Titration studies overestimate continuous positive airway pressure requirements in uncomplicated obstructive sleep apnea

Study Objectives: Attended manual continuous positive airway pressure (CPAP) titration is the standard practice for determining optimal positive airway pressures for obstructive sleep apnea (OSA) treatment. However, an unattended single night auto-titrating positive airway pressure (APAP) titration is an alternative. The goal of this study was to determine whether therapeutic CPAP pressures determined during manual titrations are higher than APAP-generated surrogate pressures. Methods: We conducted a retrospective review of 165 adults with uncomplicated OSA who had full/split-night manual CPAP titrations prior to commencing treatment with APAP. Demographic and clinical data including 30-day APAP compliance data were obtained. We compared the recommended CPAP pressure from manual titrations with the 90th/95th percentile pressure generated from APAP usage over 30 days. Results: The recommended CPAP pressures during the manual titrations were higher than the 90th/95th percentile pressures generated from APAP (11.4 ± 3.4 vs 10.3 ± 2.4 cmH2O; P = .000). Almost half the group (41.9%) had their manually derived titration pressure at least 1.5 cm above the 90th/95th percentile pressure. In multivariate analyses, body mass index was the only variable that predicted higher manual titration pressures. Notably, the average residual apnea-hypopnea index on 30-day APAP data was less than the average residual apnea-hypopnea index observed at the recommended pressure during the manual titration (5.0 ± 4.3 vs 7.2 ± 8.5; P = .006). Conclusions: Manual CPAP titrations may overestimate pressure requirements, particularly in patients with higher body mass index, and may not be necessary in managing patients with uncomplicated OSA. APAP appears to be at least as effective as single-pressure CPAP, while delivering lower positive airway pressure.