Over the past few decades, continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea has evolved into more and more sophisticated modes of therapy for various forms of sleep-disordered breathing. While the principles of splinting the airway and delivering assisted ventilation underpin the basics of this therapy, the introduction of newer technologies and miniaturization are revolutionizing the former conventions of the field. The purpose of this review is to improve our understanding of various forms of PAP therapy by providing the rationale for such modalities, gaining a basic working knowledge of device technology, and critically assessing the clinical research evidence while identifying barriers to implementation. Dissemination of such information is vital in order to prevent knowledge gaps in healthcare providers and systems.
SullivanCE, IssaFG, Berthon-JonesM, EvesL. Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares. Lancet, 1981; 1(8225):862–865.
2.
LeungR, BradleyTD. Sleep apnea and cardiovascular disease. Am J Respir Crit Care Med, 2001; 164(12):2147–2165.
3.
AyasNT, FoxJ, EpsteinL, RyanCF, FleethamJA. Initial use of portable monitoring versus polysomnography to confirm obstructive sleep apnea in symptomatic patients: an economic decision model. Sleep Med, 2010; 11(3):320–324.
4.
KushidaCA, ChediakA, BerryRB, BrownLK, GozalD, IberC, et al. Clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea. J Clin Sleep Med, 2008; 4(2):157–171.
5.
ArchboldKH, ParthasarathyS. Adherence to positive airway pressure therapy in adults and children. Curr Opin Pulm Med, 2009Aug26 [Epub ahead of print].
6.
WeaverTE, GrunsteinRR. Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc, 2008; 5(2):173–178.
7.
MarinJM, CarrizoSJ, VicenteE, AgustiAG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet, 2005; 365(9464):1046–1053.
8.
StepnowskyCJ, PalauJJ, GiffordAL, Ancoli-IsraelS. A self-management approach to improving continuous positive airway pressure adherence and outcomes. Behav Sleep Med, 2007; 5(2):131–146.
9.
ParthasarathyS, HaynesPL, BudhirajaR, HabibMP, QuanSF. A national survey of the effect of sleep medicine specialists and American Academy of Sleep Medicine Accreditation on management of obstructive sleep apnea. J Clin Sleep Med, 2006; 2(2):133–142.
10.
WeaverTE, MaislinG, DingesDF, YoungerJ, CantorC, McCloskeyS, et al. Self-efficacy in sleep apnea: instrument development and patient perceptions of obstructive sleep apnea risk, treatment benefit, and volition to use continuous positive airway pressure. Sleep, 2003; 26(6):727–732.
11.
Simon-TuvalT, ReuveniH, Greenberg-DotanS, OksenbergA, TalA, TarasiukA. Low socioeconomic status is a risk factor for CPAP acceptance among adult OSAS patients requiring treatment. Sleep, 2009; 32(4):545–552.
12.
PlattAB, FieldSH, AschDA, ChenZ, PatelNP, GuptaR, et al. Neighborhood of residence is associated with daily adherence to CPAP therapy. Sleep, 2009; 32(6):799–806.
13.
RichardsD, BartlettDJ, WongK, MalouffJ, GrunsteinRR. Increased adherence to CPAP with a group cognitive behavioral treatment intervention: a randomized trial. Sleep, 2007; 30(5):635–640.
14.
DamjanovicD, FluckA, BremerH, Muller-QuernheimJ, IdzkoM, SorichterS. Compliance in sleep apnoea therapy: influence of home care support and pressure mode. Eur Respir J, 2009; 33(4):804–811.
15.
FriedmanM, SoansR, JosephN, KakodkarS, FriedmanJ. The effect of multilevel upper airway surgery on continuous positive airway pressure therapy in obstructive sleep apnea/hypopnea syndrome. Laryngoscope, 2009; 119(1):193–196.
16.
SmithI, NadigV, LassersonTJ. Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines for adults with obstructive sleep apnoea. Cochrane Database Syst Rev, 2009;(2):CD007736.
17.
LettieriCJ, CollenJF, EliassonAH, QuastTN. Sedative use during continuous positive airway pressure titration improves subsequent compliance. A randomized, double-blinded, placebo-controlled trial. Chest, 2009; 136(5):1263–1268.
18.
LettieriCJ, ShahAA, HolleyAB, KellyWF, ChangAS, RoopSA. Effects of a short course of eszopiclone on continuous positive airway pressure adherence: a randomized trial. Ann Intern Med, 2009; 151(10):696–702.
19.
BudhirajaR, ParthasarathyS, DrakeCL, RothT, ShariefI, BudhirajaP, et al. Early CPAP use identifies subsequent adherence to CPAP therapy. Sleep, 2007; 30(3):320–324.
ParthasarathyS, JubranA, TobinMJ. Cycling of inspiratory and expiratory muscle groups with the ventilator in airflow limitation. Am J Respir Crit Care Med, 1998; 158(5 Pt 1):1471–1478.
22.
YounesM, KunJ, WebsterK, RobertsD. Response of ventilator-dependent patients to delayed opening of exhalation valve. Am J Respir Crit Care Med, 2002; 166(1):21–30.
23.
MezaS, MendezM, OstrowskiM, YounesM. Susceptibility to periodic breathing with assisted ventilation during sleep in normal subjects. J Appl Physiol, 1998; 85(5):1929–1940.
24.
HotchkissJRJr, AdamsAB, StoneMK, DriesDJ, MariniJJ, CrookePS. Oscillations and noise: inherent instability of pressure support ventilation?. Am J Respir Crit Care Med, 2002; 165(1):47–53.
25.
BallardRD, GayPC, StrolloPJ. Interventions to improve compliance in sleep apnea patients previously non-compliant with continuous positive airway pressure. J Clin Sleep Med, 2007; 3(7):706–712.
26.
BarbéF, Durán-CantollaJ, CapoteF, de la PeñaM, ChinerE, MasaJF, et al. Long-term effect of continuous positive airway pressure in hypertensive patients with sleep apnea. Am J Respir Crit Care Med, 2010; 181(7):718–26.
27.
PatelSR, WhiteDP, MalhotraA, StanchinaML, AyasNT. Continuous positive airway pressure therapy for treating sleepiness in a diverse population with obstructive sleep apnea: results of a meta-analysis. Arch Intern Med, 2003; 163(5):565–571.
28.
FindleyL, SmithC, HooperJ, DineenM, SurattPM. Treatment with nasal CPAP decreases automobile accidents in patients with sleep apnea. Am J Respir Crit Care Med, 2000; 161(3):857–859.
29.
MillerRG, JacksonCE, KasarskisEJ, EnglandJD, ForshewD, JohnstonW, et al. Practice parameter update: the care of the patient with amyotrophic lateral sclerosis: drug, nutritional, and respiratory therapies (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 2009; 73(15):1218–1226.
30.
AloiaMS, StanchinaM, ArnedtJT, MalhotraA, MillmanRP. Treatment adherence and outcomes in flexible vs standard continuous positive airway pressure therapy. Chest, 2005; 127(6):2085–2093.
31.
DolanDC, OkonkwoR, GfullnerF, HansbroughJR, StrobelRJ, RosenthalL. Longitudinal comparison study of pressure relief (C-Flex) vs CPAP in OSA patients. Sleep Breath, 2009; 13(1):73–77.
32.
PepinJL, MuirJF, GentinaT, DauvilliersY, TamisierR, SapeneM, et al. Pressure reduction during exhalation in sleep apnea patients treated by continuous positive airway pressure. Chest, 2009; 136(2):490–497.
33.
FickerJH, ClarenbachCF, NeukirchnerC, FuchsFS, WiestGH, SchahinSP, et al. Auto-CPAP therapy based on the forced oscillation technique. Biomed Tech (Berl), 2003; 48(3):68–72.
34.
CollerD, StanleyD, ParthasarathyS. Effect of air leak on the performance of auto-PAP devices: a bench study. Sleep Breath, 2005; 9(4):167–175.
35.
BrownLK. Autotitrating CPAP: how shall we judge safety and efficacy of a “black box”?. Chest, 2006; 130(2):312–314.
36.
AmbrogioC, LowmanX, KuoM, MaloJ, PrasadAR, ParthasarathyS. Sleep and non-invasive ventilation in patients with chronic respiratory insufficiency. Intensive Care Med, 2009; 35(2):306–313.
37.
StorreJH, SeutheB, FiechterR, MilioglouS, DreherM, SorichterS, et al. Average volume-assured pressure support in obesity hypoventilation: a randomized crossover trial. Chest, 2006; 130(3):815–821.
38.
MorgenthalerTI, GayPC, GordonN, BrownLK. Adaptive servoventilation versus noninvasive positive pressure ventilation for central, mixed, and complex sleep apnea syndromes. Sleep, 2007; 30(4):468–475.
39.
TeschlerH, DohringJ, WangYM, Berthon-JonesM. Adaptive pressure support servo-ventilation: a novel treatment for Cheyne-Stokes respiration in heart failure. Am J Respir Crit Care Med, 2001; 164(4):614–619.
40.
LofasoF, DesmaraisG, LerouxK, ZalcV, FodilR, IsabeyD, et al. Bench evaluation of flow limitation detection by automated continuous positive airway pressure devices. Chest, 2006; 130(2):343–349.
41.
FarreR, MontserratJM, RigauJ, TrepatX, PintoP, NavajasD. Response of automatic continuous positive airway pressure devices to different sleep breathing patterns: a bench study. Am J Respir Crit Care Med, 2002; 166(4):469–473.
42.
HiroseM, HondaJ, SatoE, ShinboT, KokuboK, IchiwataT, et al. Bench study of auto-CPAP devices using a collapsible upper airway model with upstream resistance. Respir Physiol Neurobiol, 2008; 162(1):48–54.
43.
RigauJ, MontserratJM, WohrleH, PlattnerD, SchwaiboldM, NavajasD, et al. Bench model to simulate upper airway obstruction for analyzing automatic continuous positive airway pressure devices. Chest, 2006; 130(2):350–361.
44.
ToKW, ChanWC, ChooKL, LamWK, WongKK, HuiDS. A randomized cross-over study of auto-continuous positive airway pressure versus fixed-continuous positive airway pressure in patients with obstructive sleep apnoea. Respirology, 2008; 13(1):79–86.
45.
MasaJF, JimenezA, DuranJ, CapoteF, MonasterioC, MayosM, et al. Alternative methods of titrating continuous positive airway pressure: a large multicenter study. Am J Respir Crit Care Med, 2004; 170(11):1218–1224.
46.
VennelleM, WhiteS, RihaRL, MackayTW, EnglemanHM, DouglasNJ. Randomized controlled trial of variable-pressure versus fixed-pressure continuous positive airway pressure (CPAP) treatment for patients with obstructive sleep apnea/hypopnea syndrome (OSAHS). Sleep, 2010; 33(2):267–271.
47.
NosedaA, KempenaersC, KerkhofsM, BraunS, LinkowskiP, JannE. Constant vs auto-continuous positive airway pressure in patients with sleep apnea hypopnea syndrome and a high variability in pressure requirement. Chest, 2004; 126(1):31–37.
48.
MassieCA, McArdleN, HartRW, Schmidt-NowaraWW, LankfordA, HudgelDW, et al. Comparison between automatic and fixed positive airway pressure therapy in the home. Am J Respir Crit Care Med, 2003; 167(1):20–23.
49.
PatrunoV, AiolfiS, CostantinoG, MurgiaR, SelmiC, MallianiA, et al. Fixed and autoadjusting continuous positive airway pressure treatments are not similar in reducing cardiovascular risk factors in patients with obstructive sleep apnea. Chest, 2007; 131(5):1393–1399.
50.
GaletkeW, RanderathWJ, StieglitzS, LaumannsC, AnduleitN, RichterK, et al. Comparison of manual titration and automatic titration based on forced oscillation technique, flow and snoring in obstructive sleep apnea. Sleep Med, 2009; 10(3):337–343.
51.
BerryRB, HillG, ThompsonL, McLaurinV. Portable monitoring and autotitration versus polysomnography for the diagnosis and treatment of sleep apnea. Sleep, 2008; 31(10):1423–1431.
52.
MulgrewAT, FoxN, AyasNT, RyanCF. Diagnosis and initial management of obstructive sleep apnea without polysomnography: a randomized validation study. Ann Intern Med, 2007; 146(3):157–166.
AnticNA, BuchanC, EstermanA, HensleyM, NaughtonMT, RowlandS, et al. A randomized controlled trial of nurse-led care for symptomatic moderate-severe obstructive sleep apnea. Am J Respir Crit Care Med, 2009; 179(6):501–508.
55.
SennO, BrackT, MatthewsF, RussiEW, BlochKE. Randomized short-term trial of two autoCPAP devices versus fixed continuous positive airway pressure for the treatment of sleep apnea. Am J Respir Crit Care Med, 2003; 168(12):1506–1511.
56.
SérièsF, PlanteJ, LacasseY. Reliability of home CPAP titration with different automatic CPAP devices. Respir Res, 2008; 9:56.
57.
ParthasarathyS, HabibM, QuanSF. How are automatic positive airway pressure and related devices prescribed by sleep physicians? A web-based survey. J Clin Sleep Med, 2005; 1(1):27–34.
58.
MorgenthalerTI, AuroraRN, BrownT, ZakR, AlessiC, BoehleckeB, et al. Practice parameters for the use of autotitrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome: an update for 2007. An American Academy of Sleep Medicine report. Sleep, 2008; 31(1):141–147.
59.
PepperellJC, MaskellNA, JonesDR, Langford-WileyBA, CrosthwaiteN, StradlingJR, et al. A randomized controlled trial of adaptive ventilation for Cheyne-Stokes breathing in heart failure. Am J Respir Crit Care Med, 2003; 168(9):1109–1114.
60.
ArztM, WenselR, MontalvanS, SchichtlT, SchrollS, BudweiserS, et al. Effects of dynamic bilevel positive airway pressure support on central sleep apnea in men with heart failure. Chest, 2008; 134(1):61–66.
61.
RanderathWJ, GaletkeW, KenterM, RichterK, SchaferT. Combined adaptive servo-ventilation and automatic positive airway pressure (anticyclic modulated ventilation) in co-existing obstructive and central sleep apnea syndrome and periodic breathing. Sleep Med, 2009; 10(8):898–903.
62.
PiperAJ, WangD, YeeBJ, BarnesDJ, GrunsteinRR. Randomised trial of CPAP vs bilevel support in the treatment of obesity hypoventilation syndrome without severe nocturnal desaturation. Thorax, 2008; 63(5):395–401.
FitzpatrickMF, AllowayCE, WakefordTM, MacLeanAW, MuntPW, DayAG. Can patients with obstructive sleep apnea titrate their own continuous positive airway pressure?. Am J Respir Crit Care Med, 2003; 167(5):716–722.
65.
HoffsteinV, MateikaS. Predicting nasal continuous positive airway pressure. Am J Respir Crit Care Med, 1994; 150(2):486–488.
66.
LoredoJS, BerryC, NelesenRA, DimsdaleJE. Prediction of continuous positive airway pressure in obstructive sleep apnea. Sleep Breath, 2007; 11(1):45–51.
67.
GarberAM, TunisSR. Does comparative-effectiveness research threaten personalized medicine?. N Engl J Med, 2009; 360(19):1925–1927.
68.
GarberAM. Modernizing device regulation. N Engl J Med, 2010; 362(13):1161–1163.
