Cyclic alternating pattern and positive airway pressure titration

To demonstrate that stability of the upper airway during continuous positive airway pressure (CPAP) titration is influenced by the microstructure of sleep as defined by the cyclic alternating pattern (CAP).

Retrospective review of 12 CPAP titration records. The patterns of flow-limitation during CPAP at subtherapeutic pressures were characterized as 'stable' (persistent and non-progressive inspiratory flow limitation) or 'unstable' (progressive increase in inspiratory flow-limitation terminating in an arousal), and continuous periods of at least 10 min were identified. Sleep stage scoring by both conventional Rechtshaffen and Kales criteria and the CAP were done. The relationship between flow type and CAP was determined. Responses to an increase in applied pressure on flow-limitation were noted.

There were a total of 50 periods fulfilling the above criteria, totaling 1113 min of titration time. Thirty periods (757 min, 68% of total) showed a stable flow-limitation pattern. A total of 29/30 periods showing a stable flow pattern during sleep was scored as non-CAP, and only a single 18-min period of stable flow was scored as CAP. A total of 19/20 periods showing an unstable flow pattern was in sleep with CAP characteristics, the exception being a single 14-min period where unstable flow was noted in non-CAP. Flow-limitation was stable and non-progressive or absent during non-CAP, even at less than optimal pressures. This was noted irrespective of the presence or absence of delta sleep as scored by conventional criteria. Pressure increases during non-CAP, when the profile of the inspiratory flow was flattened, never resulted in a discernable change in the flow profile, while at least two-thirds of pressure increments during CAP periods improved flow.

The microstructure of sleep as determined by CAP and non-CAP have practical implications for manual pressure titration algorithms and research on upper airway physiology during sleep. The appearance of a period of non-CAP, irrespective of conventionally scored delta sleep, may falsely suggest that the CPAP is optimal or close to it. Large increases in non-CAP that may be seen during a titration night can reduce the window of opportunity for titration. Increases in CPAP should be avoided in non-CAP.