Titration

Although it has never been clearly proven as to precisely how the titration of BPAP should best proceed, the Sander's protocol proposed a workable methodology as shown in Figure 2. A critical opening pressure with EPAP must first be established to create airway patency and then titration of the IPAP level can progress to eliminate whatever degree of hypopnea or flow limitation still exists. The importance of obtaining an adequate EPAP level was highlighted in an anatomic study performed in eight awake patients with OSA using computed tomography to measure minimum and maximum pharyngeal cross-sectional areas of the velopharynx and hypopharynx (10). The pharyngeal areas were measured while breathing without and with either 12 cm H2O CPAP or BPAP set at an IPAP = 12 cm H2O and EPAP = 6 cm H2O. Compared with normal unassisted breathing, CPAP showed a significant increase in the minimum area of both the velopharynx and the hypopharynx but BPAP did not. Although they did not do their evaluation during sleep, they concluded that CPAP at 12 cm H2O

FIGURE 1 Representative tracing demonstrating elimination of apnea in the same patient by increasing inspiratory positive airway pressure (IPAP) during nasal bilevel positive airway pressure (BiPAP®) therapy. (A) Obstructive apnea during nasal BiPAP® (IPAP = 12.5 cm H2O, expiratory positive airway pressure = 10 cm H2O). (B) Elimination of obstructive apnea after increasing IPAP to 15 cm H2O. Abbreviations: EEG, electroencephalogram; EMG, electromyogram; ROC and LOC, right and left outer canthi (eye movements), respectively; SaO2, oxygen saturation. Source: From Ref. 9.

FIGURE 1 Representative tracing demonstrating elimination of apnea in the same patient by increasing inspiratory positive airway pressure (IPAP) during nasal bilevel positive airway pressure (BiPAP®) therapy. (A) Obstructive apnea during nasal BiPAP® (IPAP = 12.5 cm H2O, expiratory positive airway pressure = 10 cm H2O). (B) Elimination of obstructive apnea after increasing IPAP to 15 cm H2O. Abbreviations: EEG, electroencephalogram; EMG, electromyogram; ROC and LOC, right and left outer canthi (eye movements), respectively; SaO2, oxygen saturation. Source: From Ref. 9.

Continue to alternate I PAP and EPAP i

If persistent apnea

If persistent apnea

Sleep Apnea

Sleep Apnea

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