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Blog Feature

By: Rita Brooks on May 22nd, 2020

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So, you think you know everything about CPAP and BiPAP….

advanced sleep titration

Most sleep technologists know that PAP therapy is indicated for Obstructive Sleep Apnea (OSA). Did you know that PAP therapy is also indicated for Central Sleep Apnea (CSA) and hypoventilation?

If you would like to feel confident while titrating PAP therapy for your patients, the CPAP and BPAP module in the new AAST Titration Modules series is an excellent source of foundational information on both CPAP and BPAP that is based on current guidelines.

AAST Advanced Sleep Titration e-Learning Course


Click here to watch the video summarizing the advanced sleep titration e-Learning course 

This module reviews indications and criteria for providing PAP therapy for a variety of sleep related breathing disorders, as well as contraindications. Learn how to provide effective reproducible titration results using a standardized approach to titration that improves sleep quality along with sleep disordered breathing – the ultimate goal of any PAP titration.


Physician Order for PAP Titrations

The physician order and associated patient information should always provide an indication of the type of titration you will need to perform. As sleep technologists, we only provide PAP therapy under the order of a licensed medical provider.

Most sleep centers have protocols for titration that indicate when an emergency split titration should be performed, along with when to call the physician for further direction if a titration is not going well. When the patient population includes children or infants, specific testing and titration guidelines should also be provided for these populations.


PAP Titration Guidelines for Children

Did you know there are specific titration guidelines for children that are different from those we use for a standard adult titration? The number of events as well as the duration of loud snoring, both indications of the need for a PAP pressure increase, are lower in children less than 12 than in adults. In addition, the indices that indicate OSA in pediatric patients are lower. This is important to know if you are testing and treating anyone under the age of 12. And what about maximum pressures? Are they also different?

Central Sleep Apnea: CPAP vs BiPAP vs ASV

What about central apnea? Have you ever started a CPAP titration and seen obstructive events suddenly transition to central events? Or been asked to titrate CPAP on a patient with predominantly central events on their diagnostic study? Although CPAP is suggested as the first line of therapy for CSA, if your patient has a central apnea syndrome you will probably be transitioning from CPAP to BPAP and perhaps eventually to ASV.

The most common central apnea syndromes seen in the sleep center include periodic breathing, Cheyne-Stokes respiration, and treatment emergent central sleep apnea. Sleep related hypoventilation disorders present another indication for BPAP, and you may need to begin with BPAP or use advanced therapy modalities for these patients.


When to Change from CPAP to BiPAP

How do you know you have titrated to the correct final pressure for your patient? Or that you have used the correct mode of therapy for that patient? Do you know when to begin your titration using BPAP, or when to switch to BPAP? Your initial BPAP settings may be indicated by the results of a previous CPAP titration, or in the case of a switch during a CPAP titration, determined in part by the CPAP level that eliminated apnea.


Things to Consider During a BiPAP Titration


What about the pressure differential between EPAP and IPAP? Do you know when to raise both EPAP and IPAP, or when to raise only IPAP, and what the limit is on pressure differential? Is that different for pediatric patients? This is critical knowledge for the technologist in the sleep lab attempting to treat a patient with a complicated sleep disordered breathing presentation. The more you know, the better your night will go!


Optimal, Good, Adequate, or Unacceptable PAP Titrations 

The goal of PAP therapy is to control respiratory events and keep oxygen saturation > 90% with an acceptable leak at optimum pressure. Do you know the standards for what makes a titration optimal, good, adequate or unacceptable? What part does sleep play in these standards? Remember the goal is to improve the patient’s sleep along with their breathing. Can you look at a sleep histogram and determine if your titration was effective?

Documentation During a PAP Titration


How much do you know about documentation and its important role in any titration? Documentation allows the scorer and physician to not only see what was done, but why – and the effects of changes in body position and PAP pressures. It is critically important to document why each PAP pressure change was made, as well as to pay attention to the effects of that change. This information informs your next step in the titration process, which may include a reduction in pressure or a switch to another mode of therapy.

Performing a good PAP titration, regardless of modality, requires attention to detail and an understanding of what changes may improve the situation and what changes may make things worse. Keep in mind that the mask or interface used, and or how it fits the patient, may play a part in your difficult titration. Poor fit may cause a need for higher than actually necessary pressures, significant mask leaks can cause patient discomfort or awakening, or even inability to tolerate therapy.


PAP "Down" Titration and Supplemental Oxygen

Do you know what a “down” titration is and how to perform it when titrating CPAP or BPAP? When, and how, do you add supplemental oxygen? Remember oxygen use always requires a physician order! Information on intentional versus unintentional leak, how to calibrate a PAP instrument to your polysomnograph, and great basic CPAP and BPAP titration algorithms are also provided in this module.



PAP titration is a skill that requires knowledge, including knowledge of physiology and disease, as well as consistent practice. As you move into using some of the more sophisticated advanced titration platforms now available, a good basic CPAP and BPAP foundation is imperative. Even a skilled and experienced technologist can learn something from this learning module!

AAST Advanced Sleep Titration e-Learning Course