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Volume 09 No. 11
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Accepted Papers

Scientific Investigations

Air Leak during CPAP Titration as a Risk Factor for Central Apnea

Sydney B. Montesi, M.D.1,2; Jessie P. Bakker, Ph.D.1; Mary Macdonald3; Lauren Hueser, M.S.B.M.E.3; Stephen Pittman, M.S.B.M.E.3; David P. White, M.D., F.A.A.S.M.1,3; Atul Malhotra, M.D., F.A.A.S.M.1,4
1Sleep Disorders Research Program, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; 2Pulmonary and Critical Care Unit, Massachusetts General Hospital, Boston, MA; 3Philips Respironics, Boston, MA; 4 Division of Pulmonary and Critical Care Medicine, UCSD, San Diego, CA


Emergence of central sleep apnea has been described in the setting of continuous positive airway pressure (CPAP) initiation. The underlying mechanism is unclear; however, we postulate that air leak washing out anatomical dead space is a contributing factor.


Data were obtained from 310 patients with obstructive sleep apnea (OSA) who underwent either split-night or full-night CPAP titration during January to July of 2009. The majority (n = 245) underwent titration with a nasal mask. Average total leak and maximum total leak were measured at therapeutic CPAP level. Unintentional leak was calculated by subtracting manufacturer-defined intentional leak from maximum leak.


Subjects were divided into two groups: central apnea index (CAI) during titration < 5/hour and ≥ 5/hour. The groups were similar in terms of gender, age, BMI, and AHI. The CAI < 5 group had a median average leak of 45.5 L/min (IQR 20.8 L/min) versus 51.0 L/min (IQR 21.0 L/min) with CAI ≥ 5 (p = 0.056). Maximum leak was 59.5 L/min (IQR 27.0 L/min) with CAI < 5 and 75.0 L/min (IQR 27.8 L/min) with CAI ≥ 5 (p = 0.003). In the subset of subjects titrated using a nasal mask, median average leak was 42.0 L/min (IQR 17.0) in the CAI < 5 group and 50.0 L/min (IQR 16.8) in the CAI ≥ 5 group (p = 0.001). In the CAI < 5 group, median maximum leak was 57.0 L/min (IQR 23.0) versus 74.5 L/min (IQR 24.3) in the CAI ≥ 5 group (p < 0.001).


Leak during CPAP titration is associated with the development of acute central apnea; these data may have mechanistic and therapeutic implications for complex apnea.


A commentary on this article appears in this issue on page 1193.


Montesi SB; Bakker JP; Macdonald M; Hueser L; Pittman S; White DP; Malhotra A. Air leak during CPAP titration as a risk factor for central apnea. J Clin Sleep Med 2013;9(11):1187-1191.

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