Polysomnographic Determinants of Requirement for Advanced Positive Pressure Therapeutic Options for Obstructive Sleep Apnea

Background: A small percentage of adult patients with severe obstructive sleep apnea (OSA) has been recognized to be extraordinarily difficult to treat with conventional continuous or Bi-level positive airway pressure (together referred to as PAP) therapy.

Aim And Objectives: The aim of this study was to determine polysomnographic (PSG) characteristics, which may help predict the requirement for advanced therapeutic options for OSA.

Methods: Consecutive patients who underwent PAP titration at our sleep laboratory over a 2-year period were included. Patients with technically inadequate studies, those with incomplete titration due to intolerance, mask-related problems, or lack of sleep and those with significant co-morbidity and with other primary sleep disorders, were excluded. The PSGs (diagnostic + titration parts) were categorized into three types: type A (respiratory events evenly distributed over all sleep stages), type B (REM dominant respiratory events), and type C (non-REM dominant respiratory events, mainly during cyclic alternating pattern [CAP] sleep). Group A was further subdivided into A1 (those whose hypnogram normalized after adequate titration) and A2 (those whose hypnogram converted to a type C pattern on titration). These were categorized again into treatment group I (adequately PAP titrated) and group II (poor response to conventional PAP) for studying factors determining poor response to PAP.

Results: Among 249 patients evaluated in the sleep laboratory over the study period, 123 (103 males, mean age 49.9 ± 10.8 years, mean BMI 29.3 ± 4) fulfilled inclusion criteria. These could be grouped as type A (n = 85), B (n = 33), and C (n = 5). On titration, 57 patients of type A and 21 of type B could be successfully titrated, while 24 in type A and 11 in type B, converted into type C. Therefore, in group II (n = 43), 38 patients fell in type C, overtly and after titration. Twelve of these had been successfully treated using adaptive servo ventilation (ASV) while another 28 could be treated using the Bi-level PAP-ST mode. The only PSG feature predicting poor response to conventional PAP was the presence of post-arousal central apnea (p = 0.001). The main difference between the A1 + B groups and A2 + C groups was the significantly higher non-REM apnea hypopnea index in the latter. Among these, on 1-year follow-up, eight patients were using Bi-level PAP-ST mode, while four patients were using ASV and were asymptomatic.

Conclusion: Non-REM sleep instability and the presence of post-arousal central apneas may be important determinants of poor response to conventional PAP and requirement for advanced therapeutic options among patients with severe OSA.