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APAP and Alternative Titration Methods
APAP and Alternative Titration Methods ... Sept 2010

While APAP devices are generally categorized as low-risk devices by the Food and Drug Administration, their performance in an individual patient may depend on how they are set, where they are set-up, how patients are selected and instructed, and how patients on such therapy are monitored (45). The concern is that physicians in busy practices may be unable to keep up with the changes in technology.

Unlike pharmaceutical products, physicians do not receive information regarding post-approval trials, nor do they receive education by a cadre of pharmaceutical representatives. In a 2004 survey of board-certified sleep physicians, only 30% of physicians correctly identified the contra-indications for administration of APAP devices (36).

Moreover, thirty percent of sleep physicians never prescribed APAP devices. Physicians who never prescribe APAP devices tended to interpret fewer sleep studies and tended to prescribe fewer PAP devices per month than physicians who prescribed APAP devices suggesting that patient volumes were indicative of physician confidence in prescribing such devices (36).

Moreover, 90% of physicians who prescribed auto-PAP devices reported that they reviewed the data downloaded from the device for pressure, leak, and adherence information. The time spent in interpreting the downloads for leak, appropriate pressure level, and troubleshooting during care delivery in an ambulatory APAP program are, however, not reimbursed for physician time. Future policy changes to reimbursement should consider provider compensation to such care delivery if APAP is envisioned to be embraced by providers.

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APAP and Alternative Titration Methods.
Ahmed O, Parthasarathy S.
Fellow, Pulmonary and Critical Care Medicine, Department of Medicine, University of Arizona, Tucson, AZ.

Positive airway pressure therapy (PAP) is commonly prescribed treatment for obstructive sleep apnea (OSA). Traditionally, the determination of the optimal pressure for treatment of sleep-disordered breathing was made by manual titration of the device by a sleep technician in attendance during polysomnography. However, the advent of alternative methods for determination of optimal PAP - such as auto-titrating PAP (APAP) - has seen tremendous growth over the past decade. The purpose of this review is to improve our understanding of the currently available alternative methods for titration of PAP in patients with sleep-disordered breathing (SDB) with special emphasis on obstructive sleep apnea.

Recent prospective-randomized studies of alternative methods of titration suggest that pressure determinations made by such devices are comparable to traditional manual titrations made in the sleep laboratory. Obstacles to the adoption of such alternative modes of titration into day-to-day practice may be attributable to issues surrounding appropriate patient selection, differences between devices, re-imbursement policies of third party payors, consensus amongst sleep experts, and individual physicians' practice patterns and volumes. While newer generations and types of auto-titrating PAP devices are entering the sleep field constantly, providers' knowledge and time availability remain limiting factors.

There is tremendous growth in the technology and scientific evidence in support of alternative modes of PAP titration for sleep-disordered breathing, but barriers to implementation remain.
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