Managing patients with obstructive sleep apnea (OSA)

Obstructive sleep apnea (OSA) is estimated to affect 3–10% of individuals under the age of 50 and 9–17% of those older than 50 years of age—making this a common problem clinicians will face.

There are eight main risk factors that would lead to an evaluation for OSA:

1. Snoring
2. Daytime somnolence
3. Unrefreshed sleep
4. Sedentary fatigue
5. Nocturia
6. Morning headaches
7. High body mass index (BMI)
8. Increased neck circumference

The diagnosis of obstructive sleep apnea is made with polysomnography to determine the number of apneas and hypopneas per hour.

The collapse of the upper airway that causes obstruction and apnea during sleep is reversed with the application of positive-pressure ventilation. This is most commonly delivered as continuous positive airway pressure (CPAP).

How should I titrate CPAP for my patient with OSA?

Laboratory titration

Initial titration of CPAP is typically done in the laboratory setting (during sleep) and is adjusted to reduce the number of obstructive events. Typically, CPAP is started at 4 cmH₂O and can be adjusted in fixed increments to a maximum of 20 cmH₂O.

Automated titration

Newer evidence suggests that automated CPAP titration—where titration is done by the machine itself—appears as effective as sleep lab titration for initiating CPAP.

Though typically sleep apnea is treated at home, patients with sleep apnea often have other medical problems and may become hospitalized. CPAP should be continued in the hospital for patients with sleep apnea, but a common problem is that many patients don’t know or can’t recall what their home settings are. In these situations, automated titration of CPAP is convenient and sets reliable pressures to improve the patient’s apnea. So, if available on your hospital’s CPAP machines, automated titration is the ideal choice.

What do you do if you don't have an automated titrate CPAP machine? Use BMI-based settings.

Setting a CPAP machine based on BMI has been evaluated and results in settings similar to those set by polysomnography. Start with a pressure of 8 cmH₂O for patients with a BMI of less than 30. Use 10 cmH₂0 if the BMI is 30 through 35, and 12 cmH₂O if the BMI is greater than 35.