President Susan Keller Yenney,

RPSGT

Presidentelect Rock Conner, RRT, RPSGT

Secretary Kim Goins, RPSGT

Treasurer Jennifer Phipps, RPSGT/RST, MBA, CPC, CHCC,

CHCO, CPAR

Clinical Board Members David Westerman, MD

Manoj Maggan, DDS

Technical Board Members Joel Porquez, BS, RPSGT/

RST

Jarrod Rowe, RPSGT

Facility Board Members Octavian Ioachimescu,

MD, PhD

Sigurjon Kristjansson

Immediate Past President Jeffrey Michaelson MD

Executive Director Maryann McGrail

mbmcgrail@gasleep.org 404-310-5866

GASP Policy Regarding Auto-titrating Positive Airway Pressure (APAP) Devices

Background

The American Academy of Sleep Medicine (AASM) published specific Practice Parameters in 2008

(Practice Parameters for the Use of Autotitrating Continuous Positive Airway Pressure Devices for

Titrating Pressures and Treating Adult Patients with Obstructive Sleep Apnea Syndrome: An Update

for 2007, SLEEP, Vol 31, No.1, 2008 pp. 141- 147). The document states:

• APAP should NOT be used for the diagnosis of Obstructive Sleep Apnea.

• APAP may be used appropriately to establish an optimal pressure for use of fixed-setting

CPAP, or to provide long-term treatment for obstructive sleep apnea (OSA), provided

that close clinical follow-up is maintained to evaluate effectiveness, patient safety and

outcomes.

• Conversely, APAP is not recommended for patients with Central Sleep Apnea (CSA) or in

patients with co-morbid conditions such congestive heart failure, chronic obstructive

pulmonary disease, or hypoventilation syndromes.

Technology

• Auto titrating Positive Pressure technologies and algorithms vary from device to device

and manufacturer to manufacturer. Some of the technologies mentioned below may not

be present in every Auto Titrating device, except where specified:

• Flow limitation detection;

• Snoring (vibration) detection;

• Apnea detection algorithms (technology can differentiate OSA from CSA);

• RERA (Respiratory Effort Related Arousals) detection; “subtle reduction in airflow and

progressive flow limitation.” (e.g., Remstar Auto);

• Hypopnea detection: 40% reduction from baseline flow, lasting 10 seconds (e.g.,:

Remstar Auto)*;

• Unit responds by increasing pressure to reverse abnormal signal.

*80% reduction from baseline for 10 seconds (Remstar Auto Guide)

*75% reduction from baseline for 10 seconds (Auto Set)

GASP Recommendations

While selection of APAP for long-term use without a formal CPAP titration study may be appropriate

in specific subgroups of OSA patients (e.g., those without co-existent sleep or medical disorders),

APAP may not be acceptable in other patients with OSA. For these reasons, APAP is an option, but

should NOT be considered the default treatment for OSA patients following either a home sleep testing

(HST) or a polysomnogram (PSG).

1. APAP may NOT be appropriate in the following patients:

a. Patients with very severe excessive daytime sleepiness, as other sleep pathologies may

be present and/or in need to be treated. (e.g., restless legs syndrome, periodic limb

movement disorder, narcolepsy, and other hypersomnia syndromes of central nervous

system etiology etc.);

b. Patients with uncontrolled hypertension, severe coronary artery disease, arrhythmias, a

history of congestive heart failure, individuals with pulmonary disease, and/or

individuals with neuromuscular conditions;

c. Morbidly obese individuals and/or individuals at risk for hypoventilation syndromes;

d. Patients with a significant central component of the respiratory disturbance

characterized initially on the diagnostic study;

e. Patients at risk for Complex Sleep Apnea (CxSA);

f. Patients who use opiates or routinely take sedating pain or sleep medications.

Georgia Association of Sleep Professionals

6134 Poplar Bluff Circle, Suite 101, Norcross, Georgia 30092

tel 770-613-0932, fax 305-422-3327, www. gasleep.org

2. Appropriate APAP usage and device-specific technology configurations should be determined by a physician

with training in Sleep Medicine, who meets the ABSM or ABIM criteria for Board Certification or Eligibility in

Sleep Medicine. This recommendation will ensure the patient is provided follow-up care by a provider who

will most appropriately monitor symptoms, ensure compliance and have the knowledge to adjust device

parameters if/when indicated.

GASP encourages each sleep center to define which patients fit into the various sub-groups described above and

develop policies accordingly.