Time-Course of Stepwise CPAP Titration. Behavior of Respiratory and Neurological Variables

Because successful medical treatment of obstructive sleep apnea/hypopnea syndrome (SAHS) depends on adequate CPAP treatment, we have analyzed in nine SAHS patients the behavior of respiratory and neurological parameters during a stepwise, polysomnography-controlled CPAP titration to achieve an optimal CPAP. Particularly, we have focused on which simple variable could predict the optimal CPAP pressure and could better define a distinctive optimal-suboptimal pattern. Main parameters analyzed through the CPAP titration procedure were respiratory events (apnea, hypopnea), the contour of inspiratory flow, the pleural pressure behavior, the thoraco-abdominal motion, oximetry, arousals, and sleep stage. During the CPAP titration we observed: (1) a rounded shape in the inspiratory flow contour was associated with the lowest esophageal pressure; (2) during stepwise increases in CPAP, almost all apnea events changed to hypopnea periods, followed by prolonged periods of limited inspiratory flow with still high esophageal pressure but without arousals (probably suboptimal CPAP); and (3) as CPAP reached suboptimal levels, sleep stage moved to deeper stages without arousals. We conclude that if during CPAP titration the end point is the disappearance of arousals, most patients with SAHS will still exhibit periods of high intrathoracic pressures with limited inspiratory flow. Alternatively, if the end point to be reached is the lowest esophageal pressure, higher CPAP levels will be needed. The contour of inspiratory flow appears as the simplest variable that best correlates with lowest esophageal pressure during CPAP titration.