Practical Aspects Of Treatment

Originally, most patients commenced CPAP under supervision, usually in a hospital-based sleep laboratory. The purposes of this supervision included ensuring that the patient was appropriately educated about the therapy, to select the best interface (mask) for the individual, and determine the adequacy of CPAP across the night. Such observation also allowed an evaluation of the immediate acceptance of or problems with the therapy. Economic pressures within health systems however

FIGURE 2 Subject wearing nasal continuous positive airway pressure.

have challenged this approach. Alternative nonlaboratory-based approaches to initiating CPAP are being applied in numerous health systems. For example, in 2004, throughout New Zealand nearly all (> 90% in some centers) CPAP initiation was implemented via either an attended in-laboratory split-night or unattended home auto-CPAP titration (Neill A, personal communication). Similarly, in the United Kingdom full in-laboratory CPAP titration studies are not routinely undertaken in many centers. Economic drivers have been of major importance in the adoption of these practices in these and other health services. As part of the drive toward economic rationalization, health authorities expect some evidence base for clinical CPAP titration strategies. Some such evidence has been accumulated; however, findings are somewhat contradictory.

Irrespective of the location or method of CPAP titration, there is a clear demand for proper patient assessment (e.g., does the patient have awake respiratory failure or marked hypoxemia in sleep?), which in turn requires specific physician training and experience. Until recently there was no evidence for the safety and efficacy of CPAP titration outside of a medically supervised process (17). Current evidence supports the use of trained technologists to provide patient education, technical aspects of titration, and follow-up. However, data from studies of small patient samples have challenged the presumption of close medical supervision during the initiation of therapy. Clearly this area requires further major research focus before a consensus may be derived (18-20).

Sleep Apnea

Sleep Apnea

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