Using Auto-CPAP (APAP) Therapy: It's not a set-and-forget option


Obstructive sleep apnea (OSA) can be difficult to treat. Finding the perfect air pressure setting for some patients can be a real challenge. For this reason, many physicians prescribe an Auto-CPAP (or APAP) machine instead of a CPAP delivery system, because they put their trust in the “smart technology” that comes with auto-titrating devices.

While CPAP offers only one fixed setting with a ramping feature and C-Flex option to help with patient comfort, Auto-CPAP offers a range of settings that adjust based on the breathing patterns of the users. 

It’s become common practice these days for a physician to initiate an HSAT (Home Sleep Apnea Test) for potential OSA patients, and follow through on a confirmed diagnosis by prescribing the use of the Auto-CPAP or APAP therapy instead of scheduling a titration at the lab. This model bypasses CPAP altogether.

Many physicians believe this practice is in their patients' best interests. It is based on concerns regarding low CPAP compliance rates and data that shows APAP or Auto-CPAP is far more user-friendly. And the convenience and cost savings of going straight to auto-titration cannot be overlooked.

However, this technology, like every other PAP therapy, does have its limitations.

Disadvantages to using APAP or Auto-CPAP

Technology variables

APAP and Auto-CPAP machines are not standardized like CPAP machines. Auto-titration uses special algorithms to identify appropriate pressure ranges for an individual patient; these algorithms vary from one manufacturer to the next and are based on different variables. For this reason, doctors may not be able to discern the differences between these machines.

A September 2009 Sleep Review article described a bench comparison of five different auto-titrating devices. The researchers looked at response rates to apnea, hypopnea, and flow limitation. They also identified variables in machine performance.

General consensus in that study said that, while all the devices examined showed the potential to treat OSA and lead to a positive outcome, there was no standardized way to differentiate which device would best relay the “appropriate” pressure response to a patient's unique breathing issues.

This begs the question: Even if all these different devices work, they work differently...  How can doctors know which is the best among them for treating the specific needs of their individual patients?  

Since then, some manufacturers have been more specific about the way their machines work without giving out too much proprietary information, and that has been useful.

But by no means should a physician assume these different makes and models all work in the same fashion. Nor should they consider a "one-range-fits-all" approach is in the best interest of their patients.

Fortunately, a knowledgeable sleep technologist or PAP educator, in consult with the prescribing physician in their sleep medicine team, may have enough familiarity with the latest differences in auto-titration technologies to help determine which system is best.

Timing of pressure delivery

All patients have changes in their pressure needs throughout the night. However, some patients' changes are much more distinct. One consequence is that APAP therapy or Auto-CPAP may not be able to deliver the appropriate pressure to them in a timely fashion when respiratory events take place.

The most noticeable problems occur during REM sleep. Patients may not be able to tolerate slow changes in pressure at these critical moments, and this can lead to frequent respiratory arousals, complaints of discomfort, and a lower overall compliance rate, if the problem is not corrected. This is why monitoring APAP or Auto-CPAP users' data is key.

One strategy to counteract slow response times to severe apneas is to monitor the patient, paying special attention to baseline pressures. These lower pressures can be raised within the patient's comfort zone to close gaps when severe events occur and can lead to improved sleep and compliance.

It's worth noting that patients who only experience episodes of apnea while supine or during REM sleep may actually benefit from a precisely tuned auto-titration device rather than a fixed-pressure delivery system like CPAP.

Healthcare costs

Because they are a “smarter” technology, APAP machines generally cost more than CPAP machines. Though insurance companies are more inclined to recognize and pay for the benefits of auto-titration due to its usually higher patient adherence percentages, some insurance companies may still dictate that a patient must first “fail” CPAP before they pay out for auto-titration. And some patients may simply not have coverage for this technology.

Some patients cannot use APAP therapy or Auto-CPAP

Patients with chronic heart failure, central sleep apnea, and obesity hypoventilation syndrome are not safe candidates for APAP; the unique challenges to their breathing while asleep can be aggravated using auto-titrated therapy. 

Like other PAP therapies, using Auto-CPAP and APAP therapy will still require fine tuning. Choosing a machine with a technology you understand, and one which includes long-distance monitoring to help your team manage adjustments, will help you give your patients the best possible therapy.

But this will require regular observation and thoughtful 
adjustments until that perfect pressure range can be established, which hardly makes APAP or Auto-CPAP a set-and-forget therapy.

Here at Sound Sleep Health, matching the right patient to the right therapy is a top priority. We have 3 locations in the greater Seattle/Kirkland areas. We hope you'll reach out to us with your sleep health concerns. 

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