APAP, BPAP, CPAP, and New Modes of Positive Airway Pressure Therapy.

Positive airway pressure (PAP) is the primary treatment of sleep-disordered breathing including obstructive sleep apnea, central sleep apnea, and sleep-related hypoventilation. Just as clinicians use pharmacological mechanism of action and pharmacokinetic data to optimize medication therapy for an individual, understanding how PAP works and choosing the right mode and device are critical to optimizing therapy in an individual patient. The first section of this chapter will describe the technology inside PAP devices that is essential for understanding the algorithms used to control the airflow and pressure. The second section will review how different comfort settings including ramp and expiratory pressure relief and modes of PAP therapy including continuous positive airway pressure (CPAP), autotitrating CPAP, bilevel positive airway pressure, adaptive servoventilation, and volume-assured pressure support control the airflow and pressure. Proprietary algorithms from several different manufacturers are described. This chapter derives its descriptions of algorithms from multiple sources including literature review, manufacture publications and websites, patents, and peer-reviewed device comparisons and from personal communication with manufacturer representatives. Clinical considerations related to the technological aspects of the different algorithms and features will be reviewed.

Long-term health outcomes for patients with obstructive sleep apnea: placing the Agency for Healthcare Research and Quality report in context-a multisociety commentary.

This multisociety commentary critically examines the Agency for Healthcare Research and Quality (AHRQ) final report and systematic review on long-term health outcomes in obstructive sleep apnea. The AHRQ report was commissioned by the Centers for Medicare & Medicaid Services and particularly focused on the long-term patient-centered outcomes of continuous positive airway pressure, the variability of sleep-disordered breathing metrics, and the validity of these metrics as surrogate outcomes. This commentary raises concerns regarding the AHRQ report conclusions and their potential implications for policy decisions. A major concern expressed in this commentary is that the AHRQ report inadequately acknowledges the benefits of continuous positive airway pressure for several established, long-term clinically important outcomes including excessive sleepiness, motor vehicle accidents, and blood pressure. While acknowledging the limited evidence for the long-term benefits of continuous positive airway pressure treatment, especially cardiovascular outcomes, as summarized by the AHRQ report, this commentary reviews the limitations of recent randomized controlled trials and nonrandomized controlled studies and the challenges of conducting future randomized controlled trials. A research agenda to address these challenges is proposed including study designs that may include both high quality randomized controlled trials and nonrandomized controlled studies. This commentary concludes by highlighting implications for the safety and quality of life for the millions of people living with obstructive sleep apnea if the AHRQ report alone was used by payers to limit coverage for the treatment of obstructive sleep apnea while not considering the totality of available evidence. CITATION: Patil SP, Billings ME, Bourjeily G, et al. Long-term health outcomes for patients with obstructive sleep apnea: placing the Agency for Healthcare Research and Quality report in context-a multisociety commentary. J Clin Sleep Med. 2024;20(1):135-149.

Improvement in headaches with continuous positive airway pressure for obstructive sleep apnea: a retrospective analysis.

OBJECTIVE: We aimed to identify clinical features in patients with severe headaches that predicted obstructive sleep apnea (OSA) and determine clinical and sleep study characteristics that predicted headache improvement with continuous positive airway pressure (CPAP). BACKGROUND: Many patients with headaches complain of sleep symptoms and have OSA. There is often improvement of headaches with CPAP treatment. METHODS: We conducted a retrospective chart review of all patients referred to adult neurology clinic for headaches and sent for polysomnography between January 2008 and December 2009. Follow-up ranged from 18 to 42 months. RESULTS: Eighty-two headache patients (70 females, 12 males) were studied. Mean age was 45±13 years (females 45±13, males 43±11) and mean body mass index was 32±9. Headache types included 17% chronic migraine without aura, 22% episodic migraine without aura, 32% migraine with aura, 21% tension-type headache, 6% chronic post-traumatic headache, 11% medication overuse headache, and 7% other types. All patients were receiving standard treatment for their headaches by their neurologist. Fifty-two patients (63%) had OSA. Increasing age, female gender, and chronic migraine without aura were predictive of OSA. Of the patients with OSA, 33 (63%) used CPAP and 27 (82%) were adherent to CPAP. Headache improvement was reported by 40 patients (49%) due to either standard medical therapy or CPAP. Patients with OSA who were CPAP adherent (21/27) were more likely to have improvement in headaches than patients intolerant of CPAP (2/6), those that did not try CPAP (8/19), and those who did not have OSA (16/30) (P=.045). Of the 33 patients who used CPAP, 13 reported improvement in headaches specifically due to CPAP therapy and 10 additional patients noted benefit in sleep symptoms. The presence of witnessed apneas (P=.045) and male gender (P=.021) predicted improvement in headaches due to CPAP. CONCLUSIONS: Headache patients should be evaluated for the presence of OSA. Treating OSA improves headaches in some patients.

Obstructive Sleep Apnea.

OBJECTIVE: Obstructive sleep apnea (OSA) is the most common type of sleep-disordered breathing. This article describes advances in the diagnosis, testing, treatment, and monitoring of OSA. LATEST DEVELOPMENTS: Home sleep apnea testing and in-laboratory polysomnography are the most commonly used diagnostic tools in the identification and monitoring of OSA, but new methods for diagnosis and at-home monitoring of treatment response are being developed and validated. While the apnea-hypopnea index is regularly used to define OSA severity, recognition is increasing of its inability to risk-stratify patients. Other sleep study data including arousal threshold, hypoxic burden, and pulse rate variability as well as clinical characteristics can help with risk stratification. The most effective treatment is continuous positive airway pressure (CPAP), which can be limited by adherence and tolerance in some patients. Newer masks and comfort features including heated tubing and expiratory pressure relief may improve tolerance to positive airway pressure (PAP) therapy. Additional treatment options include other PAP modalities, mandibular advancement devices, tongue stimulation therapy, negative inspiratory pressure, nasal expiratory pressure valves, nasal congestion treatments, upper airway surgeries including hypoglossal nerve stimulation, and medications. ESSENTIAL POINTS: OSA is a common disorder that causes sleep and daytime symptoms and increases the risk of neurologic and medical complications. Neurologists should be aware of atypical presentations and understand the diagnostic and treatment options.

Implications of Sleep Health Policy: Daylight Saving and School Start Times.

ABSTRACT: Two proposed public policies, ending seasonal clock change with a transition to permanent Standard Time and moving middle school and high school start times later, are population-based initiatives to improve sleep health. Daylight Saving Time and early school start times are associated with reduced sleep duration and increased circadian misalignment, the effects of which impact not only long-term health outcomes including obesity, cerebrovascular and cardiovascular disease, and cancer, but also mental health, academics, workforce productivity, and safety outcomes. This article highlights studies that led to the endorsement of these public policies by multiple scientific and medical organizations. Neurologists should advocate at the state and federal levels and educate the population about the importance of sleep health.

Sleep-related motor disorders.

Sleep-related motor disorders include non-rapid-eye movement (NREM) sleep parasomnias, rapid-eye movement (REM), sleep parasomnias including REM sleep behavior disorder (RBD), isolated motor phenomena in sleep, and periodic limb movement disorder. Restless legs syndrome (RLS) occurs while awake but is closely related to sleep and has a circadian pattern. The pontine sublaterodorsal tegmental nucleus has an important role in aligning motor control with sleep states, and dysfunction in this region can explain motor activities including cataplexy and loss of REM atonia seen in REM sleep behavior disorder. This chapter begins with a review of motor control in sleep. The rest of the chapter summarizes the clinical presentation, epidemiology, differential and treatment of NREM, REM, and isolated sleep-related motor disorders as well as restless legs syndrome.

PAP therapy and readmission rates after in-hospital laboratory titration polysomnography in patients with hypoventilation.

STUDY OBJECTIVES: Hypoventilation associated with sleep-disordered breathing in inpatients is associated with higher risk of morbidity, hospitalizations, and death. In-hospital titration polysomnography qualifies patients for positive airway pressure (PAP) therapy and optimizes settings, but impact is unknown. This study describes a process for in-hospital sleep testing and evaluates subsequent PAP adherence and readmission. METHODS: A retrospective cohort of patients with hypoventilation and in-hospital titration polysomnography with available PAP data were analyzed to determine whether PAP adherence was associated with 90-day readmission. Absolute differences were obtained using logistic regression models. Models were adjusted for body mass index, age, and Elixhauser index. PAP adherence and nonadherence were defined as ≥ 4 and < 4 hours of daily average use prior to readmission or first 90 days postdischarge. RESULTS: Eighty-one patients, 50.6% male, with age (mean ± SD) 61.1 ± 13.5 years were included. Comorbid sleep disorders included 91.4% with obstructive sleep apnea and 23.5% with central sleep apnea. Twenty-eight of 52 (53.8%) nonadherent and 6 of 29 (20.7%) adherent patients had 90-day readmissions. Eleven (13.6%) patients (all nonadherent) were readmitted within 2 weeks of discharge. The adjusted model showed a 35.6% (95% confidence interval 15.9-55.2%) reduction in 90-day readmission in the adherent group compared with the nonadherent group (P = .004). Similar reductions in readmission were found with adherence of ≥ 50% and ≥ 70% of days ≥ 4 hours. Male sex, treatment with iVAPS (intelligent volume-assured pressure support), and highest CO2 ≥ 60 mmHg on polysomnography were associated with the largest differences in readmission rates between adherent and nonadherent patients. CONCLUSIONS: Adherence to optimized PAP therapy after in-hospital titration polysomnography in patients with hypoventilation may decrease readmissions. CITATION: Johnson KG, Rastegar V, Scuderi N, Johnson DC, Visintainer P. PAP therapy and readmission rates after in-hospital laboratory titration polysomnography in patients with hypoventilation. J Clin Sleep Med. 2022;18(7):1739-1748.

Sleep Medicine Health-Care Worker Concerns About COVID-19: An Early Pandemic Survey.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has produced numerous safety concerns for sleep medicine patients and health-care workers, especially related to the use of aerosol-generating positive airway pressure devices. Differences between physician and sleep technologist concerns with regard to viral exposure and mitigation strategies may inform protocols to ensure safety and promote patient and health-care worker resilience and retention. METHODS: An anonymous online survey aimed at sleep medicine practitioners was active from April 29, 2020 to May 8, 2020. RESULTS: We obtained 379 responses, including from 75 physicians and 283 technologists. The proportion of all the respondents who were extremely/very concerned about the following: exposing patients (70.8%), exposing technologists (81.7%), and droplet (82.7%) and airborne (81.6%) transmission from CPAP. The proportion of respondents who felt that aerosol precautions were extremely/very important varied by scenario: always needed (45.6%); only with CPAP (25.9%); and needed, despite negative viral testing (67.0%). More technologists versus physicians rated the following as extremely/very important: testing parents for COVID-19 (71.2 vs 47.5%; P = .01), high-efficiency particulate air filters (75.1 vs 61.8%; P = .02), and extremely/very concerned about shared-ventilation systems (65.9 vs 51.5%; shared ventilation P = .041). The respondents in northeastern and western United States were more concerned about the availability of COVID-19 testing than were those in other regions of the United States. Among the total number of respondents, 68.0% expected a ≥ 50% drop in patients willing to have in-laboratory testing, with greatest drops anticipated in northeastern United States. CONCLUSIONS: Sleep health-care workers reported high levels of concern about exposure to COVID-19. Physicians and technologists generally showed high concordance with regard to the need for mitigation strategies, but the respondents differed widely with regard to which strategies were necessary.

The impact of the COVID-19 pandemic on sleep medicine practices.

STUDY OBJECTIVES: The COVID-19 pandemic required sleep centers to consider and implement infection control strategies to mitigate viral transmission to patients and staff. Our aim was to assess measures taken by sleep centers due to the COVID-19 pandemic and plans surrounding reinstatement of sleep services. METHODS: We distributed an anonymous online survey to health care providers in sleep medicine on April 29, 2020. From responders, we identified a subset of unique centers by region and demographic variables. RESULTS: We obtained 379 individual responses, which represented 297 unique centers. A total of 93.6% of unique centers reported stopping all or nearly all sleep testing of at least one type, without significant differences between adult and pediatric labs, geographic region, or surrounding population density. By contrast, a greater proportion of respondents continued home sleep apnea testing services. A total of 60.3% reduced home sleep apnea testing volume by at least 90%, compared to 90.4% that reduced in-laboratory testing by at least 90%. Respondents acknowledged that they implemented a wide variety of mitigation strategies. While no respondents reported virtual visits to be ≥ 25% of clinical visits prior to the pandemic, more than half (51.9%) anticipated maintaining ≥ 25% virtual visits after the pandemic. CONCLUSIONS: Among surveyed sleep centers, the vast majority reported near-cessation of in-laboratory sleep studies, while a smaller proportion reported reductions in home sleep apnea tests. A large increase in the use of telemedicine was reported, with the majority of respondents expecting the use of telehealth to endure in the future.

Optimal NIV Medicare Access Promotion: Patients With Central Sleep Apnea: A Technical Expert Panel Report From the American College of Chest Physicians, the American Association for Respiratory Care, the American Academy of Sleep Medicine, and the American Thoracic Society.

This document summarizes suggestions of the central sleep apnea (CSA) Technical Expert Panel working group. This paper shares our vision for bringing the right device to the right patient at the right time. For patients with CSA, current coverage criteria do not align with guideline treatment recommendations. For example, CPAP and oxygen therapy are recommended but not covered for CSA. On the other hand, bilevel positive airway pressure (BPAP) without a backup rate may be a covered therapy for OSA, but it may worsen CSA. Narrow coverage criteria that require near elimination of obstructive breathing events on CPAP or BPAP in the spontaneous mode, even if at poorly tolerated pressure levels, may preclude therapy with BPAP with backup rate or adaptive servoventilation, even when those devices provide demonstrably better therapy. CSA is a dynamic disorder that may require different treatments over time, sometimes switching from one device to another; an example is switching from BPAP with backup rate to an adaptive servoventilation with automatic end-expiratory pressure adjustments, which may not be covered. To address these challenges, we suggest several changes to the coverage determinations, including: (1) a single simplified initial and continuing coverage definition of CSA that aligns with OSA; (2) removal of hypoventilation terminology from coverage criteria for CSA; (3) all effective therapies for CSA should be covered, including oxygen and all PAP devices with or without backup rates or servo-mechanisms; and (4) patients shown to have a suboptimal response to one PAP device should be allowed to add oxygen or change to another PAP device with different capabilities if shown to be effective with testing.

Future of Positive Airway Pressure Technology.

This article discusses the future of positive airway pressure (PAP) technology. The focus is on (1) technology improvements in the delivery of PAP; (2) improvements in PAP algorithms; and (3) improvements in PAP informatics. Current limitations of PAP technology and whether technological improvements are sufficient to PAP are discussed.

Bilevel positive airway pressure worsens central apneas during sleep.

STUDY OBJECTIVES: While most patients with sleep-disordered breathing are treated with continuous positive airway pressure (CPAP), bilevel positive airway pressure (BLPAP) is often used. Having observed that BLPAP therapy increased central apneas in some of our patients undergoing sleep studies, we conducted this study to evaluate the effects of BLPAP. DESIGN: Retrospective analysis of all sleep studies performed in an outpatient sleep center that used BLPAP over a 2-year period. We assessed the incidence and frequency of events during rapid eye movement (REM) sleep and non-REM sleep during baseline conditions, CPAP, and BLPAP. Desaturations, hypopneas, obstructive apneas, and central events, including periodic breathing (PB), Cheyne-Stokes respiration (CSR), and non-CSR central apneas were evaluated. PATIENTS: Ninety-five of the 719 patients who underwent sleep studies met inclusion criteria. Eighty of the 95 patients treated with BLPAP were also treated with CPAP. RESULTS: BLPAP was more likely to worsen than improve CSR (p = 0.002), non-CSR central apneas (p < 0.001), and CSR or PB (p < 0.001). CSR (p = 0.03) and non-CSR central apneas (p = 0.01) were more likely to worsen with BLPAP (24% and 23%, respectively) than with CPAP (11% and 8%). Central events (p = 0.04) and CSR (p = 0.009) were more likely to worsen during BLPAP in patients with baseline CSR or PB (62% and 48%, respectively) than develop in those without baseline CSR or PB (34% and 18%). Higher BLPAP differences worsened central events in 28% of patients, while 7% improved (p = 0.02). During REM sleep, central apneas improved, while hypopneas and obstructive apneas worsened (p < 0.001). CONCLUSIONS: BLPAP often increases the frequency of CSR and non-CSR central apneas during sleep. Since CSR has adverse effects on cardiac function and sleep, it is important to consider this possible adverse effect of BLPAP.