Reversal of PAP Failure With the REPAP Protocol

Krakow, Barry; Ulibarri, Victor A.; McIver, Natalia D.; Yonemoto, Carli; Tidler, Alyssa; Obando, Jessica J.; Foley-Shea, Michelle R; Ornelas, Jonathan; Dawson, Spencer C.

doi:10.4187/respcare.05032

Cited by 9 publications

(29 citation statements)

References 63 publications

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“…Anecdotally, manually titrated, autoadjusting algorithms embedded in these devices create a smoother airflow delivery system, which in turn diminishes insomnia patients’ anxious responses to pressurized air 43,44. These findings are consistent with prior research showing the inadequacy of exclusive reliance on autotitrating algorithms in these devices,45 despite their known ambulatory rescue capabilities 46,47…”

Section: Introductionsupporting

confidence: 80%

“…Autoadjusting PAP devices seemed especially salient for complex insomnia patients, who were prone to anxious tendencies that may have increased vulnerability to EPI and claustrophobic feelings. Speculatively, advanced PAP technology may provide an adaptation advantage for those who might otherwise struggle with traditional PAP therapy devices 39,43,44,47…”

Section: Resultsmentioning

confidence: 99%

“…When manually titrating advanced technology in the sleep laboratory, a fine-tuning process permits minute increases in inspiratory pressures to treat RERAs while simultaneously providing concomitant pressure relief through fastidious titration of expiratory pressures. Thus, the synergistic goals of normalized airflow and patient comfort are achieved 39,47…”

Section: Methodsmentioning

confidence: 99%

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Retrospective, nonrandomized controlled study on autoadjusting, dual-pressure positive airway pressure therapy for a consecutive series of complex insomnia disorder patients

Krakow¹,

McIver²,

Ulibarri³

et al. 2017

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PurposeEmerging evidence shows that positive airway pressure (PAP) treatment of obstructive sleep apnea (OSA) and upper airway resistance syndrome (UARS) in chronic insomnia patients (proposed “complex insomnia” disorder) leads to substantial decreases in insomnia severity. Although continuous PAP (CPAP) is the pressure mode most widely researched, intolerance to fixed pressurized air is rarely investigated or described in comorbidity patients. This retrospective study examined dual pressure, autoadjusting PAP modes in chronic, complex insomnia disorder patients.Patients and methodsChronic insomnia disorder patients (mean [SD] insomnia severity index [ISI] =19.11 [3.34]) objectively diagnosed with OSA or UARS and using either autobilevel PAP device or adaptive servoventilation (ASV) device after failing CPAP therapy (frequently due to intolerance to pressurized air, poor outcomes, or emergence of CSA) were divided into PAP users (≥20 h/wk) and partial users (<20 h/wk) for comparison. Subjective and objective baseline and follow-up measures were analyzed.ResultsOf the 302 complex insomnia patients, PAP users (n=246) averaged 6.10 (1.78) nightly hours and 42.71 (12.48) weekly hours and partial users (n=56) averaged 1.67 (0.76) nightly hours and 11.70 (5.31) weekly hours. For mean (SD) decreases in total ISI scores, a significant (group × time) interaction was observed (F[1,300]=13.566; P<0.0001) with PAP users (–7.59 [5.92]; d=1.63) showing superior results to partial users (−4.34 [6.13]; d=0.81). Anecdotally, patients reported better tolerability with advanced PAP compared to previous experience with CPAP. Both adaptive servoventilation and autobilevel PAP showed similar ISI score improvement without statistical differences between devices. Total weekly hours of PAP use correlated inversely with change in insomnia symptoms (r=−0.256, P<0.01).ConclusionInsomnia severity significantly decreased in patients using autoadjusting PAP devices, but the study design restricts interpretation to an association. Future research must elucidate the interaction between insomnia and OSA/UARS as well as the adverse influence of pressure intolerance on PAP adaptation in complex insomnia patients. Randomized controlled studies must determine whether advanced PAP modes provide benefits over standard CPAP modes in these comorbidity patients.

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Section: Introductionsupporting

confidence: 80%

Section: Resultsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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Retrospective, nonrandomized controlled study on autoadjusting, dual-pressure positive airway pressure therapy for a consecutive series of complex insomnia disorder patients

Krakow¹,

McIver²,

Ulibarri³

et al. 2017

NSS

Self Cite

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show abstract

“…PAP treatment of non-sleepy patients with obstructive sleep apnea demands effort, and PAP treatment of patients with psychiatric comorbidity is even a bigger challenge because PAP adherence was shown to be significantly lower in these patient populations. 7 In this issue of RESPIRATORY CARE, Krakow et al 8 evaluate the use of a re-titration protocol (REPAP) in PAP failure subjects, of which 70% reported co-occurring psychiatric disease. This protocol includes technical solutions emphasizing the handling of mask issues and attempts to eliminate all breathing events, including respiratory effort-related arousals, while also addressing expiratory pressure intolerance (to titrate out respiratory effort-related arousals, higher pressure is needed, which may induce expiratory pressure intolerance).…”

mentioning

confidence: 99%

“…The latter problems are often encountered in patients with psychiatric co-morbidities; consequently, we fully agree with the authors of the present article that in case (re-)titration is necessary in such a patient population, it should be performed in an attended sleep laboratory. 8 The use of the REPAP protocol led to re-initiation of PAP treatment in 72% of the subjects, with psychiatric comorbidity present in the large majority. This also implies that 28% of the included subjects did not use PAP in the end, despite the frequent use of multiple re-titrations.…”

mentioning

confidence: 99%