Bilevel positive airway pressure for obstructive sleep apnea

Abstract

For most patients with obstructive sleep apnea syndrome (OSA), continuous positive airway pressure (CPAP) is an effective therapy. However, for a subset of individuals, CPAP is either not effective or is poorly tolerated. Bilevel positive airway pressure (BPAP) is potentially capable of treating OSA at a lower mean pressure than CPAP and can help augment ventilation via pressure support. This review summarizes the evidence for the use of BPAP in spontaneous mode in the initial treatment of patients with OSA and in those who are poorly compliant with CPAP therapy. It also examines evidence regarding use of BPAP in OSA with associated hypoventilation, such as in chronic obstructive pulmonary disease or severe obesity. Finally, current clinical guidelines that help determine which patients would be candidates for a BPAP device and how to manually titrate BPAP to determine the optimal settings to be prescribed are also discussed.

Keywords::

• bilevel positive airway pressure
• hypercapnia
• hypoventilation
• obstructive sleep apnea
• titration

Financial & competing interests disclosure

TI Morgenthaler conducted research funded by ResMed, Inc regarding treatment of Complex Sleep Apnea Syndrome. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Continuous positive airway pressure (CPAP), the most commonly used treatment for obstructive sleep apnea (OSA), though effective, is limited by a number of side effects and low compliance.

• Bilevel positive pressure (BPAP), delivering different inspiratory and expiratory pressures are capable of reducing the average pressure required to keep the airway open in patients with OSA and could conceivably reduce some PAP-related side effects.

• Evidence demonstrating superior efficacy or adherence rates to BPAP over CPAP as initial treatment in OSA patients with/without a concurrent respiratory disorder, however, is lacking.

• There is limited evidence to suggest that patients with OSA who are poorly tolerant or compliant with CPAP treatment may benefit from BPAP.

• There is no conclusive evidence demonstrating the superiority of BPAP over CPAP in OSA patients with an associated condition causing hypoventilation such as chronic obstructive pulmonary disease or severe obesity.

• Current clinical guidelines that are mostly based on expert consensus indicate that CPAP can be switched to BPAP during titration polysomnography if there are continued disordered breathing events at ≥15 cmH₂O or if the patient complains of difficulty exhaling against the high pressure.

• Further studies are needed to ascertain the role of autotitrating BPAP as well as BPAP with end-expiratory and early inspiratory pressure relief features.

Notes