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Positive Airway Pressure (PAP) Therapies

Positive Airway Pressure (PAP) Therapies

Positive airway pressure (PAP) Therapy refers to sleep apnea treatments that use a flow of air to support the airway during sleep. With PAP therapy, you wear a mask or a smaller nose interface during sleep. A portable machine gently blows pressurized room air into your upper airway through a tube connected to the mask. This positive airflow helps keep the airway open (like an "air splint"), preventing the collapse that occurs during apnea, thus allowing normal breathing.

PAP therapy is a prescribed treatment because the air pressure required to stabilize the airway, known as the "therapeutic pressure," is different for everyone. The treatment pressure is measured in centimeters of water (cm H2O) and most machines can be set by the provider to deliver pressures between 4 and 20cm H2O. Several factors impact the therapeutic pressure, including severity of OSA and structure of the airway.  The correct setting is critical because if the air pressure is set too low, the airway can still collapse. If it’s set too high, you can become over-ventilated.  An individual’s therapeutic level is determined during a Continuous Positive Airway Pressure (CPAP) Titration sleep study.

For optimal improvement, it’s important to use your PAP machine every time you sleep, including daytime naps!

There are different types of PAP treatment available:

Overall PAP therapy is a safe and effective treatment, however there are a few contra-indications. Be sure to tell your doctor if you have bullous lung disease, pneumothorax, cerebrospinal fluid leak or severe epistaxis (nosebleeds).

Resources at CGH Medical Center

The Sauk Valley Sleep Disorders Support Group includes people who use CPAP; it meets on the third Tuesday of each month, at 6pm, in the Ryberg Auditorium of CGH Medical Center. Please plan on attending to learn about sleep disorders and discuss treatment options for sleep apnea and other sleep disorders; review what is on downloaded data reports; how to troubleshoot device; mask problems and more.

Reservation is not needed, if questions please contact the sleep clinic at (815) 632-5357 or  Toll free 1-855-SLEEP-30 (1-855-753-3730)

Continuous Positive Airway Pressure (CPAP)

Continuous Positive Airway Pressure (CPAP) therapy delivers a fixed or stable, pre-determined level of air pressure. Since there is only one pressure, it remains the same during the inhalation and exhalation, throughout the night.

CPAP is normally the first PAP therapy used to treat sleep disordered breathing. It is a simple approach to supporting the airway is effective for many people with sleep apnea. However, it may not successfully treat everyone. If your symptoms are not eliminated after consistent use of the device, contact your sleep specialist  to assess whether your pressure needs to be adjusted or if you would benefit from a different PAP option such as an auto-titrating device or a Bi-level machine.

Bi-level Positive Airway Pressure (BIPAP)

Bi-level Positive Airway Pressure (Bi-level or BIPAP) machines deliver two different pressures; a higher pressure when breathing in and a lower pressure when breathing out. By alternating the inhalation and exhalation pressures, the Bi-level encourages the lungs to operate more efficiently, and to possibly increase comfort.

Most Bi-level machines work by switching between the two air pressures in response to your breathing. This is known as spontaneous Bi-level. However, patients with more complicated pulmonary disorders (chronic obstructive pulmonary disease, emphysema, etc.) may require the machine to set the respiratory rate through either a backup rate or a timed rate. Most Bi-level machines can deliver up to 30 cm H2O.

Auto-Titrating Machines (Auto-PAP)

Auto-titration PAP devices (Auto-PAP) are designed to adjust the air pressure in response to changes in your breathing pattern, allowing the pressure to vary across the night. Auto-PAP machines have an algorithm that increases the air pressure when your breathing is compromised and lowers the air pressure after a period of normal respiration.

Auto-PAP machines are ideal for people who need a significantly higher pressure during just a portion of the night, for instance when sleeping on their back or in REM sleep because you don’t need to fix the pressure to the highest level needed all night. Instead, the changing pressure allows you to have the lowest pressure possible throughout the night. Auto-PAP machines also work well to compensate for minor weight changes or use of alcohol or other sedatives. However, the algorithms are not perfect, and factors such as a mask leak can interfere with the machine’s feedback loop, which may result in the wrong pressure being delivered.

Adapto-Servo-Ventilation (ASV)

Adapto-Servo-Ventilation or Adaptive-Servo-Ventilation (ASV) is a relatively new form of positive airway pressure for patients with central apnea, i.e. patients with complex sleep apnea (central apneas emerging with use of CPAP or bilevel PAP) and patients with neurological conditions and/or heart failure who have central sleep apnea - with or without obstructive sleep apneas.

The ASV unit continuously monitors the patient's breathing pattern. Whenever it detects significant reductions or pauses in breathing, it intervenes with just enough support to maintain the patient's breathing at 90% of what had been normal for that individual just prior to the decrease in breathing.  Then, when the patient's breathing problem ends, the machine "backs out" gently.  Also, when the patient's breathing is stable, ASV provides just enough pressure support to help maintain airway patency: thereby providing an approximate 50% reduction in the work of breathing.

There are three parameters of ASV that must be adjusted to the individual patient's needs:

  • the end-expiratory pressure
  • the minimal pressure support settings
  • the maximal pressure support settings

While a large number of established sleep centers do not attempt to treat central apneas at all and do not even offer trials of ASV, at CGH Sleep Center we have the capability to offer a trial of ASV, after titrating the device adjusting all setting to the patient’s needs.


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