J Clin Neurol.  2020 Jan;16(1):90-95. 10.3988/jcn.2020.16.1.90.

Effective Continuous Positive Airway Pressure Changes Related to Sleep Stage and Body Position in Obstructive Sleep Apnea during Upward and Downward Titration: An Experimental Study

  • 1Department of Neurology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea.
  • 2Department of Otorhinolaryngology-Head and Neck Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea. jknam0266@naver.com


The aim of this study was to determine how the sleep stage and body position influence the effective pressure (Peff) in standard upward titration and experimental downward titration.
This study applied successful manual titration of continuous positive airway pressure over 3 hours [including at least 15 min in supine rapid eye movement (REM) sleep] followed by consecutive downward titration for at least 1 hour to 22 patients with moderate-to-severe obstructive sleep apnea. We analyzed baseline polysomnography variables and compared the effective pressures (Peff1(upward) and Peff2(downward)) between non-REM and REM sleep and between supine and lateral positions using the paired t-test or Wilcoxon signed-rank test.
During upward titration, Peff1 increased during REM sleep compared to non-REM sleep [9.5±2.9 vs. 8.9±2.7 cm Hâ‚‚O (mean±SD), ΔPeff1(REM-non-REM)=0.6±1.1 cm Hâ‚‚O; p=0.024]. During downward titration, Peff2 was higher in a supine than a lateral position (7.3±1.7 vs. 4.8±1.5 cm Hâ‚‚O, ΔPeff2(supine-lateral)=2.5±1.3 cm Hâ‚‚O; p=0.068). When comparing both upward and downward titration conditions, we found that Peff2 was significantly lower than Peff1 in all sleep stages, especially during REM sleep (Peff1(REM) vs. Peff2(REM)=9.5±2.9 vs. 7.4±3.3 cm Hâ‚‚O) with an overall difference of 2.1±1.7 cm Hâ‚‚O (p < 0.001). Peff in supine sleep decreased from 9.4±3.0 cm Hâ‚‚O (Peff1(supine)) to 7.6±3.3 cm Hâ‚‚O (Peff2(supine)), with an overall difference of 1.8±1.6 cm Hâ‚‚O (p < 0.001).
This study has revealed that the collapsibility of the upper airway is influenced by sleep stage and body position. After achieving an initial Peff1, a lower pressure was acceptable to maintain airway patency during the rest of the sleep. The observed pressure decrease may support the use of an automated titration device that integrates real-time positional and sleep-stage factors, and the use of a lower pressure may improve fixed-pressure-related intolerance.


obstructive sleep apnea; continuous positive airway pressure; sleep position; sleep stages

MeSH Terms

Continuous Positive Airway Pressure*
Sleep Apnea, Obstructive*
Sleep Stages*
Sleep, REM
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