The impact of changing people with sleep apnea using CPAP less than 4 h per night to a Bi-level device

Abstract

Pressure intolerance is a reason for poor acceptance and subsequent compliance in some patients starting treatment with continuous positive airway pressure (CPAP). In unselected populations initiating CPAP; different types of pressure generating device have not been found to improve compliance. We hypothesized that using Bi-level PAP for patients who reported pressure related discomfort as a cause for poor compliance with CPAP might increase their hours of treatment use. Patients using CPAP <4 h/night with symptoms to suggest pressure intolerance were randomized to receive either a Bi-level PAP device or a new CPAP for 4 weeks. Following a washout period of 2 weeks, they were crossed over to the other device for 4 weeks. Twenty eight volunteers completed the protocol. Compared to the baseline (mean 1.49 h per night), improvement in compliance was noticed when changed to a new CPAP (2.23 h, p = 0.006) or Bi-level PAP (2.73 h, p < 0.001). The trend suggesting superior compliance with a Bi-level PAP device compared to new CPAP was not significant (p = 0.059) and there were no differences in subjective or objective measures of sleepiness. The results of this study suggest that routine intervention with Bi-level PAP in this group of sub-optimally compliant individuals was not very effective in improving PAP usage. There is however a subgroup of patients who complains of difficulty with exhalation; where favorable trends towards improved compliance were observed on Bi-level PAP.

Reversal of PAP Failure With the REPAP Protocol

“…adverse effect triggered in susceptible individuals when exhaling against incoming pressurized air flow. 1,2,27,28 In our experience, these 2 therapeutic goals diminish claustrophobic tendencies observed among many PAP attempters, [15][16][17] particularly those with psychiatric comorbidities. 26 Successful management of respiratory effort-related arousals and expiratory pressure intolerance has been associated with renewed use of PAP therapy and more satisfied patients.…”

“…Our policies and procedures for re-titrations align with AASM practice parameters for PAP therapy indications for BPAP "… where high pressure is needed and the patient experiences difficulty exhaling against a fixed pressure …" 27 ; Other researchers describe this phenomenon as intolerance to higher pressures on exhalation, 28,[39][40][41] that is, subjective or objective expiratory pressure intolerance, the latter manifesting as subtle irregularities on the expiratory limb of the air-flow curve. 26 As described above, raising pressures to titrate out respiratory effort-related arousals may induce expiratory pressure intolerance in susceptible individuals (eg, anxiety or other mental health patients).…”

Clinical side effects of continuous positive airway pressure in patients with obstructive sleep apnoea

“…Suggested solutions to alleviate pressure intolerance are: (i) ramping from a lower initial pressure on CPAP or a feature to allow easier exhalation; (ii) Overall pressure reduction; (iii) auto‐PAP—continually adjusting the airway pressure leading to slightly lower average pressures; expiratory relief PAP which lowers the delivered pressure towards the end of expiration; and (iv) bi‐level PAP, where one pressure is used to breathe in and a lower pressure is used to breathe out . However, intervention with bi‐level PAP of suboptimally compliant individuals was not very effective in improving pressure intolerance . In addition, it has been argued that auto‐titrating CPAP mode is a method to overcome pressure intolerance but evidence is lacking and most studies show no difference in outcomes but cost is usually greater.…”

“…59 However, intervention with bi-level PAP of suboptimally compliant individuals was not very effective in improving pressure intolerance. 60 In addition, it has been argued that auto-titrating CPAP mode is a method to overcome pressure intolerance but evidence is lacking 10 and most studies show no difference in outcomes but cost is usually greater. Fixed-pressure CPAP is more effective at reducing 24 h blood pressure than auto-CPAP.…”

Biomimetic Oral Appliance Therapy in Adults with Severe Obstructive Sleep Apnea

“…However, it is prone to intolerance, and compliance is typically less than optimal [1]. As an alternative, it was thought that mandibular advancement devices (MADs) would be an effective treatment in patients with mild to moderate OSA who have failed treatment with CPAP therapy.…”