This is the current release of the guideline.

This guideline updates a previous version: Standards of Practice Committee. Practice parameters for the use of auto-titrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea. Sleep 2002;25(2):143-7.

Obstructive sleep apnea syndrome

Assessment of Therapeutic Effectiveness
Treatment

Dentistry
Internal Medicine
Neurology
Otolaryngology
Pulmonary Medicine
Sleep Medicine

Advanced Practice Nurses
Allied Health Personnel
Dentists
Physician Assistants
Physicians
Respiratory Care Practitioners

To present updated recommendations for using auto-titrating positive airway pressure (APAP) to determine the need for or to provide treatment for obstructive sleep apnea (OSA)

Adults with obstructive sleep apnea syndrome

1. Use of standard (i.e., fixed) continuous positive airway pressure (CPAP) (titration and treatment)
2. Use of auto-titrating continuous positive airway pressure (APAP) titration and treatment
3. Follow-up of patients to determine effectiveness and safety of treatment

Clinical utility of autotitrating positive airway pressure (APAP) for diagnosing and treating obstructive sleep apnea syndrome

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

A search for articles on treatment of obstructive sleep apnea with autotitrating continuous positive airway pressure (CPAP) (APAP) was conducted using EMBASE, Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, and the Cochrane Clinical Trial Registry, first on August 25, 2006, and updated on November 7, 2006. Key words for searches included autoCPAP, automatic CPAP, autotitrating CPAP, autoset, auto PAP, and autoadjusting CPAP. Each search was run separately and findings were merged. When the search was limited to articles published in English and regarding humans, a total of 167 articles were identified. Abstracts from these articles were reviewed to determine if they met inclusion criteria. Articles were included for evaluation if they had more than 9 subjects and if they compared APAP use with standard PSG directed CPAP therapy, a standard alternate therapy (oral appliance, surgery), or another APAP device. The articles had to address at least one of eight "PICO" questions (acronym standing for Patient, Population or Problem, provided a specific Intervention or exposure, after which a defined Comparison is performed on specified Outcomes) that were decided upon ahead of the review process. While the PICO questions do not map one-to-one with the practice parameters, they were designed to generate information that would be useful in updating the existing practice parameters. Articles meeting these criteria in addition to those identified by pearling (i.e., checking the reference sections of search results for articles otherwise missed) provided 22 articles for review and grading (see accompanying evidence table in the original guideline document).

This guideline is based on a review of 22 articles published in peer reviewed journals.

Weighting According to a Rating Scheme (Scheme Given)

Evidence Levels

1. Randomized well-designed trials with low-alpha and low-beta error*
2. Randomized trials with high alpha and beta error*
3. Nonrandomized concurrently controlled studies
4. Nonrandomized historically controlled studies
5. Case series

* Alpha (type I error) refers to the probability that the null hypothesis is rejected when in fact it is true (generally acceptable at 5% or less, or P <0.05). Beta (type II error) refers to the probability that the null hypothesis is mistakenly accepted when in fact it is false (generally trials accept a beta error of 0.20). The estimation of type II error is generally the result of a power analysis. The power analysis takes into account the variability and the effect size to determine if sample size is adequate to find a difference in means when it is present (power generally acceptable at 80% to 90%).

Systematic Review with Evidence Tables

All evidence grading was performed by independent review of the article by two members of the task force. Areas of disagreement were addressed by the task force until resolved.

Expert Consensus

The Standards of Practice Committee (SPC) of the American Academy of Sleep Medicine (AASM) commissioned among its members four individuals with expertise in the use of autotitrating positive airway pressure (APAP) to conduce this review. These content experts were appointed in June, 2006 to review and grade evidence in the peer-reviewed scientific literature regarding the use of APAP.

Levels of Recommendation

Standard: This is a generally accepted patient-care strategy which reflects a high degree of clinical certainty. The term standard generally implies the use of Level I evidence, which directly addresses the clinical issue, or overwhelming Level II evidence.

Guideline: This is a patient-care strategy which reflects a moderate degree of clinical certainty. The term guideline implies the use of Level II evidence or a consensus of Level III evidence.

Option: This is a patient-care strategy which reflects uncertain clinical use. The term option implies either inconclusive or conflicting evidence or conflicting expert opinion.

A formal cost analysis was not performed and published cost analyses were not reviewed.

External Peer Review
Internal Peer Review

The recommendations were reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine.

The evidence levels (I-IV) and the levels of recommendations (standard, guideline, option) are defined at the end of the "Major Recommendations" field.

Auto-titrating continuous positive airway pressure (APAP) is not recommended to diagnosis obstructive sleep apnea (OSA). (Standard)

Patients with congestive heart failure, significant lung disease such as chronic obstructive pulmonary disease, patients expected to have nocturnal arterial oxyhemoglobin desaturation due to conditions other than OSA (e.g., obesity hypoventilation syndrome), patients who do not snore (either naturally or as a result of palate surgery), and patients who have central sleep apnea syndromes are not currently candidates for APAP titration or treatment. (Standard)

APAP devices are not currently recommended for split-night titration. (Standard)

Certain APAP devices may be used during attended titration with polysomnography to identify a single pressure for use with standard continuous positive airway pressure (CPAP) for treatment of moderate to severe OSA (Guideline)

Certain APAP devices may be initiated and used in the self-adjusting mode for unattended treatment of patients with moderate to severe OSA without significant comorbidities (congestive heart failure [CHF], chronic obstructive pulmonary disease [COPD], central sleep apnea syndromes, or hypoventilation syndromes). (Option)

Certain APAP devices may be used in an unattended way to determine a fixed CPAP treatment pressure for patients with moderate to severe OSA without significant comorbidities (CHF, COPD, central sleep apnea syndromes, or hypoventilation syndromes). (Option)

Patients being treated with fixed CPAP on the basis of APAP titration or being treated with APAP must have close clinical follow-up to determine treatment effectiveness and safety. This is especially important during the first few weeks of positive airway pressure (PAP) use. (Standard)

A reevaluation and, if necessary, a standard attended CPAP titration should be performed if symptoms do not resolve or if the APAP treatment otherwise appears to lack efficacy. (Standard)

Definitions:

Evidence Levels

1. Randomized, well-designed trials with low alpha and beta error
2. Randomized trials with high alpha and beta error
3. Nonrandomized concurrently controlled studies
4. Nonrandomized historically controlled studies
5. Case series

Levels of Recommendations

Standard - This is a generally accepted patient-care strategy, which reflects a high degree of clinical certainty. The term standard generally implies the use of Level I Evidence, which directly addresses the clinical issue, or overwhelming Level II Evidence.

Guideline - This is a patient-care strategy, which reflects a moderate degree of clinical certainty. The term guideline implies the use of Level II Evidence or a consensus of Level III Evidence.

Option - This is a patient-care strategy, which reflects uncertain clinical use. The term option implies either inconclusive or conflicting evidence or conflicting expert opinion.

None provided

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Appropriate use of autotitrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome

Not stated

• These practice parameters define principles of practice that should meet the needs of most patients in most situations. These guidelines should not, however, be considered inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding propriety of any specific care must be made by the physician in light of the individual circumstances presented by the patient, available diagnostic tools, accessible treatment options, and resources.
• The American Academy of Sleep Medicine (AASM) expects these guidelines to have an impact on professional behavior, patient outcomes, and, possibly, health care costs. These practice parameters reflect the state of knowledge at the time of publication and will be reviewed, updated, and revised as new information becomes available.

An implementation strategy was not provided.

Living with Illness

Effectiveness

Not applicable: The guideline was not adapted from another source.

2002 March 15 (revised 2008 Jan)

American Academy of Sleep Medicine - Professional Association

American Academy of Sleep Medicine

Standards of Practice Committee

Standards of Practice Committee: Timothy I. Morgenthaler, MD; R. Nisha Aurora, MD; Terry Brown, DO; Rochelle Zak, MD; Cathy Alessi, MD; Brian Boehlecke, MD; Andrew L. Chesson Jr, MD; Leah Friedman, MA, PhD; Vishesh Kapur, MD, MPH; Rama Maganti, MD; Judith Owens, MD; Jeffrey Pancer, DDS; Todd J. Swick, MD

All members of the American Academy of Sleep Medicine´s Standards of Practice Committee and Board of Directors completed detailed conflict-of-interest statements and were found to have no conflicts of interest with regard to this subject.

This is the current release of the guideline.

This guideline updates a previous version: Standards of Practice Committee. Practice parameters for the use of auto-titrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea. Sleep 2002;25(2):143-7.

None available

None available

This summary was completed by ECRI on July 19, 2002. The information was verified by the guideline developer on September 13, 2002. This NGC summary was updated by ECRI Institute on May 13, 2008.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Please contact the American Academy of Sleep Medicine (AASM) for information regarding reproduction of AASM guidelines.