# Management of Obstructive Sleep Apnea in Hospitalized Patients
## 4 Treatment Options in Hospitalized Patients
### Bilevel-Positive Airway Pressure Therapy (BPAP)  
BPAP devices use two pressures: inspiratory (IPAP) and expiratory (EPAP). BPAP devices are the preferred treatment modality in patients requiring ventilation support, those unable to tolerate high CPAP pressures, and those with conditions such as overlap syndrome (comorbid COPD and OSA) and obesity hypoventilation syndrome (OHS) [67]. \begin{table}
\begin{tabular}{c c} \hline \hline
**Type of Sleep Study** & **Parameters** \\ \hline  & Continuous monitoring. Done at a lab \\  & 7 Channels or more: \\  & Cardiac rhythm rate: EKG \\  & Oxygen saturation: SPO2 \\ Type I—Polysomnogram & Stages of sleep/wakefulness: EEG \\  & Nasal/oral airflow \\  & Chin/limb movement (EMG) \\  & Chest/abdomen movement \\  & Snoring detection \\ \hline Type II—Polysomnogram & Same parameters as type I but un-attended Also done at a sleep lab \\ \hline  & HSAT fall under type III \\ Type III—Portable home sleep apnea & Could be used at home or hospital \\  & 4–7 channels except EEG \\  & Variable based on device technology \\  & Atleast 2 respiratory sensors (flow, effort) EKG, SPO2 \\ \hline Type IV—overnight pulse oximetry, & 1 or 2 channel usually pulse oximetry and EKG. No \\  & respiratory flow information \\ \hline EKG, electrocardiogram; SPO2 pulse oximetry; EEG, Electroencephalogram; Electromyogram EMG; HSAT, home sleep apnea testing. \\ \hline \hline \end{tabular}
\end{table} 
Table 2: Classification of sleep studies. Typical starting pressures for BPAP are 12 cm H2O IPAP and 8 cm H2O with adjustments based on patient response. Compliance with PAP therapy is a significant issue in outpatient and inpatient settings. Early aversion to PAP therapy results in poor compliance. Most of these arise from a feeling  
Figure 1: Algorithm for managing hospitalized patients with OSA. \begin{table}
\begin{tabular}{c c c} \hline \hline
**Treatment Options in Hospital** & **Pros** & **Cons** \\ \hline \multirow{2}{*}{Repositioning/using non supine position} & Simple intervention. Reduces AHI & Limited efficacy. \\  & event frequency. & Might not be possible in post op/post \\  & & procedure patients \\ \hline \multirow{3}{*}{Oxygen Therapy} & Well tolerated. Improves hypoxemia. & \\  & Shown to OSA related blood & Does not stop apnea/hypopnea events \\  & pressure spikes & \\ \hline \multirow{3}{*}{CPAP/AutoCPAP} & Established treatment & Patient tolerance \\  & Effective for OSA, OHS, CSA except in & Contraindicated in some patients \\  & patients with EF \textless{}45\% & \\ \hline \multirow{2}{*}{Bilevel PAP} & Can be used on patients with ventilation & \\  & problems, OHS, CSA & Same as above \\ \hline \multirow{3}{*}{High flow NC} & Effective in at least reducing AHI & \\  & Well tolerated & Less effective than PAP \\ \cline{1-1}  & Safer in patients with contraindications & \\ \cline{1-1}  & for PAP therapy & \\ \hline \multirow{3}{*}{OSA, obstructive sleep apnea; CPAP, continuous positive airway pressure; OHS, obesity hypoventilation syndrome, CSA, central sleep apnea; EF, ejection fraction; PAP, positive airway pressure; AHI, apnea hypopnea index; NC, nasal cannula.} & \\ \cline{1-1}  & Noc & No previous diagnosis of OSA STOP. & \\ \cline{1-1}  & OSA & BANG & \\ \cline{1-1}  & & \\ \cline{1-1}  & & \\ \cline{1-1}  & & \\ \cline{1-1}  & & \\ \cline{1-1}  & & \\ \hline \hline \end{tabular}
\end{table} 
Table 3: Treatment therapies for OSA in hospitalized patients. of continuous pressure and/or claustrophobia. Specifically, in the inpatient population, there are contraindications to receiving PAP therapy, such as GI bleeding, altered mental status, risk of aspiration, cranio-facial trauma, or surgery. Moreover, patients who need support above 15 mmHg tolerate bilevel therapy better due to the pressure release effect during expiration. There may be value in starting patients on PAP therapy in the hospital and helping with compliance/troubleshooting issues.