Chest
Volume 115, Issue 3, March 1999, Pages 863-866
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Consensus Statement
Indications for Positive Airway Pressure Treatment of Adult Obstructive Sleep Apnea Patients: A Consensus Statement

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We developed a short-length document that clearly delineates a prudent approach to and criteria for reimbursement of positive airway pressure (PAP) costs for the treatment of obstructive sleep apnea (OSA). Treatment modalities for OSA with PAP include continuous positive airway pressure, bilevel or variable PAP, and autotitrating PAP. This guidance on the appropriate criteria for PAP use in OSA is based on widely acknowledged peer-reviewed studies and widely accepted clinical practice. These criteria reflect current opinion on the appropriate clinical management of OSA in lieu of data pending from the Sleep Heart Health Study and upcoming outcome studies. This document is not intended to provide a complete review and analysis of the OSA clinical literature. The key to the success of this document is to foster consensus within and outside the clinical sleep community by providing a common sense and easily understood approach to the treatment of OSA with PAP.

Section snippets

I. Accepted Diagnostic Techniques

A. Standard Diagnostic Nocturnal Polysomnography (NPSG)

Based on the 1997 American Sleep Disorders Association Indications for Polysomnography Task Force Report1:

• Indicated for the diagnosis of possible obstructive sleep apnea (OSA).

• Includes recording and analysis of the following parameters: EEG, electro-oculogram (EOG), electromyogram (EMG), oronasal airflow, chest wall effort, body position, snore microphone, ECG, and oxyhemoglobin saturation. The duration of a diagnostic NPSG is at least

II. Diagnostic Criteria (Employing the Previously Specified Techniques)

Based on the American Sleep Disorders Association Criteria for Measurements, Definitions, and Severity Ratings of the Sleep Related Breathing Disorders Task Force Report10:

• Apnea is defined as the cessation of airflow≥ 10 s.

• Hypopnea is defined as a recognizable, transient reduction, but not a complete cessation of, breathing ≥ 10 s. A ≥ 50% decrease in the amplitude of a validated measure of breathing or a < 50% amplitude reduction that is associated with either an oxygen desaturation of ≥

III. Treatment Criteria

• CPAP treatment is indicated for all OSA patients with an RDI ≥ 30 events per hour, regardless of symptoms, based on the increased risk of hypertension evident from the Wisconsin sleep cohort data.11

• Treatment with CPAP is indicated for patients with an RDI of 5 to 30 events per hour accompanied by symptoms of excessive daytime sleepiness,12impaired cognition,13,14 mood disorders,13insomnia,15 or documented cardiovascular diseases to include hypertension,16 ischemic heart disease,17 or stroke.

IV. CPAP Titration

• On a subsequent night following a diagnostic NPSG or following the diagnostic portion of a split-night study, OSA patients receive CPAP titration to specify the lowest CPAP level, which abolishes obstructive apneas, hypopneas, RERAs, and snoring in all sleep positions and sleep stages.20

• Minimum parameters to be monitored and analyzed with CPAP titration NPSG include the following: EEG, EOG, EMG, oronasal airflow, chest wall effort, body position, snore microphone, ECG, and oxyhemoglobin

V. Bilevel Positive Airway Pressure

• Bilevel positive airway pressure (PAP) allows for independent adjustment of inspiratory and expiratory pressures. A timed, back-up rate capability is not required for OSA treatment.

• A trial of bilevel PAP may be indicated for OSA patients who cannot tolerate CPAP due to persistent massive nasal mask air leakage or discomfort exhaling against positive pressure.21

• A trial of bilevel PAP may be indicated for OSA patients with concomitant nocturnal breathing disorders to include restrictive

VI. Autotitrating PAP

• Autotitrating PAP allows for the titration of CPAP without the immediate involvement of a technologist.

• Recent studies suggest that some autotitrating PAP systems are effective in determining the optimal CPAP setting for most OSA patients.25

• Treatment with autotitrating PAP systems in some studies shows slight increases in adherence as compared with CPAP.26,27

• An additional NPSG may be required to titrate CPAP if autotitrating PAP treatment failure occurs.

VII. Repeat NPSG

• Indications for repeat NPSG are persistence of symptoms despite adherence to PAP treatment and assessment of treatment response to upper airway surgical procedures, oral appliances, or significant sustained weight change (> 15%).1

VIII. Adherence to PAP Treatment

• Efforts directed at OSA patient education are warranted for at least the first month of PAP treatment to promote effective long-term adherence with treatment.21,28 This education may be provided by physicians, specially trained technologists, or nurses.

• To enhance and ensure PAP adherence and equipment maintenance, follow-up with a physician or a designated surrogate should occur at least once after the initiation of PAP treatment, and thereafter on at least a yearly basis.21

• Adjustments or

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    The opinions or assertions contained herein are the private views of the authors and do not necessarily represent the opinion of the Department of the Army or of the Department of Defense.

    This consensus statement does not reflect the official views of the American College of Chest Physicians.

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