Clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea.
Clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea.
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DOI：
10.5664/jcsm.27133
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发表时间：
2008-04
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影响因子：
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通讯作者：
C. Kushida;A. Chediak;R. Berry;L. Brown;D. Gozal;C. Iber;S. Parthasarathy;S. Quan;J. Rowley
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文献类型：
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作者：
C. Kushida;A. Chediak;R. Berry;L. Brown;D. Gozal;C. Iber;S. Parthasarathy;S. Quan;J. Rowley
气道正压通气 (PAP) 设备用于治疗患有睡眠相关呼吸障碍 (SRBD) 的患者，包括阻塞性睡眠呼吸暂停 (OSA)。患者被诊断患有 OSA 后，当前的实践标准包括进行有人参与的多导睡眠图 (PSG)，在此期间在整个记录期间调整气道正压，以确定维持上呼吸道通畅的最佳压力。持续气道正压通气 (CPAP) 和双水平气道正压通气 (BPAP) 代表两种形式的 PAP，在 PSG 期间手动滴定，以确定 CPAP 的单一固定压力或 BPAP 的固定吸气和呼气正压（分别为 IPAP 和 EPAP），以便随后每晚使用。美国睡眠医学会的 PAP 滴定工作组审查了现有文献。根据这次审查，工作组制定了这些关于进行 CPAP 和 BPAP 滴定的建议。主要建议如下： (1) 所有潜在的 PAP 滴定候选人应在滴定前接受充分的 PAP 教育、实践演示、仔细的面罩佩戴和适应。 (2) 应增加 CPAP（使用 BPAP 患者的 IPAP 和/或 EPAP），直至以下阻塞性呼吸事件消除（无特定顺序）或达到建议的最大 CPAP（使用 BPAP 患者的 IPAP）：呼吸暂停、呼吸不足、呼吸用力相关觉醒 (RERA) 和打鼾。 (3) 对于儿童和成人患者，建议的最低起始 CPAP 应为 4 cm H2O；对于接受 BPAP 的儿童和成人患者，建议的最低起始 IPAP 和 EPAP 应分别为 8 cm H2O 和 4 cm H2O。 (4) 对于 12 岁或以上的患者，建议的最大 CPAP 压力应为 15 cm H2O（如果使用 BPAP，建议的最大 IPAP 压力应为 20 cm H2O）。 (5) 建议的最小 IPAP-EPAP 差值为 4 cm H2O，建议的最大 IPAP-EPAP 差值为 10 cm H2O (6) CPAP（使用 BPAP 患者的 IPAP 和/或 EPAP，取决于事件类型）应增加至少 1 cm H2O，间隔不少于 5 分钟，以消除阻塞性呼吸事件。 (7) 如果观察到患者至少有 1 次阻塞性呼吸暂停或 = 12 年，CPAP（使用 BPAP 患者的 IPAP 和 EPAP）应从任何 CPAP（或 IPAP）水平增加。 (8) 如果观察到患者至少有 1 次呼吸不足或 = 12 年，CPAP（使用 BPAP 患者的 IPAP）应从任何 CPAP（或 IPAP）水平增加。 (9) 如果患者观察到至少 3 个 RERA 或 = 12 年，CPAP（使用 BPAP 患者的 IPAP）应从任何 CPAP（或 IPAP）水平增加。 (10) 如果观察到患者或 = 12 年至少 1 分钟大声或明确打鼾，CPAP（使用 BPAP 患者的 IPAP）可能会从任何 CPAP（或 IPAP）水平增加。 (11) 分夜 CPAP 或 BPAP 滴定研究的滴定算法应分别与整夜 CPAP 或 BPAP 滴定研究的滴定算法相同。 (12) 如果患者感到不舒服或不能耐受 CPAP 高压，患者可以尝试使用 BPAP。如果在滴定研究期间在 15 cm H2O CPAP 持续存在阻塞性呼吸事件，患者可能会改用 BPAP。 (13) 滴定研究后选择供患者使用的 CPAP 或 BPAP 压力应反映对患者阻塞性呼吸的控制较低（最好是 3 小时）。
Positive airway pressure (PAP) devices are used to treat patients with sleep related breathing disorders (SRBDs), including obstructive sleep apnea (OSA). After a patient is diagnosed with OSA, the current standard of practice involves performing attended polysomnography (PSG), during which positive airway pressure is adjusted throughout the recording period to determine the optimal pressure for maintaining upper airway patency. Continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BPAP) represent the two forms of PAP that are manually titrated during PSG to determine the single fixed pressure of CPAP or the fixed inspiratory and expiratory positive airway pressures (IPAP and EPAP, respectively) of BPAP for subsequent nightly usage. A PAP Titration Task Force of the American Academy of Sleep Medicine reviewed the available literature. Based on this review, the Task Force developed these recommendations for conducting CPAP and BPAP titrations. Major recommendations are as follows: (1) All potential PAP titration candidates should receive adequate PAP education, hands-on demonstration, careful mask fitting, and acclimatization prior to titration. (2) CPAP (IPAP and/or EPAP for patients on BPAP) should be increased until the following obstructive respiratory events are eliminated (no specific order) or the recommended maximum CPAP (IPAP for patients on BPAP) is reached: apneas, hypopneas, respiratory effort-related arousals (RERAs), and snoring. (3) The recommended minimum starting CPAP should be 4 cm H2O for pediatric and adult patients, and the recommended minimum starting IPAP and EPAP should be 8 cm H2O and 4 cm H2O, respectively, for pediatric and adult patients on BPAP. (4) The recommended maximum CPAP should be 15 cm H2O (or recommended maximum IPAP of 20 cm H2O if on BPAP) for patients or = 12 years. (5) The recommended minimum IPAP-EPAP differential is 4 cm H2O and the recommended maximum IPAP-EPAP differential is 10 cm H2O (6) CPAP (IPAP and/or EPAP for patients on BPAP depending on the type of event) should be increased by at least 1 cm H2O with an interval no shorter than 5 min, with the goal of eliminating obstructive respiratory events. (7) CPAP (IPAP and EPAP for patients on BPAP) should be increased from any CPAP (or IPAP) level if at least 1 obstructive apnea is observed for patients or = 12 years. (8) CPAP (IPAP for patients on BPAP) should be increased from any CPAP (or IPAP) level if at least 1 hypopnea is observed for patients or = 12 years. (9) CPAP (IPAP for patients on BPAP) should be increased from any CPAP (or IPAP) level if at least 3 RERAs are observed for patients or = 12 years. (10) CPAP (IPAP for patients on BPAP) may be increased from any CPAP (or IPAP) level if at least 1 min of loud or unambiguous snoring is observed for patients or = 12 years. (11) The titration algorithm for split-night CPAP or BPAP titration studies should be identical to that of full-night CPAP or BPAP titration studies, respectively. (12) If the patient is uncomfortable or intolerant of high pressures on CPAP, the patient may be tried on BPAP. If there are continued obstructive respiratory events at 15 cm H2O of CPAP during the titration study, the patient may be switched to BPAP. (13) The pressure of CPAP or BPAP selected for patient use following the titration study should reflect control of the patient's obstructive respiration by a low (preferably 3 hr).