Response to Marcus, CL. Letter to the editor: Concerns regarding the pediatric component of the AASM clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea. J Clin Sleep Med 2008;4:607

The authors of the Positive Airway Pressure Titration Task Force of the American Academy of Sleep Medicine (AASM) thank Dr. Carole Marcus for her thoughtful review1 of the AASM’s recently published clinical guidelines paper in the Journal of Clinical Sleep Medicine.2 It is stated in the clinical guidelines paper that these recommendations should not be con sidered inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results and that the ultimate judgment regarding the propriety of any specific care must be made by the clinician in light of the indi vidual circumstances presented by the patient. It is also mentioned that sleep technologists and clinicians should combine their experience and judgment with the application of these recommendations to attain the best possible titration in any given patient. The recommendations in the paper were developed by our multidisciplinary task force (including those who have titrated pediatric patients with PAP) using a formal consensus process. Consensus recommendations are a maximum CPAP of 15 cm H2O (Recommendation 4.2.1.3) and a maximum IPAP of 20 cm H2O (Recommendation 4.3.1.4) for patients 15 cm H2O were switched to BPAP.3 The task force recognizes that there will always be exceptions to any guidelines, and this is the reason that the task force indicated that these are recommendations and that they were obtained by consensus. Dr. Marcus also indicated that the time duration is not clearly stated in the recommendation for an increase in pressure level in response to an obstructive apnea, i.e., whether the time duration is one hour or all night (Recommendation 4.2.2.2). She correctly points out that differences in time duration over which the apnea occurs could result in the apnea-hypopnea index (AHI) to fall on either side of an AHI of 1 per hour (the upper limit of the normative value in children). The underpinnings for our recommendation are based on the fact that the titration is done “real-time,” and the technologist cannot predict whether the obstructive apnea is a solitary or soon to be recurring event. If this obstructive apnea is soon to be a recurrent event, then valuable time available for titration is not wasted by our recommendation to increase the pressure. Alternatively, if it is indeed a solitary event, then our recommendation to increase the pressure by 1 cm H2O will, at worse, result in a treatment pressure that is just 1 cm H2O greater than the optimal pressure. However, for a given sleep state and body position, a 1 cm H2O increment in response to an obstructive apnea may not result in resolution of future hypopneas, RERAs, and unambiguous snoring. It should be noted that the task force also recommends that the pressure increments should not occur at intervals shorter than 5 min in order to allow for transient events that occur around sleep-wake transitions to resolve on their own without pressure increments (Recommendation 4.2.2.1). This time-based recommendation will abrogate unwarranted pressure increments in response to such transient respiratory events. She also expresses concern that our recommendation to increase pressure in response to an obstructive apnea in children <12 years of age may not be the best option for a child requiring higher pressure levels who is having a hard time tolerating CPAP in the laboratory. But, once again, we believe that the judgment by the technologist and clinician regarding the titration must be made in light of the individual circumstances presented by the patient. Additionally, there is always the option of “down” titration (Recommendation 4.2.2.8) that could be subsequently conducted during the night by technologists and clinicians who have such concerns. The task force very much appreciates the opportunity to respond to these comments and we welcome further commentary.