Initiation of Continuous Positive Airway Pressure in the Home Setting

There may be theoretical economic advantages from starting CPAP at home and avoiding a formal in-laboratory polysomnographic (PSG) CPAP titration. However, outcome studies showing true cost versus benefit analyses are not available. Current reviews and guidelines do not advocate home commencement of CPAP, particularly using auto-titrating devices (46). This is a controversial area as it implies a major change of practice in sleep centers. One study has observed poorer CPAP adherence in patients assessed only with respiratory monitoring (47); another study has shown poorer adherence outcomes with patients having initial unattended CPAP PSG at home (48). Conversely, equivalence of outcomes between in-laboratory and home-based studies have also been reported (19,30,49). Other workers have found reasonable utility with unattended in-hospital CPAP titration in patients with mild-to-moderate disease but not severe OSA (50). Some studies have suggested that equations can be determined which would allow an empirical CPAP level to be set, potentially preventing the need for any investigation of CPAP efficacy (30,44). Data from a small group of patients support an empirical method of home CPAP titration instead of laboratory initiation (18). A further multicenter three-month trial involving 360 CPAP-nai've OSA patients has shown equivalence of some key outcomes (AHI, subjective daytime sleepiness, adherence, dropout rates) whether CPAP was titrated in-laboratory, by auto-CPAP or by using a prediction formula (29). A six-month assessment of outcomes has shown equivalence for three methods of CPAP initiation including auto-CPAP as a long-term therapy, fixed-pressure CPAP with pressure calculated using an algorithm, or after one week of auto-CPAP to determine therapeutic fixed CPAP levels (30). Thus, even though long-term outcome data are lacking, there is a growing body of evidence supporting effective alternatives to in-laboratory CPAP titration in selected groups of OSA patients.

Sleep Apnea

Sleep Apnea

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