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## Complete Summary

#### GUIDELINE TITLE

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.

#### BIBLIOGRAPHIC SOURCE(S)

Morgenthaler TI, Aurora RN, Brown T, Zak R, Alessi C, Boehlecke B,
Chesson AL Jr, Friedman L, Kapur V, Maganti R, Owens J, Pancer J, Swick
TJ, Standards of Practice Committee of the AASM, American Academy of
Sleep Medicine. 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 Jan
1;31(1):141-7. \[40 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=18220088)

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Standards of Practice
Committee. Practice parameters for the use of auto-titrating continuous
positive airway pressure devices for titrating pressures and treating
adult patients with obstructive sleep apnea. Sleep 2002;25(2):143-7.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Obstructive sleep apnea syndrome

#### GUIDELINE CATEGORY

Assessment of Therapeutic Effectiveness\
Treatment

#### CLINICAL SPECIALTY

Dentistry\
Internal Medicine\
Neurology\
Otolaryngology\
Pulmonary Medicine\
Sleep Medicine

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Dentists\
Physician Assistants\
Physicians\
Respiratory Care Practitioners

#### GUIDELINE OBJECTIVE(S)

To present updated recommendations for using auto-titrating positive
airway pressure (APAP) to determine the need for or to provide treatment
for obstructive sleep apnea (OSA)

#### TARGET POPULATION

Adults with obstructive sleep apnea syndrome

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Use of standard (i.e., fixed) continuous positive airway pressure
    (CPAP) (titration and treatment)

2.  Use of auto-titrating continuous positive airway pressure (APAP)
    titration and treatment

3.  Follow-up of patients to determine effectiveness and safety of
    treatment

#### MAJOR OUTCOMES CONSIDERED

Clinical utility of autotitrating positive airway pressure (APAP) for
diagnosing and treating obstructive sleep apnea syndrome

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

A search for articles on treatment of obstructive sleep apnea with
autotitrating continuous positive airway pressure (CPAP) (APAP) was
conducted using EMBASE, Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process &
Other Non-Indexed Citations, and the Cochrane Clinical Trial Registry,
first on August 25, 2006, and updated on November 7, 2006. Key words for
searches included autoCPAP, automatic CPAP, autotitrating CPAP, autoset,
auto PAP, and autoadjusting CPAP. Each search was run separately and
findings were merged. When the search was limited to articles published
in English and regarding humans, a total of 167 articles were
identified. Abstracts from these articles were reviewed to determine if
they met inclusion criteria. Articles were included for evaluation if
they had more than 9 subjects and if they compared APAP use with
standard PSG directed CPAP therapy, a standard alternate therapy (oral
appliance, surgery), or another APAP device. The articles had to address
at least one of eight \"PICO\" questions (acronym standing for Patient,
Population or Problem, provided a specific Intervention or exposure,
after which a defined Comparison is performed on specified Outcomes)
that were decided upon ahead of the review process. While the PICO
questions do not map one-to-one with the practice parameters, they were
designed to generate information that would be useful in updating the
existing practice parameters. Articles meeting these criteria in
addition to those identified by pearling (i.e., checking the reference
sections of search results for articles otherwise missed) provided 22
articles for review and grading (see accompanying evidence table in the
original guideline document).

#### NUMBER OF SOURCE DOCUMENTS

This guideline is based on a review of 22 articles published in peer
reviewed journals.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Evidence Levels**

I.  Randomized well-designed trials with low-alpha and low-beta error\*

II. Randomized trials with high alpha and beta error\*

III. Nonrandomized concurrently controlled studies

IV. Nonrandomized historically controlled studies

V.  Case series

\* Alpha (type I error) refers to the probability that the null
hypothesis is rejected when in fact it is true (generally acceptable at
5% or less, or P \<0.05). Beta (type II error) refers to the probability
that the null hypothesis is mistakenly accepted when in fact it is false
(generally trials accept a beta error of 0.20). The estimation of type
II error is generally the result of a power analysis. The power analysis
takes into account the variability and the effect size to determine if
sample size is adequate to find a difference in means when it is present
(power generally acceptable at 80% to 90%).

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

All evidence grading was performed by independent review of the article
by two members of the task force. Areas of disagreement were addressed
by the task force until resolved.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The Standards of Practice Committee (SPC) of the American Academy of
Sleep Medicine (AASM) commissioned among its members four individuals
with expertise in the use of autotitrating positive airway pressure
(APAP) to conduce this review. These content experts were appointed in
June, 2006 to review and grade evidence in the peer-reviewed scientific
literature regarding the use of APAP.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Levels of Recommendation**

**Standard**: This is a generally accepted patient-care strategy which
reflects a high degree of clinical certainty. The term *standard*
generally implies the use of Level I evidence, which directly addresses
the clinical issue, or overwhelming Level II evidence.

**Guideline**: This is a patient-care strategy which reflects a moderate
degree of clinical certainty. The term *guideline* implies the use of
Level II evidence or a consensus of Level III evidence.

**Option**: This is a patient-care strategy which reflects uncertain
clinical use. The term *option* implies either inconclusive or
conflicting evidence or conflicting expert opinion.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The recommendations were reviewed and approved by the Board of Directors
of the American Academy of Sleep Medicine.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The evidence levels (I-IV) and the levels of recommendations (standard,
guideline, option) are defined at the end of the \"Major
Recommendations\" field.

Auto-titrating continuous positive airway pressure (APAP) is not
recommended to diagnosis obstructive sleep apnea (OSA). (**Standard**)

Patients with congestive heart failure, significant lung disease such as
chronic obstructive pulmonary disease, patients expected to have
nocturnal arterial oxyhemoglobin desaturation due to conditions other
than OSA (e.g., obesity hypoventilation syndrome), patients who do not
snore (either naturally or as a result of palate surgery), and patients
who have central sleep apnea syndromes are not currently candidates for
APAP titration or treatment. (**Standard**)

APAP devices are not currently recommended for split-night titration.
(**Standard**)

Certain APAP devices may be used during attended titration with
polysomnography to identify a single pressure for use with standard
continuous positive airway pressure (CPAP) for treatment of moderate to
severe OSA (**Guideline**)

Certain APAP devices may be initiated and used in the self-adjusting
mode for unattended treatment of patients with moderate to severe OSA
without significant comorbidities (congestive heart failure \[CHF\],
chronic obstructive pulmonary disease \[COPD\], central sleep apnea
syndromes, or hypoventilation syndromes). (**Option**)

Certain APAP devices may be used in an unattended way to determine a
fixed CPAP treatment pressure for patients with moderate to severe OSA
without significant comorbidities (CHF, COPD, central sleep apnea
syndromes, or hypoventilation syndromes). (**Option**)

Patients being treated with fixed CPAP on the basis of APAP titration or
being treated with APAP must have close clinical follow-up to determine
treatment effectiveness and safety. This is especially important during
the first few weeks of positive airway pressure (PAP) use.
(**Standard**)

A reevaluation and, if necessary, a standard attended CPAP titration
should be performed if symptoms do not resolve or if the APAP treatment
otherwise appears to lack efficacy. (**Standard**)

**[Definitions]{.underline}**:

**Evidence Levels**

I.  Randomized, well-designed trials with low alpha and beta error

II. Randomized trials with high alpha and beta error

III. Nonrandomized concurrently controlled studies

IV. Nonrandomized historically controlled studies

V.  Case series

**Levels of Recommendations**

**Standard** - This is a generally accepted patient-care strategy, which
reflects a high degree of clinical certainty. The term *standard*
generally implies the use of Level I Evidence, which directly addresses
the clinical issue, or overwhelming Level II Evidence.

**Guideline** - This is a patient-care strategy, which reflects a
moderate degree of clinical certainty. The term *guideline* implies the
use of Level II Evidence or a consensus of Level III Evidence.

**Option** - This is a patient-care strategy, which reflects uncertain
clinical use. The term *option* implies either inconclusive or
conflicting evidence or conflicting expert opinion.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see the \"Major Recommendations\" field).

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate use of autotitrating continuous positive airway pressure
devices for titrating pressures and treating adult patients with
obstructive sleep apnea syndrome

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   These practice parameters define principles of practice that should
    meet the needs of most patients in most situations. These guidelines
    should not, however, be considered inclusive of all proper methods
    of care or exclusive of other methods of care reasonably directed to
    obtaining the same results. The ultimate judgment regarding
    propriety of any specific care must be made by the physician in
    light of the individual circumstances presented by the patient,
    available diagnostic tools, accessible treatment options, and
    resources.

-   The American Academy of Sleep Medicine (AASM) expects these
    guidelines to have an impact on professional behavior, patient
    outcomes, and, possibly, health care costs. These practice
    parameters reflect the state of knowledge at the time of publication
    and will be reviewed, updated, and revised as new information
    becomes available.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Morgenthaler TI, Aurora RN, Brown T, Zak R, Alessi C, Boehlecke B,
Chesson AL Jr, Friedman L, Kapur V, Maganti R, Owens J, Pancer J, Swick
TJ, Standards of Practice Committee of the AASM, American Academy of
Sleep Medicine. 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 Jan
1;31(1):141-7. \[40 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=18220088)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2002 March 15 (revised 2008 Jan)

#### GUIDELINE DEVELOPER(S)

American Academy of Sleep Medicine - Professional Association

#### SOURCE(S) OF FUNDING

American Academy of Sleep Medicine

#### GUIDELINE COMMITTEE

Standards of Practice Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Standards of Practice Committee*: Timothy I. Morgenthaler, MD; R. Nisha
Aurora, MD; Terry Brown, DO; Rochelle Zak, MD; Cathy Alessi, MD; Brian
Boehlecke, MD; Andrew L. Chesson Jr, MD; Leah Friedman, MA, PhD; Vishesh
Kapur, MD, MPH; Rama Maganti, MD; Judith Owens, MD; Jeffrey Pancer, DDS;
Todd J. Swick, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

All members of the American Academy of Sleep Medicine´s Standards of
Practice Committee and Board of Directors completed detailed
conflict-of-interest statements and were found to have no conflicts of
interest with regard to this subject.

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Standards of Practice
Committee. Practice parameters for the use of auto-titrating continuous
positive airway pressure devices for titrating pressures and treating
adult patients with obstructive sleep apnea. Sleep 2002;25(2):143-7.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American Academy of Sleep Medicine Web
site](http://www.aasmnet.org/Resources/PracticeParameters/PP_Autotitrating_Update.pdf).

Print copies: Available from the Standards of Practice Committee,
American Academy of Sleep Medicine, One Westbrook Corporate Center,
Suite 920, Westchester, IL 60154. Web site:
[http://www.aasmnet.org](http://www.aasmnet.org/).

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on July 19, 2002. The information was
verified by the guideline developer on September 13, 2002. This NGC
summary was updated by ECRI Institute on May 13, 2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions. Please contact the
American Academy of Sleep Medicine (AASM) for information regarding
reproduction of AASM guidelines.

### DISCLAIMER

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Date Modified: 11/3/2008