sleep 2012; 35 (4) 477-481
  PubMedGoogle Scholar
• 43 Respironics BiPAP autoSV Clinical Applications Guide: Respironics, Inc.; 2008
  PubMed
• 44 Teschler H, Döhring J, Wang YM, Berthon-Jones M. Adaptive pressure support servo-ventilation: a novel treatment for Cheyne-Stokes respiration in heart failure. Am J Respir Crit Care Med 2001; 164 (4) 614-619
  CrossrefPubMedGoogle Scholar
• 45 Pepperell JC, Maskell NA, Jones DR , et al. A randomized controlled trial of adaptive ventilation for Cheyne-Stokes breathing in heart failure. Am J Respir Crit Care Med 2003; 168 (9) 1109-1114
  CrossrefPubMedGoogle Scholar
• 46 Philippe C, Stoïca-Herman M, Drouot X , et al. Compliance with and effectiveness of adaptive servoventilation versus continuous positive airway pressure in the treatment of Cheyne-Stokes respiration in heart failure over a six month period. Heart 2006; 92 (3) 337-342
  PubMedGoogle Scholar
• 47 Randerath WJ, Nothofer G, Priegnitz C , et al. Long-term auto-servoventilation or constant positive pressure in heart failure and coexisting central with obstructive sleep apnea. Chest 2012; 142 (2) 440-447
  CrossrefPubMedGoogle Scholar
• 48 Sharma BK, Bakker JP, McSharry DG, Desai AS, Javaheri S, Malhotra A. Adaptive servoventilation for treatment of sleep-disordered breathing in heart failure: a systematic review and meta-analysis. Chest 2012; 142 (5) 1211-1221
  CrossrefPubMedGoogle Scholar
• 49 Yoshihisa A, Suzuki S, Yamaki T , et al. Impact of adaptive servo-ventilation on cardiovascular function and prognosis in heart failure patients with preserved left ventricular ejection fraction and sleep-disordered breathing. Eur J Heart Fail 2013; 15 (5) 543-550
  CrossrefPubMedGoogle Scholar
• 50 Owada T, Yoshihisa A, Yamauchi H , et al. Adaptive servoventilation improves cardiorenal function and prognosis in heart failure patients with chronic kidney disease and sleep-disordered breathing. J Card Fail 2013; 19 (4) 225-232
  CrossrefPubMedGoogle Scholar
• 51 Aurora RN, Chowdhuri S, Ramar K , et al. The treatment of central sleep apnea syndromes in adults: practice parameters with an evidence-based literature review and meta-analyses. Sleep 2012; 35 (1) 17-40
  PubMedGoogle Scholar
• 52 Bradley TD, Logan AG, Kimoff RJ , et al; CANPAP Investigators. Continuous positive airway pressure for central sleep apnea and heart failure. N Engl J Med 2005; 353 (19) 2025-2033
  CrossrefPubMedGoogle Scholar
• 53 Arzt M, Floras JS, Logan AG , et al; CANPAP Investigators. Suppression of central sleep apnea by continuous positive airway pressure and transplant-free survival in heart failure: a post hoc analysis of the Canadian Continuous Positive Airway Pressure for Patients with Central Sleep Apnea and Heart Failure Trial (CANPAP). Circulation 2007; 115 (25) 3173-3180
  CrossrefPubMedGoogle Scholar
• 54 Cowie MR, Woehrle H, Wegscheider K , et al. Rationale and design of the SERVE-HF study: treatment of sleep-disordered breathing with predominant central sleep apnoea with adaptive servo-ventilation in patients with chronic heart failure. Eur J Heart Fail 2013; 15 (8) 937-943
  CrossrefPubMedGoogle Scholar
• 55 Malhotra A, Bertisch S, Wellman A. Complex sleep apnea: it isn't really a disease. J Clin Sleep Med 2008; 4 (5) 406-408
  PubMedGoogle Scholar
• 56 Javaheri S, Smith J, Chung E. The prevalence and natural history of complex sleep apnea. J Clin Sleep Med 2009; 5 (3) 205-211
  PubMedGoogle Scholar
• 57 Allam JS, Olson EJ, Gay PC, Morgenthaler TI. Efficacy of adaptive servoventilation in treatment of complex and central sleep apnea syndromes. Chest 2007; 132 (6) 1839-1846
  CrossrefPubMedGoogle Scholar
• 58 Morgenthaler TI, Gay PC, Gordon N, Brown LK. Adaptive servoventilation versus noninvasive positive pressure ventilation for central, mixed, and complex sleep apnea syndromes. Sleep 2007; 30 (4) 468-475
  PubMedGoogle Scholar
• 59 Brown SE, Mosko SS, Davis JA, Pierce RA, Godfrey-Pixton TV. A retrospective case series of adaptive servoventilation for complex sleep apnea. J Clin Sleep Med 2011; 7 (2) 187-195
  PubMedGoogle Scholar
• 60 Johnson KG, Johnson DC. Bilevel positive airway pressure worsens central apneas during sleep. Chest 2005; 128 (4) 2141-2150
  CrossrefPubMedGoogle Scholar
• 61 Dellweg D, Kerl J, Hoehn E, Wenzel M, Koehler D. Randomized controlled trial of noninvasive positive pressure ventilation (NPPV) versus servoventilation in patients with CPAP-induced central sleep apnea (complex sleep apnea). Sleep 2013; 36 (8) 1163-1171
  PubMedGoogle Scholar
• 62 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 (4) 311-319
  PubMedGoogle Scholar
• 63 Javaheri S, Malik A, Smith J, Chung E. Adaptive pressure support servoventilation: a novel treatment for sleep apnea associated with use of opioids. J Clin Sleep Med 2008; 4 (4) 305-310
  PubMedGoogle Scholar
• 64 Ramar K, Ramar P, Morgenthaler TI. Adaptive servoventilation in patients with central or complex sleep apnea related to chronic opioid use and congestive heart failure. J Clin Sleep Med 2012; 8 (5) 569-576
  PubMedGoogle Scholar
• 65 Banno K, Okamura K, Kryger MH. Adaptive servo-ventilation in patients with idiopathic Cheyne-Stokes breathing. J Clin Sleep Med 2006; 2 (2) 181-186
  PubMedGoogle Scholar
• 66 Troitino A, Labedi N, Kufel T, El-Solh AA. Positive airway pressure therapy in patients with opioid-related central sleep apnea. Sleep Breath 2014; 18 (2) 367-373
  CrossrefPubMedGoogle Scholar
• 67 Carnevale C, Georges M, Rabec C, Tamisier R, Levy P, Pépin JL. Effectiveness of Adaptive Servo Ventilation in the treatment of hypocapnic central sleep apnea of various etiologies. Sleep Med 2011; 12 (10) 952-958
  CrossrefPubMedGoogle Scholar
• 68 BiPAP autoSV-Advanced Titration guide. 2014 . Available at: http://www.healthcare.philips.com/pwc_hc/us_en/homehealth/sleep/bipapautosvadvanced/downloads/BiPAPAutoSVAdvanced_Protocol.pdf . (Accessed March 21, 2014)
  PubMedGoogle Scholar
• 69 Ozsancak A, D'Ambrosio C, Hill NS. Nocturnal noninvasive ventilation. Chest 2008; 133 (5) 1275-1286
  CrossrefPubMedGoogle Scholar
• 70 Struik FM, Lacasse Y, Goldstein R, Kerstjens HM, Wijkstra PJ. Nocturnal non-invasive positive pressure ventilation for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2013; 6: CD002878
  PubMedGoogle Scholar
• 71 Blau A, Minx M, Peter JG , et al. Auto bi-level pressure relief-PAP is as effective as CPAP in OSA patients—a pilot study. Sleep Breath 2012; 16 (3) 773-779
  CrossrefPubMedGoogle Scholar
• 72 Jaye J, Chatwin M, Dayer M, Morrell MJ, Simonds AK. Autotitrating versus standard noninvasive ventilation: a randomised crossover trial. Eur Respir J 2009; 33 (3) 566-571
  CrossrefPubMedGoogle Scholar
• 73 Storre JH, Seuthe B, Fiechter R , et al. Average volume-assured pressure support in obesity hypoventilation: A randomized crossover trial. Chest 2006; 130 (3) 815-821
  CrossrefPubMedGoogle Scholar
• 74 Janssens JP, Metzger M, Sforza E. Impact of volume targeting on efficacy of bi-level non-invasive ventilation and sleep in obesity-hypoventilation. Respir Med 2009; 103 (2) 165-172
  CrossrefPubMedGoogle Scholar
• 75 Murphy PB, Davidson C, Hind MD , et al. Volume targeted versus pressure support non-invasive ventilation in patients with super obesity and chronic respiratory failure: a randomised controlled trial. Thorax 2012; 67 (8) 727-734
  CrossrefPubMedGoogle Scholar
• 76 Ambrogio C, Lowman X, Kuo M, Malo J, Prasad AR, Parthasarathy S. Sleep and non-invasive ventilation in patients with chronic respiratory insufficiency. Intensive Care Med 2009; 35 (2) 306-313
  CrossrefPubMedGoogle Scholar
• 77 Crisafulli E, Manni G, Kidonias M, Trianni L, Clini EM. Subjective sleep quality during average volume assured pressure support (AVAPS) ventilation in patients with hypercapnic COPD: a physiological pilot study. Lung 2009; 187 (5) 299-305
  CrossrefPubMedGoogle Scholar
• 78 Banerjee D, Yee BJ, Piper AJ, Zwillich CW, Grunstein RR. Obesity hypoventilation syndrome: hypoxemia during continuous positive airway pressure. Chest 2007; 131 (6) 1678-1684
  CrossrefPubMedGoogle Scholar
• 79 Priou P, Hamel JF, Person C , et al. Long-term outcome of noninvasive positive pressure ventilation for obesity hypoventilation syndrome. Chest 2010; 138 (1) 84-90
  CrossrefPubMedGoogle Scholar