The gold standard for the titration of PAP is attended polysomnography with full-electroencephalogram (EEG) monitoring to detect the presence and stage of sleep (12). Respiratory monitoring allows classification of apneas (obstructive, mixed, and central) and detection of hypopnea or drop in arterial oxygen saturation. Snoring and evidence of airflow limitation or leak can also be detected with the proper monitoring equipment. Body position is identified by technologist documentation or by position sensors. Manual PAP titration is labor intensive and usually a single technologist can titrate only two patients at a time. Patients in some geographical areas may have limited or delayed access to a sleep laboratory offering polysomnography. In addition, the gold standard PAP titration method may result in suboptimal titrations due to a number of problems including poor sleep, lack of supine REM sleep, high mask leak, or uncorrected mouth leak. Patient characteristics such as weight gain may also render previously selected pressures inadequate. Auto-titrating PAP devices can be used to address some of these problems.

FIGURE 3 A single night profile showing changes in inspiratory positive airway pressure and expiratory positive airway pressure over the night with auto-bilevel positive airway pressure.
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