Correlation of therapeutic pressure between home automatic positive airway pressure and in laboratory polysomnography manual titration in patients with obstructive sleep apnea

Apiwat Pugongchai; Kanyada Leelasittikul; Narongkorn Saiphoklang

doi:10.12688/f1000research.144758.1

Home Browse Correlation of therapeutic pressure between home automatic positive...

ALL Metrics

-

Views

-

Downloads

Get PDF

Get XML

Export

▬

✚

Research Article

Correlation of therapeutic pressure between home automatic positive airway pressure and in laboratory polysomnography manual titration in patients with obstructive sleep apnea

[version 1; peer review: 1 approved with reservations, 1 not approved]

Apiwat Pugongchai^1,2, Kanyada Leelasittikul^1,2, Narongkorn Saiphoklang ^1-3

PUBLISHED 27 Jun 2024

Author details Author details

¹ Medical Diagnostics Unit, Thammasat University Hospital, Pathum Thani, 12120, Thailand
² Sleep center of Thammasat, Thammasat University Hospital, Pathum Thani, 12120, Thailand
³ Internal Medicine, Thammasat University, Pathum Thani, 12120, Thailand

Apiwat Pugongchai
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Resources, Software, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Kanyada Leelasittikul
Roles: Conceptualization, Data Curation, Investigation, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Narongkorn Saiphoklang
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Software, Supervision, Validation, Visualization, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Background

Continuous positive airway pressure (CPAP) is an effective treatment for obstructive sleep apnea (OSA). Automatic positive airway pressure (APAP) at home might be an alternative choice to identify optimal treatment pressure for OSA patients requiring CPAP treatment. Data on the association of effective treatment pressure between laboratory polysomnography (in-lab PSG) and home APAP has been limited. The aim of this study was to determine the correlation of effective CPAP pressure between in-lab PSG and home APAP.

Methods

A prospective cohort study was conducted. OSA participants aged 18 years or older who required CPAP therapy were included. Patients underwent in-lab PSG with manual CPAP titration to identify an effective treatment pressure. Patients also underwent APAP at home for 2 weeks to identify 95 percentile treatment pressure as an effective pressure.

Results

Fifty OSA patients (82% male) were included. Mean age was 48.9±14.6 years. Body mass index was 28.7±6.1 kg/m². Polysomnographic data showed the effective treatment pressure of 10.4±2.9 cmH2O and the apnea-hypopnea index was 55.1±29.0 events/hour. Severe OSA was 76%. Home APAP data showed effective treatment pressure of 10.8±1.8 cmH2O. There was positive correlation of effective pressure between home APAP and in-lab PSG (r=0.472, P=0.001). The equation for predicting an in-lab effective pressure was: predicted pressure (cmH2O) = 2 + (home APAP ⁎ 0.78). Bland-Altman analysis showed good agreement between them, with a low mean difference of -0.428 cmH2O and 96% within the limit of agreement.

Conclusions

Home APAP pressure is moderately positively correlated with in-lab PSG effective pressure. The accuracy of home APAP is in agreement with in-lab PSG with manual CPAP titration. This APAP might be able to determine an effective therapeutic pressure in the sleep laboratory for OSA treatment.

Keywords

APAP, automatic positive airway pressure, continuous positive airway pressure, CPAP, obstructive sleep apnea, OSA

Corresponding author: Narongkorn Saiphoklang

Competing interests: No competing interests were disclosed.

Grant information: The financial support was provided by Thammasat University Hospital, Thailand.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Copyright: © 2024 Pugongchai A et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Pugongchai A, Leelasittikul K and Saiphoklang N. Correlation of therapeutic pressure between home automatic positive airway pressure and in laboratory polysomnography manual titration in patients with obstructive sleep apnea [version 1; peer review: 1 approved with reservations, 1 not approved]. F1000Research 2024, 13:699 (https://doi.org/10.12688/f1000research.144758.1) First published: 27 Jun 2024, 13:699 (https://doi.org/10.12688/f1000research.144758.1) Latest published: 27 Jun 2024, 13:699 (https://doi.org/10.12688/f1000research.144758.1)

Introduction

Obstructive sleep apnea (OSA) is a condition caused by obstruction of the upper airway during sleep and can occur at any age, but the incidence is highest in middle-aged individuals. This disease is more prevalent in males than females.¹^,² The main risk factor is obesity, which has been found in 70% of OSA patients.² Symptoms of OSA usually include snoring, gasping during sleep, excessive daytime sleepiness, and lack of concentration while working. Diagnosis of OSA relies on the patient's medical history, symptoms, and risk assessment from a sleep questionnaire. Polysomnography (PSG), also known as a sleep test, is the standardized tool for diagnosing OSA.³

Continuous positive airway pressure (CPAP) is a standard effective treatment for moderate to severe OSA.²^,⁴^,⁵ CPAP delivers air pressure through a mask into the airway to keep the airway open during sleep to prevent apnea.⁴^,⁵ There are two CPAP systems; 1) fixed-pressure or manual CPAP, and 2) automatic positive airway pressure (APAP). Fixed-pressure CPAP provides the optimal constant pressure determined by a full night CPAP titration in-laboratory PSG (in-lab PSG) or a split-night in-lab PSG. APAP provides multiple pressure levels, which can be adjusted automatically according to the patient's condition, detected by airflow resistance, body position, and nasal congestion. APAP can improve compliance and reduce daytime sleepiness better than fixed CPAP.⁴ Some previous studies have found no significant difference in treatment pressure between APAP and fixed-pressure CPAP,⁶^–¹² while other studies have reported significant differences in pressure.¹³^–²⁰ CPAP pressure titrated in-lab by an automatic device is usually higher than that titrated in-lab manually.¹⁶^,¹⁸^–²⁰ There are conflicting data and unclear results. Advantageously, home APAP titration is more cost-effective than manual laboratory titration to determine optimal CPAP pressure for long-term use.⁹ Therefore, the aim of this study was to evaluate the correlation of the effective CPAP pressure between in-lab PSG and home APAP in Thai patients with OSA.

Methods

Clinical trial registration

This study, entitled “Correlation of therapeutic pressure between home automatic positive airway pressure and in laboratory polysomnography manual titration in patients with obstructive sleep apnea”, was prospectively registered with Thaiclinicaltrials.org with number TCTR20210331002 on 31 March 2021. https://www.thaiclinicaltrials.org/export/xml/TCTR20210331002

Study design and population

A prospective cohort study was conducted in Thammasat University Hospital, Thailand from April 2021 to January 2022. Subjects with suspected OSA aged 18 years or older and undergoing split-night PSG were included. Exclusion criteria were congestive heart failure, myocardial infarction, obesity hypoventilation syndrome, chronic obstructive pulmonary disease, stroke, claustrophobia, tracheostomy, uncontrolled psychiatric disorders, and residual apnea-hypopnea index (AHI) of 5 events per hour or more during in-lab CPAP titration.

Demographic data including age, sex, height, weight, body mass index, neck circumference, Epworth sleepiness scale (ESS), comorbidity, and in-lab PSG data including AHI, lowest pulse oxygen saturation, 3%oxygen desaturation index, optimal CPAP pressure and residual AHI after optimal CPAP trial were recorded. Moreover, home auto-CPAP data including 95th percentile pressure, residual AHI after optimal CPAP use, and duration of CPAP use were also recorded.

Ethic approval was obtained from the Human Research Ethics Committee of Thammasat University (Medicine), Thailand (IRB No. MTU-EC-OO-6-087/63, the approval number: 142/2020, the date of approval on July 2, 2022), in full compliance with international guidelines such as the Declaration of Helsinki, the Belmont Report, CIOMS Guidelines, and the International Conference on Harmonisation-Good Clinical Practice (ICH-GCP). All methods were performed in accordance with these guidelines and regulations. All participants provided written informed consent. This study was registered with thaiclinicaltrials.org with number TCTR20210331002 on 31 March, 2021.

CPAP manual titration in laboratory PSG

All subjects underwent split-night PSG using Compumedics Profusion® Sleep Software (Compumedics, Ltd, Victoria, Australia, Available from: https://www.compumedics.com.au/en/products/profusion-sleep-software/). Titration and scoring procedures followed the American Academy of Sleep Medicine guideline version 2.6.²¹^,²² PSG data were manually scored by a certified sleep technician and were reviewed and verified by a certified a sleep specialist. CPAP titration was performed to determine a pressure to reduce the AHI to less than 5 events per hour and achieve a supine REM sleep duration of at least 15 minutes. CPAP was manually titrated with Resmed Lumis® 150 VPAP ST-A (Resmed, Sydney, Australia) in our sleep lab under full PSG monitoring that included electroencephalogram, electrooculogram, submental electromyogram, airflow from a thermistor, snoring, body position, thoracic and abdominal movements, and oxygen saturation. CPAP began at 4 cmH₂O and gradually increased by 1 cmH₂O steps every 10 min until apnea-hypopnea events disappeared. Optimal pressure, residual AHI, and all PSG data were also recorded.

Home APAP titration

All subjects used Resmed AirStart®10 APAP model (Resmed, Sydney, Australia) for a period of 2 weeks within 3 months after split-night PSG. APAP data were downloaded using ResScan® software version 5.9.0.9629 (Resmed, Sydney, Australia, Available from: https://support.resmed.com/en-gb/software-and-data-management/resscan/). An effective APAP pressure was the 95th percentile of the pressure results. An effective pressure, residual AHI, and all APAP data were also recorded. Good APAP compliance was defined as usage ≥4 hours per night for ≥70% of nights.²³

Statistical analysis

Based on a previous study,¹⁶ the optimal CPAP pressure determined by in-lab APAP titration in OSA patients was 9.8± 2.2 cmH₂O, whereas the optimal CPAP pressure determined by in-lab manual CPAP titration was 7.3 ± 1.5 cmH₂O. We hypothesized that the two titration methods in our study would provide optimal pressures like this previous study. Thus, we needed to study 34 participants with 90% power and 5% type I error.

Data is presented as number (%) and mean ± standard deviation (SD). Student’s t-test was used to compare continuous variables between in-lab PSG and home APAP groups. Pearson’s correlation was used to determine the relationship of optimal pressure between two groups and to develop a predictive equation of the optimal CPAP pressure of in-lab PSG. Bland-Altman plots were used to determine agreement between the optimal pressures obtained from in-lab PSG and home APAP. The 95% limits of agreement, which represent where 95% of the future differences between the two methods would be expected, were calculated. The proportional bias was also assessed by performing a linear regression between the difference between the two measures and mean pressure for paired measurement. Two-tailed P-values of less than 0.05 were considered statistically significant. All data analyses were done on SPSS version 26.0 software (IBM Corp., Armonk, NY, USA).

Results

A total of 55 subjects with suspected OSA were screened, and 5 subjects were excluded (Figure 1). Fifty OSA subjects were included. Mean age was 48.9±14.6 years. 82% of subjects were male. Body mass index was 28.7±6.1 kg/m². ESS score was 8.7±4.7. Common comorbidities were hypertension (40%), hyperlipidemia (44%), and allergic rhinitis (36%). PSG data showed AHI of 55.1±29.0 events/hour, optimal CPAP pressure of 10.4±2.9 cmH₂O, and residual AHI was 1.6±1.5 events/hour. 76% of patients had severe OSA. The effective pressure of home APAP was 10.8±1.8 cmH₂O, residual AHI was 1.5±1.0 events/hour and good APAP compliance was 58% (Table 1). There are no significant differences in the optimal pressure and the residual AHI between in-lab PSG and home APAP groups (Table 2).

Figure 1. Flowchart of recruitment to the study for patients with obstructive sleep apnea (OSA).

APAP=automatic positive airway pressure, CPAP=continuous positive airway pressure.

Table 1. Baseline characteristics of patients with obstructive sleep apnea.

Characteristics	Data (n=50)
Age, years	48.9±14.6
Male	41 (82)
BMI, kg/m²	28.7±6.1
Neck circumference, cm	39.3±4.4
ESS, points	8.7±4.7
Comorbidity
Hypertension	20 (40)
Dyslipidemia	22 (44)
Allergic rhinitis	18 (36)
Heart disease	5 (10)
Diabetes	9 (18.0)
Obesity	9 (18)
COPD	1 (2)
Stroke	1 (2)
Polysomnographic data
Total sleep time, minutes	378.0±59.6
Sleep efficiency, %	77.5±13.4
AHI, events/hour	55.1±29.0
Lowest SpO₂, %	80.7±10.7
3%ODI, events/hour	9.3±8.7
Optimal CPAP pressure, cmH₂O	10.4±2.9
Residual AHI after optimal CPAP trial, events/hour	1.6±1.5
OSA severity
Mild	2 (4)
Moderate	10 (20)
Severe	38 (76)
Home APAP titration data
95th percentile pressure, cmH₂O	10.8±1.8
Residual AHI after optimal CPAP use, events/hour	1.5±1.0
95th percentile mask leak, L/minute	22.7±13.3
CPAP use, hours/night	4.7±1.9
Good compliance	29 (58)

Table 2. Comparison of optimal pressure and residual AHI obtained from in-lab PSG and home APAP in patients with obstructive sleep apnea.

Parameters	In-lab PSG	Home APAP	P-value
Pressure, cmH₂O	10.4±2.9	10.8±1.8	0.252
Residual AHI, events/hour	1.6±1.5	1.5±1.0	0.457

In all patients, including severe OSA patients, the optimal pressure obtained by in-lab PSG had significant moderately positive correlation with the effective pressure obtained by the home APAP (Table 3). Overall, an equation for predicting in-lab PSG derived optimal pressure is predicted pressure (cmH₂O) = 2 + (0.78 ⁎ home APAP derived effective pressure) (Figure 2). The Bland-Altman comparison of the pressure obtained from in-lab PSG and the home APAP in all patients showed that there was very good agreement between them, with a low mean difference of -0.428 cmH₂O (95% CI: -5.548 to 4.692 cmH₂O) and only 2 of 50 measurements (4%) were outliers; 96% were within the limit of agreement (Figure 3). However, a proportional bias was detected (B = 0.648, P <0.001).

Table 3. Correlation of optimal pressure between in-lab PSG and home APAP in patients with obstructive sleep apnea.

Patients	Data (n=50)	Correlation coefficient	P-value
All	50 (100)	0.472	0.001
Good compliance	29 (58)	0.586	0.001
Poor compliance	21 (42)	0.340	0.132
Severe OSA	38 (76)	0.452	0.004
Good compliance	24 (63)	0.615	0.001
Poor compliance	14 (37)	0.116	0.693
Non-severe OSA	12 (24)	0.257	0.420
Good compliance	5 (42)	0.614	0.271
Poor compliance	7 (58)	0.015	0.975

Figure 2. Correlation of optimal pressure between manual continuous positive airway pressure (CPAP) titration in the lab and home automatic positive airway pressure (APAP) titration in patients with obstructive sleep apnea.

The equation for predicting an in-lab effective pressure is predicted pressure (cmH₂O) = 2 + (0.78* home APAP derived effective pressure).

Figure 3. The Bland-Altman plot represents the difference in optimal pressure between manual continuous positive airway pressure (CPAP) titration in the lab and home automatic positive airway pressure (APAP) titration in patients with obstructive sleep apnea.

The continuous line indicates the mean difference of optimal pressure between CPAP titration in the lab and home APAP titration (-0.428 cmH₂O), while the dotted lines indicate 95% confidence intervals (-5.548 to 4.692 cmH₂O). SD=standard deviation.

Furthermore, all patients and severe OSA patients with good APAP compliance had higher significant positive correlation than those without good compliance (Table 3). In patients with severe OSA, a predictive equation for the optimal pressure is in-lab PSG (cmH₂O) = 4.28 + (0.64 ⁎ home APAP derived effective pressure) (Figure 4). In OSA patients with good compliance, a predictive equation for the optimal pressure is in-lab PSG (cmH₂O) = 1.49 + (0.83* home APAP derived effective pressure) (Figure 5).

Figure 4. Correlation of optimal pressure between manual continuous positive airway pressure (CPAP) titration in the lab and home automatic positive airway pressure (APAP) titration in patients with severe OSA.

The equation for predicting an in-lab effective pressure is predicted pressure (cmH₂O) = 4.28 + (0.64* home APAP pressure).

Figure 5. Correlation of optimal pressure between manual continuous positive airway pressure (CPAP) titration in the lab and home automatic positive airway pressure (APAP) titration in OSA patients with good compliance.

The equation for predicting an in-lab effective pressure is predicted pressure (cmH₂O) = 1.49 + (0.83* home APAP pressure).

Discussion

This is the first study to determine the relationship of optimal CPAP pressure between in-lab pressure titration and home APAP in Thai patients with OSA. Our results showed that there was moderately positive correlation between the two titration methods with acceptable agreement, particularly for severe OSA patients with good APAP compliance. Also, the difference of mean optimal pressure between two methods was 0.4 cmH₂O in our study.

CPAP is a standard, effective treatment for OSA patients.²^,⁴ Conventionally, the optimal pressure for treating OSA is determined by a standard PSG with manual CPAP titration in a laboratory, whether split-night PSG or full-night PSG. The latter is often performed as a follow-up to the first PSG if the optimal pressure hasn't been successfully determined.³ However, this method is time consuming and expensive. Alternatively, automatic titration is recommended instead of manual titration to identify the proper pressure for CPAP treatment in clinical practice, providing the same outcome in less time for less expense.²⁴ Automatic titration is as effective as standard manual titration in improving AHI and somnolence. In addition, automatic titration has the same effect on acceptance and compliance of CPAP treatment as manual titration.²⁴ Therefore, home APAP is an alternative choice for determining the optimal pressure.

In our study, we hypothesized that the difference of optimal pressure between home APAP and in-lab PSG study would not be more than 2 cmH₂O. Our results showed an average pressure difference of 0.4 cmH₂O between the two methods and a moderately positive correlation (correlation coefficient of 0.47). These findings are consistent with a study by Elshahaat HA, et al⁶ and Wongsritrang K, et al,¹⁸ which found weakly to strongly positive correlations of optimal pressure between in-lab PSG and home APAP with pressure difference ranging from 0.25 to 3.5 cmH₂O. It can be observed that as the difference in the optimal pressure increases, the positive correlation between two titrating methods decreases. However, there might be a few limitations of the titrating study for optimal pressure due to differences in sleep position and sleep stages between home APAP and in-lab PSG settings. The optimal pressure obtained by in-lab PSG needs to maintain an AHI less than 5 events per hour and at least 15 minutes of REM sleep in the supine position,²² which might differ from the pressure requirements of home APAP machines due to differences in sleep posture and sleep stage.

Our results showed that the majority of patients had severe OSA (approximately 76%) while moderate and mild OSA accounted for 20% and 4%, respectively. Among patients with severe OSA, there was significant moderately positive correlation (correlation coefficient of 0.45) between the pressure from home APAP and in-lab PSG study. However, there was no significant correlation in patients with mild to moderate OSA. These findings may be explained by the small sample size of this population.

In OSA patients using home APAP with good compliance (approximately 58% of all patients), there was significant moderately positive correlation between the home APAP pressure and the pressure adjusted during the in-lab PSG study (correlation coefficient of 0.586), whereas there was no significant correlation in patients without good compliance. Moreover, there was greater moderately positive correlation in severe OSA patients with good compliance for home APAP, (correlation coefficient of 0.615). These findings indicate that regular home APAP use for OSA patients, especially severe OSA, leads to closer optimal pressure obtained from both titrating methods.

According to some previous studies, the effective pressure obtained by APAP and by in-lab PSG manual titration did not usually differ significantly.⁴^,⁶^–¹²^,¹⁸^,¹⁹^,²⁵ However, some studies did show differences in optimal pressures between them,¹⁴^–¹⁷ with the pressure obtained from an APAP being about 2.5 cmH₂O higher than that obtained from in-lab PSG manual titration.¹⁶ In contrast, some studies found that the pressure obtained from in-lab PSG manual titration was higher than that obtained from APAP.¹⁴^,¹⁷

When focusing on the compliance of CPAP use, some studies found that APAP had better compliance than manual CPAP,⁴^,¹²^,²⁵ with APAP used 11 statistically significant minutes longer than manual CPAP.⁴^,¹² However, several studies found no difference in compliance between APAP and manual CPAP.¹⁰^,¹²^,¹⁴^,¹⁵^,²⁶ Fietze I, et al found that APAP was used approximately 48 minutes longer than manual CPAP.¹⁰

Clinical outcomes after following APAP or CPAP uses did not differ in quality of life for OSA patients.¹⁰^,¹²^,¹⁷^,¹⁸ There was also no difference in Epworth sleepiness scale.¹¹^,¹²^,¹⁴ Moreover, the initial use of APAP improved the quality of sleep.¹⁰ Because APAP machines are more expensive than manual CPAP machines, cost should be considered before starting of positive airway pressure treatment.¹¹ Nevertheless, APAP is cost-effective because it saves time and reduces the expense of undergoing pressure analysis.⁶^,⁸^,⁹^,²⁷^,²⁸

There are a few limitations in our study. Firstly, the sample size was small, however study results could detect the correlation of the two titrating methods for optimal pressure. Secondly, only one commercial CPAP machine was investigated, therefore study results might not apply to another type of CPAP machine. A larger study with other types of CPAP machine is needed for comparison. Furthermore, the equation for predicting in-lab PSG effective pressure is required to verify the accuracy of the optimal pressure obtained by home APAP.

Conclusions

Home APAP pressure is moderately positively correlated with in-lab PSG effective pressure. The optimum pressures of home APAP agree with in-lab PSG with manual CPAP titration. APAP might be able to determine effective therapeutic pressure for OSA treatment in the sleep laboratory. A large prospective study is needed to verify the accuracy of home APAP effective pressure for OSA patients and to determine the predictive equation for detecting in-lab PSG effective pressure.

Registration

thaiclinicaltrials.org with number TCTR20210331002

Data availability statement

Underlying data

Figshare: Correlation of therapeutic pressure between home automatic positive airway pressure and in laboratory polysomnography manual titration in patients with obstructive sleep apnea. https://doi.org/10.6084/m9.figshare.24503671.v3.²⁹

The project contains the following underlying data: OSA_TUH.xlsx

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Reporting guidelines

Figshare: CONSORT checklist for ‘Correlation of therapeutic pressure between home automatic positive airway pressure and in laboratory polysomnography manual titration in patients with obstructive sleep apnea’. https://doi.org/10.6084/m9.figshare.26010529.v1.³⁰

Data are available under the terms of the Creative Commons Zero license (CC0).

Acknowledgements

The authors would like to thank Michael Jan Everts, Faculty of Medicine, Thammasat University, for proofreading this manuscript. This work was supported by Thammasat University Research Unit in Allergy and Respiratory Medicine, and Medical Diagnostics Unit, Thammasat University Hospital, Thailand.

References

1. Jordan AS, McSharry DG, Malhotra A: Adult obstructive sleep apnoea. Lancet. 2014; 383(9918): 736–747. Publisher Full Text
2. Spicuzza L, Caruso D, Di Maria G: Obstructive sleep apnoea syndrome and its management. Ther Adv Chronic Dis. 2015; 6(5): 273–285. Publisher Full Text
3. Kapur VK, Auckley DH, Chowdhuri S, et al.: Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: An American Academy of Sleep Medicine clinical practice guideline. J. Clin. Sleep Med. 2017; 13(3): 479–504. Publisher Full Text
4. Ip S, D'Ambrosio C, Patel K, et al.: Auto-titrating versus fixed continuous positive airway pressure for the treatment of obstructive sleep apnea: a systematic review with meta-analyses. Syst. Rev. 2012; 1: 20. Publisher Full Text
5. Donovan LM, Boeder S, Malhotra A, et al.: New developments in the use of positive airway pressure for obstructive sleep apnea. J. Thorac. Dis. 2015; 7(8): 1323–1342.
6. Elshahaat HA, Mahfouz TAE, Elshora AE, et al.: Different continuous positive airway pressure titration modalities in obstructive sleep apnea syndrome patients. Int J Gen Med. 2021; 14: 10103–10115. Publisher Full Text
7. Kim H, Lee M, Hwangbo Y, et al.: Automatic derivation of continuous positive airway pressure settings: comparison with in-laboratory titration. J. Clin. Neurol. 2020; 16(2): 314–320. Publisher Full Text
8. Shaarawy H, Gharraf HS: Comparison between the use of APAP and manual titration during split night polysomnography for diagnosis and treatment of OSA. The Egyptian Journal of Chest Diseases and Tuberculosis. 2018; 67(2): 181–194. Publisher Full Text
9. McArdle N, Singh B, Murphy M, et al.: Continuous positive airway pressure titration for obstructive sleep apnoea: automatic versus manual titration. Thorax. 2010; 65(7): 606–611. Publisher Full Text
10. Fietze I, Glos M, Moebus I, et al.: Automatic pressure titration with APAP is as effective as manual titration with CPAP in patients with obstructive sleep apnea. Respiration. 2007; 74(3): 279–286. Publisher Full Text
11. Resta O, Carratu P, Depalo A, et al.: Effects of fixed compared to automatic CPAP on sleep in Obstructive Sleep Apnoea Syndrome. Monaldi Arch. Chest Dis. 2004; 61(3): 153–156.
12. Hukins C: Comparative study of autotitrating and fixed-pressure CPAP in the home: a randomized, single-blind crossover trial. Sleep. 2004; 27(8): 1512–1517. Publisher Full Text
13. Sharma S, Wali S, Pouliot Z, et al.: Treatment of obstructive sleep apnea with a self-titrating continuous positive airway pressure (CPAP) system. Sleep. 1996; 19(6): 497–501. Publisher Full Text
14. Ayas NT, Patel SR, Malhotra A, et al.: Auto-titrating versus standard continuous positive airway pressure for the treatment of obstructive sleep apnea: results of a meta-analysis. Sleep. 2004; 27(2): 249–253. Publisher Full Text
15. Hussain SF, Love L, Burt H, et al.: A randomized trial of auto-titrating CPAP and fixed CPAP in the treatment of obstructive sleep apnea-hypopnea. Respir. Med. 2004; 98(4): 330–333. Publisher Full Text
16. Luo J, Xiao S, Qiu Z, et al.: Comparison of manual versus automatic continuous positive airway pressure titration and the development of a predictive equation for therapeutic continuous positive airway pressure in Chinese patients with obstructive sleep apnoea. Respirology. 2013; 18(3): 528–533. Publisher Full Text
17. Chang ET, Shen YC, Wang HM: Comparison of improvement in quality of life between continuous positive airway pressure and autotitrating positive airway pressure treatment for obstructive sleep apnea: A randomized crossover study. Tzu Chi Medical Journal. 2015; 27(3): 110–112. Publisher Full Text
18. Wongsritrang K, Fueangkamloon S: Comparison of the clinical outcomes between unattended home APAP and polysomnography manual titration in obstructive sleep apnea patients. J. Med. Assoc. Thail. 2013; 96(9): 1159–1163.
19. Gan WL, Ban AYL, Mohamed Faisal AH: Comparing fixed and auto adjusting continuous positive airway pressure (CPAP) amongst symptomatic Obstructive Sleep Apnoea patients - A randomised controlled trial. Med J Malaysia. 2021; 76(5): 611–616.
20. Lu DX, Wu HG, Luo JY, et al.: Comparison of manual versus automatic titration in pressure determination for long-term therapy of continuous positive airway pressure in patients with obstructive sleep apnea hypopnea syndrome. Zhonghua Yi Xue Za Zhi. 2013; 93(36): 2898–2900.
21. Berry R, Quan S, Abreu A, et al.: The AASM manual for the scoring of sleep and associated events: Rules, terminology and technical specifications, Version 2.6. Darien, IL: American Academy of Sleep Medicine; 2020.
22. Kushida CA, Chediak A, Berry RB, 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.
23. Kribbs NB, Pack AI, Kline LR, et al.: Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. Am. Rev. Respir. Dis. 1993; 147(4): 887–895. Publisher Full Text
24. Gao W, Jin Y, Wang Y, et al.: Is automatic CPAP titration as effective as manual CPAP titration in OSAHS patients? A meta-analysis. Sleep Breath. 2012; 16(2): 329–340. Publisher Full Text
25. Tingting X, Danming Y, Xin C: Non-surgical treatment of obstructive sleep apnea syndrome. Eur. Arch. Otorrinolaringol. 2018; 275(2): 335–346. Publisher Full Text
26. Tovichien P, Kulbun A, Udomittipong K: Comparing adherence of continuous and automatic positive airway pressure (CPAP and APAP) in obstructive sleep apnea (OSA) children. Front. Pediatr. 2022; 10: 841705. Publisher Full Text
27. Braghiroli A, Insalaco G, Esquinas AM: Auto-CPAP: saving money as a single tool for OSA. Sleep Breath. 2016; 20(1): 249–250. Publisher Full Text
28. Krieger J: Therapeutic use of auto-CPAP. Sleep Med. Rev. 1999; 3(2): 159–174. Publisher Full Text
29. Saiphoklang N: Correlation of therapeutic pressure between home automatic positive airway pressure and in laboratory polysomnography manual titration in patients with obstructive sleep apnea. [Dataset]. figshare. 2023. Publisher Full Text
30. Saiphoklang N: Correlation of therapeutic pressure between home automatic positive airway pressure and in laboratory polysomnography manual titration in patients with obstructive sleep apnea. figshare. 2024. Publisher Full Text

Comments on this article Comments (0)

Version 1

VERSION 1 PUBLISHED 27 Jun 2024

Author details Author details

¹ Medical Diagnostics Unit, Thammasat University Hospital, Pathum Thani, 12120, Thailand
² Sleep center of Thammasat, Thammasat University Hospital, Pathum Thani, 12120, Thailand
³ Internal Medicine, Thammasat University, Pathum Thani, 12120, Thailand

Apiwat Pugongchai
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Resources, Software, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Kanyada Leelasittikul
Roles: Conceptualization, Data Curation, Investigation, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Narongkorn Saiphoklang
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Software, Supervision, Validation, Visualization, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

The financial support was provided by Thammasat University Hospital, Thailand.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Article Versions (1)

version 1

Published: 27 Jun 2024, 13:699

https://doi.org/10.12688/f1000research.144758.1

Copyright

© 2024 Pugongchai A et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Download

Export To

metrics

	Views	Downloads
F1000Research	-	-
PubMed Central Data from PMC are received and updated monthly.	-	-

Citations

0

SEE MORE DETAILS

CITE

how to cite this article

Pugongchai A, Leelasittikul K and Saiphoklang N. Correlation of therapeutic pressure between home automatic positive airway pressure and in laboratory polysomnography manual titration in patients with obstructive sleep apnea [version 1; peer review: 1 approved with reservations, 1 not approved]. F1000Research 2024, 13:699 (https://doi.org/10.12688/f1000research.144758.1)

NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.

track

receive updates on this article

Track an article to receive email alerts on any updates to this article.

Open Peer Review

Version 1

VERSION 1

PUBLISHED 27 Jun 2024

Views

6

Reviewer Report 06 Feb 2025

Krishna Sundar, Division of Pulmonary and Critical Care Medicine,, The University of Utah, Salt Lake City, Utah, USA

Katyayini Aribindi, University of California Davis School of Medicine (Ringgold ID: 12218), Sacramento, California, USA

Not Approved

https://doi.org/10.5256/f1000research.158598.r356153

This study looked at effective CPAP pressures for managing OSA in 55 patients seen at Thammasat University Hospital, Thailand that underwent split night PSG and then were placed on AutoPAP Resmed S10 for 2 weeks. The PAP pressure obtained from ... Continue reading

This study looked at effective CPAP pressures for managing OSA in 55 patients seen at Thammasat University Hospital, Thailand that underwent split night PSG and then were placed on AutoPAP Resmed S10 for 2 weeks. The PAP pressure obtained from the split night study was compared with 95^th percentile pressures obtained from APAP downloads. Following are the major and minor concerns with this study.
Major concerns

Methodology needs considerable clarification. This study is mentioned as a prospective cohort study although there is only one set of patients. It is not clear how patients were screened or selected for enrolment into this study except that the study was done between April 2021 and January 2022. There were 50 patients selected and out of this, majority had moderate or severe OSA (48/50) but 2/50 had mild OSA, so it is not clear what criteria was used to split these patients. There is mention of at least 15 minutes of supine REM sleep required during titration and it is not clarified whether this was met in all patients. There needs to be mention of the quality of titration based on AASM’s manual titration clinical guidelines.
Good compliance was defined as usage of CPAP for more than 70% of nights for 4 hours or more and while this definition has been widely used within clinical care, there are studies that have shown improvements with higher durations of PAP use. Whether this degree of CPAP usage for a period of 2 weeks is sufficient to determine optimal PAP pressures on an APAP machine is also not clear. Table 3 outlines the proportion of patients that did not meet the optimal defined compliance criteria – approximately 42% of patients had poor compliance. Additionally, in table 1, the leak values are close to the threshold for the degree of leak that is considered significant (24L/min for Resmed devices) being at 22.7±13.3L/min. The accuracy of assessing optimal pressures can significantly decrease with total leak and it is not mentioned what the individual leak values were and how they affected the AHI_flowobtained from autoPAP machines.
The power calculation used for determining the number of subjects for assessing significant differences are based on a prior similar study of 51 subjects where a similar protocol was followed. However, in this reference provided, the APAP pressures were higher than the manual titration pressures but details of how data from this study was used to generate the number of 34 patients (to determine differences at 90% power and 5% type I error) is not provided.
This study compared 95^th percentile APAP pressures and CPAP pressures determined using manual titration 2 weeks prior to initiating CPAP but how much time elapsed between the manual titration and initiation of autoPAP is not provided. Authors have used multiple ways to compared pressure values between two groups – the t test that did not show any significant differences and Pearson correlation coefficients and Bland-Altman plots. In terms of the values of correlation coefficients, authors have used terms such as “moderately positive” to describe correlation coefficients of 0.58-0.61 in the good compliance group whereas these correlation coefficients should be much higher. In terms of Bland-Altman’s degrees of agreement, while the mean differences are small, the 95% confidence intervals result in values being in much bigger pressure ranges of up to -5.4 to 4.9cm. From an individual patient standpoint, for almost 20 patients, the pressure values between manual titration and autoPAP 95^th percentile pressures differ by 2cm or more. This has been observed in other studies and discussed in the meta-analysis (Iftikhar et al. Sleep and Breathing 2023;27:1759). The authors need to discuss the implications of such individual differences in pressures seen with autoPAP downloads as compared to the pressures determined by manual titration.
Depending on the degree of compliance with AutoPAP, authors have created different groups of patients to assess how correlation coefficients differ, and the poor compliance group had much lower correlation coefficients as compared to those with compliance. Were these the patients that had greater differences between APAP and manual titration pressures? This needs to be discussed. Also had this poor compliance been accounted for (which is significant in ALL patients starting PAP therapy), the initial power calculations would have indicated a need for enrolling twice the number of patients.
Other details need to be provided. Was EPR used during therapy? Were all patients initiated on same autoPAP pressure range for 2 weeks? How severe was the COPD in the one patient that was included? Were obese patients put on higher autoPAP range of pressures?

Minor criteria
Language and grammar need to improve significantly. Some of suggested changes include the following
Abstract – in Methods, last line 95^th instead of 95 percentile. In results, instead of “Severe OSA was 75%”, it should be that “75% of patients had severe OSA”. Bland-Altman plot showed good agreement between “them” (what is them?). Conclusions regarding “home APAP is in agreement with manual CPAP titration and that home APAP might be able to determine effective pressure” needs to reworded.
Manuscript – In introduction, OSA is caused by “dynamic obstruction” during sleep rather than just obstruction. Polysomnography “also known as sleep test” can be omitted.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests: Prior consultant for Resmed Inc till 2022

Reviewer Expertise: Intermittent hypoxia,

We confirm that we have read this submission and believe that we have an appropriate level of expertise to state that we do not consider it to be of an acceptable scientific standard, for reasons outlined above.

CITE

Report a concern

Respond or Comment

Views

13

Reviewer Report 23 Aug 2024

Matthew Rahimi, Sleep group, Woolcock Institute of Medical Research (Ringgold ID: 104349), Macquarie Park, New South Wales, Australia

Fraser Lowrie, Faculty of Medicine and Health, The University of Sydney (Ringgold ID: 4334), Sydney, New South Wales, Australia

Approved with Reservations

https://doi.org/10.5256/f1000research.158598.r313793

Title: Correlation of therapeutic pressure between home automatic positive airway pressure and in laboratory polysomnography manual titration in patients with obstructive sleep apnea

Thank you for the opportunity to review the above journal article.

... Continue reading

Title: Correlation of therapeutic pressure between home automatic positive airway pressure and in laboratory polysomnography manual titration in patients with obstructive sleep apnea

Thank you for the opportunity to review the above journal article.

This prospective cohort study investigates the correlation between optimal CPAP pressures determined through home Automatic Positive Airway Pressure (APAP) and those obtained through in-laboratory Polysomnography (PSG) with manual CPAP titration. The authors aim to assess the agreement between these two methods and explore the potential of home APAP as a reliable tool for identifying effective treatment pressure for obstructive sleep apnea (OSA). The study included 50 OSA patients who underwent both in-lab PSG with manual CPAP titration and home APAP therapy for two weeks. The authors analysed data on demographics, clinical characteristics, PSG findings (AHI, optimal CPAP pressure), and home APAP effectiveness (effective pressure, residual AHI, compliance). Bland-Altman plots and linear regression analysis were used to assess the agreement between the two methods.

I commend the authors in writing a concise and easy-to-read manuscript. The strength of the study was its relevant research question and clear methodology.

The Paper would perhaps benefit from providing a clearer rationale in terms why the comparison between PSG and APAP is clinically relevant and how it could impact patient care. Although the objective has been mentioned clearly, the authors could consider a brief mention of their hypothesis in the introduction.

The authors have calculated the study’s sample size based on a previous study which then determined a sample size of 34 was needed to complete the study. Although the study finished with 50 participants. Was there a reason data collection did not stop at 34 participants? Perhaps a brief explanation of why the study over-recruited would improve the paper.

The trial registration lists the timepoint of the home APAP pressure as ‘at 1 week’. This does not seem to match the description of the methods for this outcome in the paper. Could this be elaborated on?

Did the analysis account for any potential confounding factors (e.g. sleep position or body mass index (BMI))?

The authors have provided the correlation of optimal pressure between in-lab PSG and home APAP in table 3. Could the authors perhaps consider discussing what level of correlation would be considered strong enough to justify using the at home APAP rather than in-lab PSG titration studies?

Table 1 shows data for n=50 patients. However, it includes data on comorbidities that have been listed as exclusion criteria (e.g. stroke, COPD). Please clarify this data.

In the discussion the authors have done an excellent job of interpreting the data. However, they could briefly discuss whether the study's findings are generalisable to all patients with OSA or if they are specific to the demographic and clinical characteristics of the study sample.

The discussion of clinical significance of the findings are somewhat broad. The author could provide more specific recommendations for how APAP devices could be integrated into clinical practice; for example, they could suggest criteria for selecting patients who might be good candidates for APAP titration based on the observed correlations. The finding of 11 minutes difference in compliance may be statistically significant, but is it clinically significant?

Compliance is the main drawback of CPAP therapy. How does the APAP compliance data in this study compare with the literature? Do the authors think that this may impact their findings?

Overall, the study provides an important clinical question and valuable data. The paper could be strengthened by providing more detailed explanations in the methods and results sections, particularly regarding the increase in sample size and the potential impact on the study's validity. I would suggest performing a post-hoc power analysis given the increased sample size or conduct additional analyses to confirm that the larger sample did not introduce biases.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Sleep medicine, Clinical trials, Digital health, OSA physiology

We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above.

CITE

Report a concern

Respond or Comment

Comments on this article Comments (0)

Version 1

VERSION 1 PUBLISHED 27 Jun 2024

Open Peer Review

Reviewer Status

Reviewer Reports

	Invited Reviewers
	1	2
Version 1 27 Jun 24	read	read

Matthew Rahimi, Woolcock Institute of Medical Research (Ringgold ID: 104349), Macquarie Park, Australia

Fraser Lowrie, The University of Sydney (Ringgold ID: 4334), Sydney, Australia
Krishna Sundar, The University of Utah, Salt Lake City, USA

Katyayini Aribindi, University of California Davis School of Medicine (Ringgold ID: 12218), Sacramento, USA

Comments on this article

All Comments(0)

Add a comment

Sign up for content alerts

Browse by related subjects

Back to all reports

Reviewer Report

6 Views

06 Feb 2025 | for Version 1

Krishna Sundar, Division of Pulmonary and Critical Care Medicine,, The University of Utah, Salt Lake City, Utah, USA

Katyayini Aribindi, University of California Davis School of Medicine (Ringgold ID: 12218), Sacramento, California, USA

6 Views Cite this report Responses(0)

Not Approved

This study looked at effective CPAP pressures for managing OSA in 55 patients seen at Thammasat University Hospital, Thailand that underwent split night PSG and then were placed on AutoPAP Resmed S10 for 2 weeks. The PAP pressure obtained from the split night study was compared with 95^th percentile pressures obtained from APAP downloads. Following are the major and minor concerns with this study.
Major concerns

Methodology needs considerable clarification. This study is mentioned as a prospective cohort study although there is only one set of patients. It is not clear how patients were screened or selected for enrolment into this study except that the study was done between April 2021 and January 2022. There were 50 patients selected and out of this, majority had moderate or severe OSA (48/50) but 2/50 had mild OSA, so it is not clear what criteria was used to split these patients. There is mention of at least 15 minutes of supine REM sleep required during titration and it is not clarified whether this was met in all patients. There needs to be mention of the quality of titration based on AASM’s manual titration clinical guidelines.
Good compliance was defined as usage of CPAP for more than 70% of nights for 4 hours or more and while this definition has been widely used within clinical care, there are studies that have shown improvements with higher durations of PAP use. Whether this degree of CPAP usage for a period of 2 weeks is sufficient to determine optimal PAP pressures on an APAP machine is also not clear. Table 3 outlines the proportion of patients that did not meet the optimal defined compliance criteria – approximately 42% of patients had poor compliance. Additionally, in table 1, the leak values are close to the threshold for the degree of leak that is considered significant (24L/min for Resmed devices) being at 22.7±13.3L/min. The accuracy of assessing optimal pressures can significantly decrease with total leak and it is not mentioned what the individual leak values were and how they affected the AHI_flowobtained from autoPAP machines.
The power calculation used for determining the number of subjects for assessing significant differences are based on a prior similar study of 51 subjects where a similar protocol was followed. However, in this reference provided, the APAP pressures were higher than the manual titration pressures but details of how data from this study was used to generate the number of 34 patients (to determine differences at 90% power and 5% type I error) is not provided.
This study compared 95^th percentile APAP pressures and CPAP pressures determined using manual titration 2 weeks prior to initiating CPAP but how much time elapsed between the manual titration and initiation of autoPAP is not provided. Authors have used multiple ways to compared pressure values between two groups – the t test that did not show any significant differences and Pearson correlation coefficients and Bland-Altman plots. In terms of the values of correlation coefficients, authors have used terms such as “moderately positive” to describe correlation coefficients of 0.58-0.61 in the good compliance group whereas these correlation coefficients should be much higher. In terms of Bland-Altman’s degrees of agreement, while the mean differences are small, the 95% confidence intervals result in values being in much bigger pressure ranges of up to -5.4 to 4.9cm. From an individual patient standpoint, for almost 20 patients, the pressure values between manual titration and autoPAP 95^th percentile pressures differ by 2cm or more. This has been observed in other studies and discussed in the meta-analysis (Iftikhar et al. Sleep and Breathing 2023;27:1759). The authors need to discuss the implications of such individual differences in pressures seen with autoPAP downloads as compared to the pressures determined by manual titration.
Depending on the degree of compliance with AutoPAP, authors have created different groups of patients to assess how correlation coefficients differ, and the poor compliance group had much lower correlation coefficients as compared to those with compliance. Were these the patients that had greater differences between APAP and manual titration pressures? This needs to be discussed. Also had this poor compliance been accounted for (which is significant in ALL patients starting PAP therapy), the initial power calculations would have indicated a need for enrolling twice the number of patients.
Other details need to be provided. Was EPR used during therapy? Were all patients initiated on same autoPAP pressure range for 2 weeks? How severe was the COPD in the one patient that was included? Were obese patients put on higher autoPAP range of pressures?

Minor criteria
Language and grammar need to improve significantly. Some of suggested changes include the following
Abstract – in Methods, last line 95^th instead of 95 percentile. In results, instead of “Severe OSA was 75%”, it should be that “75% of patients had severe OSA”. Bland-Altman plot showed good agreement between “them” (what is them?). Conclusions regarding “home APAP is in agreement with manual CPAP titration and that home APAP might be able to determine effective pressure” needs to reworded.
Manuscript – In introduction, OSA is caused by “dynamic obstruction” during sleep rather than just obstruction. Polysomnography “also known as sleep test” can be omitted.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests

Prior consultant for Resmed Inc till 2022

Reviewer Expertise

Intermittent hypoxia,

We confirm that we have read this submission and believe that we have an appropriate level of expertise to state that we do not consider it to be of an acceptable scientific standard, for reasons outlined above.

Respond to this report

Responses (0)

Back to all reports

Reviewer Report

13 Views

23 Aug 2024 | for Version 1

Matthew Rahimi, Sleep group, Woolcock Institute of Medical Research (Ringgold ID: 104349), Macquarie Park, New South Wales, Australia

Fraser Lowrie, Faculty of Medicine and Health, The University of Sydney (Ringgold ID: 4334), Sydney, New South Wales, Australia

13 Views Cite this report Responses(0)

Approved With Reservations

Title: Correlation of therapeutic pressure between home automatic positive airway pressure and in laboratory polysomnography manual titration in patients with obstructive sleep apnea

Thank you for the opportunity to review the above journal article.

This prospective cohort study investigates the correlation between optimal CPAP pressures determined through home Automatic Positive Airway Pressure (APAP) and those obtained through in-laboratory Polysomnography (PSG) with manual CPAP titration. The authors aim to assess the agreement between these two methods and explore the potential of home APAP as a reliable tool for identifying effective treatment pressure for obstructive sleep apnea (OSA). The study included 50 OSA patients who underwent both in-lab PSG with manual CPAP titration and home APAP therapy for two weeks. The authors analysed data on demographics, clinical characteristics, PSG findings (AHI, optimal CPAP pressure), and home APAP effectiveness (effective pressure, residual AHI, compliance). Bland-Altman plots and linear regression analysis were used to assess the agreement between the two methods.

I commend the authors in writing a concise and easy-to-read manuscript. The strength of the study was its relevant research question and clear methodology.

The Paper would perhaps benefit from providing a clearer rationale in terms why the comparison between PSG and APAP is clinically relevant and how it could impact patient care. Although the objective has been mentioned clearly, the authors could consider a brief mention of their hypothesis in the introduction.

The authors have calculated the study’s sample size based on a previous study which then determined a sample size of 34 was needed to complete the study. Although the study finished with 50 participants. Was there a reason data collection did not stop at 34 participants? Perhaps a brief explanation of why the study over-recruited would improve the paper.

The trial registration lists the timepoint of the home APAP pressure as ‘at 1 week’. This does not seem to match the description of the methods for this outcome in the paper. Could this be elaborated on?

Did the analysis account for any potential confounding factors (e.g. sleep position or body mass index (BMI))?

The authors have provided the correlation of optimal pressure between in-lab PSG and home APAP in table 3. Could the authors perhaps consider discussing what level of correlation would be considered strong enough to justify using the at home APAP rather than in-lab PSG titration studies?

Table 1 shows data for n=50 patients. However, it includes data on comorbidities that have been listed as exclusion criteria (e.g. stroke, COPD). Please clarify this data.

In the discussion the authors have done an excellent job of interpreting the data. However, they could briefly discuss whether the study's findings are generalisable to all patients with OSA or if they are specific to the demographic and clinical characteristics of the study sample.

The discussion of clinical significance of the findings are somewhat broad. The author could provide more specific recommendations for how APAP devices could be integrated into clinical practice; for example, they could suggest criteria for selecting patients who might be good candidates for APAP titration based on the observed correlations. The finding of 11 minutes difference in compliance may be statistically significant, but is it clinically significant?

Compliance is the main drawback of CPAP therapy. How does the APAP compliance data in this study compare with the literature? Do the authors think that this may impact their findings?

Overall, the study provides an important clinical question and valuable data. The paper could be strengthened by providing more detailed explanations in the methods and results sections, particularly regarding the increase in sample size and the potential impact on the study's validity. I would suggest performing a post-hoc power analysis given the increased sample size or conduct additional analyses to confirm that the larger sample did not introduce biases.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Sleep medicine, Clinical trials, Digital health, OSA physiology

We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above.

Respond to this report

Responses (0)

[1] 1. Jordan AS, McSharry DG, Malhotra A: Adult obstructive sleep apnoea. Lancet. 2014; 383(9918): 736–747. Publisher Full Text

[2] 2. Spicuzza L, Caruso D, Di Maria G: Obstructive sleep apnoea syndrome and its management. Ther Adv Chronic Dis. 2015; 6(5): 273–285. Publisher Full Text

[3] 3. Kapur VK, Auckley DH, Chowdhuri S, et al.: Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: An American Academy of Sleep Medicine clinical practice guideline. J. Clin. Sleep Med. 2017; 13(3): 479–504. Publisher Full Text

[4] 4. Ip S, D'Ambrosio C, Patel K, et al.: Auto-titrating versus fixed continuous positive airway pressure for the treatment of obstructive sleep apnea: a systematic review with meta-analyses. Syst. Rev. 2012; 1: 20. Publisher Full Text

[5] 5. Donovan LM, Boeder S, Malhotra A, et al.: New developments in the use of positive airway pressure for obstructive sleep apnea. J. Thorac. Dis. 2015; 7(8): 1323–1342.

[6] 6. Elshahaat HA, Mahfouz TAE, Elshora AE, et al.: Different continuous positive airway pressure titration modalities in obstructive sleep apnea syndrome patients. Int J Gen Med. 2021; 14: 10103–10115. Publisher Full Text

[7] 7. Kim H, Lee M, Hwangbo Y, et al.: Automatic derivation of continuous positive airway pressure settings: comparison with in-laboratory titration. J. Clin. Neurol. 2020; 16(2): 314–320. Publisher Full Text

[8] 8. Shaarawy H, Gharraf HS: Comparison between the use of APAP and manual titration during split night polysomnography for diagnosis and treatment of OSA. The Egyptian Journal of Chest Diseases and Tuberculosis. 2018; 67(2): 181–194. Publisher Full Text

[9] 9. McArdle N, Singh B, Murphy M, et al.: Continuous positive airway pressure titration for obstructive sleep apnoea: automatic versus manual titration. Thorax. 2010; 65(7): 606–611. Publisher Full Text

[10] 10. Fietze I, Glos M, Moebus I, et al.: Automatic pressure titration with APAP is as effective as manual titration with CPAP in patients with obstructive sleep apnea. Respiration. 2007; 74(3): 279–286. Publisher Full Text

[11] 11. Resta O, Carratu P, Depalo A, et al.: Effects of fixed compared to automatic CPAP on sleep in Obstructive Sleep Apnoea Syndrome. Monaldi Arch. Chest Dis. 2004; 61(3): 153–156.

[12] 12. Hukins C: Comparative study of autotitrating and fixed-pressure CPAP in the home: a randomized, single-blind crossover trial. Sleep. 2004; 27(8): 1512–1517. Publisher Full Text

[13] 13. Sharma S, Wali S, Pouliot Z, et al.: Treatment of obstructive sleep apnea with a self-titrating continuous positive airway pressure (CPAP) system. Sleep. 1996; 19(6): 497–501. Publisher Full Text

[14] 14. Ayas NT, Patel SR, Malhotra A, et al.: Auto-titrating versus standard continuous positive airway pressure for the treatment of obstructive sleep apnea: results of a meta-analysis. Sleep. 2004; 27(2): 249–253. Publisher Full Text

[15] 15. Hussain SF, Love L, Burt H, et al.: A randomized trial of auto-titrating CPAP and fixed CPAP in the treatment of obstructive sleep apnea-hypopnea. Respir. Med. 2004; 98(4): 330–333. Publisher Full Text

[16] 16. Luo J, Xiao S, Qiu Z, et al.: Comparison of manual versus automatic continuous positive airway pressure titration and the development of a predictive equation for therapeutic continuous positive airway pressure in Chinese patients with obstructive sleep apnoea. Respirology. 2013; 18(3): 528–533. Publisher Full Text

[17] 17. Chang ET, Shen YC, Wang HM: Comparison of improvement in quality of life between continuous positive airway pressure and autotitrating positive airway pressure treatment for obstructive sleep apnea: A randomized crossover study. Tzu Chi Medical Journal. 2015; 27(3): 110–112. Publisher Full Text

[18] 18. Wongsritrang K, Fueangkamloon S: Comparison of the clinical outcomes between unattended home APAP and polysomnography manual titration in obstructive sleep apnea patients. J. Med. Assoc. Thail. 2013; 96(9): 1159–1163.

[19] 19. Gan WL, Ban AYL, Mohamed Faisal AH: Comparing fixed and auto adjusting continuous positive airway pressure (CPAP) amongst symptomatic Obstructive Sleep Apnoea patients - A randomised controlled trial. Med J Malaysia. 2021; 76(5): 611–616.

[20] 20. Lu DX, Wu HG, Luo JY, et al.: Comparison of manual versus automatic titration in pressure determination for long-term therapy of continuous positive airway pressure in patients with obstructive sleep apnea hypopnea syndrome. Zhonghua Yi Xue Za Zhi. 2013; 93(36): 2898–2900.

[21] 21. Berry R, Quan S, Abreu A, et al.: The AASM manual for the scoring of sleep and associated events: Rules, terminology and technical specifications, Version 2.6. Darien, IL: American Academy of Sleep Medicine; 2020.

[22] 22. Kushida CA, Chediak A, Berry RB, 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.

[23] 23. Kribbs NB, Pack AI, Kline LR, et al.: Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. Am. Rev. Respir. Dis. 1993; 147(4): 887–895. Publisher Full Text

[24] 24. Gao W, Jin Y, Wang Y, et al.: Is automatic CPAP titration as effective as manual CPAP titration in OSAHS patients? A meta-analysis. Sleep Breath. 2012; 16(2): 329–340. Publisher Full Text

[25] 25. Tingting X, Danming Y, Xin C: Non-surgical treatment of obstructive sleep apnea syndrome. Eur. Arch. Otorrinolaringol. 2018; 275(2): 335–346. Publisher Full Text

[26] 26. Tovichien P, Kulbun A, Udomittipong K: Comparing adherence of continuous and automatic positive airway pressure (CPAP and APAP) in obstructive sleep apnea (OSA) children. Front. Pediatr. 2022; 10: 841705. Publisher Full Text

[27] 27. Braghiroli A, Insalaco G, Esquinas AM: Auto-CPAP: saving money as a single tool for OSA. Sleep Breath. 2016; 20(1): 249–250. Publisher Full Text

[28] 28. Krieger J: Therapeutic use of auto-CPAP. Sleep Med. Rev. 1999; 3(2): 159–174. Publisher Full Text

[29] 29. Saiphoklang N: Correlation of therapeutic pressure between home automatic positive airway pressure and in laboratory polysomnography manual titration in patients with obstructive sleep apnea. [Dataset]. figshare. 2023. Publisher Full Text

[30] 30. Saiphoklang N: Correlation of therapeutic pressure between home automatic positive airway pressure and in laboratory polysomnography manual titration in patients with obstructive sleep apnea. figshare. 2024. Publisher Full Text

Correlation of therapeutic pressure between home automatic positive airway pressure and in laboratory polysomnography manual titration in patients with obstructive sleep apnea

Abstract

Background

Methods

Results

Conclusions

Keywords

Introduction

Methods

Clinical trial registration

Study design and population

CPAP manual titration in laboratory PSG

Home APAP titration

Statistical analysis

Results

Figure 1. Flowchart of recruitment to the study for patients with obstructive sleep apnea (OSA).

Table 1. Baseline characteristics of patients with obstructive sleep apnea.

Table 2. Comparison of optimal pressure and residual AHI obtained from in-lab PSG and home APAP in patients with obstructive sleep apnea.

Table 3. Correlation of optimal pressure between in-lab PSG and home APAP in patients with obstructive sleep apnea.

Figure 2. Correlation of optimal pressure between manual continuous positive airway pressure (CPAP) titration in the lab and home automatic positive airway pressure (APAP) titration in patients with obstructive sleep apnea.

Figure 3. The Bland-Altman plot represents the difference in optimal pressure between manual continuous positive airway pressure (CPAP) titration in the lab and home automatic positive airway pressure (APAP) titration in patients with obstructive sleep apnea.

Figure 4. Correlation of optimal pressure between manual continuous positive airway pressure (CPAP) titration in the lab and home automatic positive airway pressure (APAP) titration in patients with severe OSA.

Figure 5. Correlation of optimal pressure between manual continuous positive airway pressure (CPAP) titration in the lab and home automatic positive airway pressure (APAP) titration in OSA patients with good compliance.

Discussion

Conclusions

Registration

Data availability statement

Underlying data

Reporting guidelines

Acknowledgements

References

Comments on this article Comments (0)

Open Peer Review

Comments on this article Comments (0)

Open Peer Review

Reviewer Status

Reviewer Reports

Comments on this article

Browse by related subjects

Competing Interests Policy

Stay Updated