1212 Higher Is Not Always Better

Abstract Introduction Positive airway pressure (PAP) is the recommended first line treatment for obstructive sleep apnea (OSA). Overnight titration studies can be performed to find the optimal PAP settings for patients. However, manual titration studies can lead to higher PAP settings. Report of case(s) Cases: A 69-year-old man with a body mass index (BMI) of 33 and severe OSA on continuous PAP (CPAP) 10 cm of H2O was referred to sleep clinic for worsening daytime fatigue. He had an in-lab titration study with a full-face mask and was successfully titrated to bilevel PAP (BPAP) with a final inspiratory PAP (IPAP) of 20 cm of H2O and expiratory PAP (EPAP) of 16 cm H2O. Notably during his sleep study, CPAP improved the AHI up to 14 cm H2O, but further increase in CPAP and switching to BPAP worsened the AHI until a final setting of BPAP 20/16 cm H2O was reached. A 75-year-old man with a BMI of 20 and moderate OSA was referred to sleep clinic for persistent daytime sleepiness despite compliant auto-CPAP use with nasal pillows. He underwent an in-lab titration study with a full-face mask and was titrated to BPAP settings of 22/17 cm of H2O. Review of his sleep study showed effective therapy at CPAP of 6 cm of H2O, but further titration on CPAP and BPAP worsened the AHI until a final setting of BPAP 22/17 cm of H2O was reached. Discussion: PAP settings are an important determinant for PAP compliance as patients often do not tolerate higher settings. Manual titration studies have shown to overestimate CPAP requirements compared to the use of auto-titrating PAP in uncomplicated OSA. Furthermore, full-face masks can paradoxically worsen upper airway obstruction and increase treatment pressures compared to nasal masks. It is thought that full-face masks can cause worsening of upper airway obstruction and lead to higher pressure requirements to pneumatically stent the airways. Conclusion In conclusion, manual PAP titration studies may exaggerate PAP requirements, especially with the use of full-face masks. Careful review of the titration and choice of mask should be an important consideration in treating OSA. Support (if any)