Elsevier

Sleep Medicine

Volume 12, Issue 2, February 2011, Pages 153-157
Sleep Medicine

Original Article
Telemetric CPAP titration at home in patients with sleep apnea–hypopnea syndrome

https://doi.org/10.1016/j.sleep.2010.07.014Get rights and content

Abstract

Background

Home continuous positive airway pressure (CPAP) titration with automatic devices is not possible in a non-negligible percentage of patients with sleep apnea–hypopnea syndrome (SAHS).

Objectives

To test the feasibility of a novel telemetric system for home CPAP titration.

Methods

One-night home CPAP titration was carried out on 20 SAHS patients (56 ± 3 years; BMI = 35 ± 2 kg/m2). A telemetric unit, based on the conventional GPRS mobile phone network and connected to a commercial CPAP device, allowed the hospital technician to monitor flow, pressure and air leaks by remote control and titrate CPAP (elimination of apneas, hypopneas, flow limitation and snoring) in real time. After 1 week, a full hospital polysomnography was performed while the patient was subjected to the value of CPAP that was previously titrated at home via telemetry.

Results

The home-titrated CPAP systematically improved patients’ breathing: the apnea–hypopnea index and percentage of sleep time with arterial oxygen saturation below 90% were reduced from 58.1 ± 5.1 to 3.8 ± 0.6 events/h and from 19.8 ± 1.1% to 4.4 ± 0.7%, respectively. This CPAP value (9.15 ± 0.47 cmH2O) was virtually the same as the pressure that optimized breathing during hospital polysomnography (9.20 ± 0.41 cmH2O; mean difference: 0.02 cmH2O, limits of agreement: ± 1.00 cmH2O).

Conclusions

This pilot study shows that a simple telemetric system, requiring neither a special telemedicine network nor any infrastructure in the patient’s home, made it possible to perform effective remote CPAP titration on SAHS patients.

Introduction

Individual titration of the level of continuous positive airway pressure (CPAP) suitable for treating each patient is commonly indicated after diagnosis of moderate-to-severe obstructive sleep apnea–hypopnea syndrome (SAHS). To this end, the standard procedure is based on the determination of the level of nasal pressure that normalizes the patient’s sleep and breathing during a full-night attended laboratory polysomnography (PSG) [1]. However, given that PSG titration is expensive and time-consuming, and bearing in mind the long waiting lists in many sleep labs, alternative procedures for simplifying CPAP titration have been proposed [2]. In most of these methods CPAP titration only involves the analysis of breathing variables during sleep [3], [4], [5], [6], [7].

One widespread simplified procedure for titrating nasal pressure in SAHS patients is based on the use of automatic CPAP devices during sleep in the patient’s home [2]. These devices measure various respiratory variables in order to detect breathing abnormalities (apneas, hypopneas, flow limitation and snoring) by means of built-in pressure and flow sensors; the machine then uses proprietary algorithms to modify nasal pressure automatically and normalize breathing. The signals recorded during the titration night are digitally stored by the device and are subsequently downloaded by the sleep lab staff and used to determine the optimal CPAP for treating the patient. Several studies evaluating the performance of automatic CPAP titration at home have shown that this procedure can predict the fixed CPAP that would eliminate all respiratory events (1–7). Unfortunately, automatic CPAP titration at home is not applicable to a non-negligible number of SAHS patients—for instance, in patients with significant comorbidities, such as chronic heart failure, chronic obstructive pulmonary disease, central sleep apnea syndromes, or hypoventilation syndromes [8]. In fact, it has been reported that around 20% of consecutive SAHS patients may not be candidates for automatic CPAP titration and therefore require full PSG titration [6], [9]. Furthermore, it could also be possible that the automatic unattended procedure fails in some eligible patients because of a lack of feedback or psychological support from sleep lab staff [10].

In order to improve simplified CPAP titration at home, this study seeks to design and assess the feasibility of a novel procedure for telemetrically titrating CPAP in the patient’s home. The approach is based on controlling the CPAP device at home through the simultaneous monitoring of breathing signals and modification of nasal pressure from the hospital in real time.

Section snippets

Patients

The study was carried out on 20 consecutive patients (age = 56 ± 3 years; body mass index (BMI) = 35 ± 2 kg/m2; mean ± SE) for whom CPAP treatment was recommended, recruited immediately after a diagnosis of SAHS with full polysomnography (apnea–hypopnea index [AHI] = 58.1 ± 5.1 events/h and percentage of sleep time with arterial oxygen saturation below 90% [CT90] = 19.8 ± 4.4%). The protocol was approved by the Ethical Committee of the Hospital Clinic of Barcelona and informed consent was obtained from the

Results

The average air leak recorded during the home telemetric titration was 0.12 ± 0.03 L/s. The percentage of recording time with air leak lower than 0.4 L/s, which could be considered a reasonable threshold to ensure correct titration from a technical viewpoint, was 7.8 ± 3.1%. Interestingly, in the 5 patients exhibiting a percentage of time with airflow >0.4 L/s greater than the mean value (7.8%), we did not observe any discrepancy between the CPAP value determined at home and the pressure that

Discussion

The results of this pilot study show that the novel telemetric procedure implemented for CPAP titration in the patient’s home was useful for determining the value of nasal pressure for treatment in a population of consecutive SAHS patients with a wide range of SAHS severity (AHI: 18–93 events/h).

The CPAP value telemetrically determined at home was shown to reduce the two main indices of sleep breathing disturbance when the patient was polysomnographically evaluated in the sleep lab 1 week

Financial support

This work was supported in part by Ministerio de Ciencia e Innovación (SAF2008-02991, FIS2008-PI081908, FIS-PI080277) and by the Italian Institute of Technology (IIT).

Conflict of Interest

The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: doi:10.1016/j.sleep.2010.07.014.

Acknowledgments

The authors wish to thank Resmed (Australia) for providing CPAP devices to carry out the study and for facilitating their interface communication code. The authors thank Maria del Mar Centelles for her excellent technical assistance in the home CPAP titration.

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