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Volume 14 No. 12
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Accepted Papers

Scientific Investigations

Practical Implementation of a Single-Night Split-Titration Protocol With BPAP-ST and AVAPS in Patients With Neuromuscular Disease

Salma I. Patel, MD, MPH1; Peter Gay, MD1; Timothy I. Morgenthaler, MD1; Eric J. Olson, MD1; Fadi E. Shamoun, MD2; Rahul Kashyap, MBBS3; Daniel Herold, RPSGT1; Sarah McNamara, RPSGT1; Bernardo Selim, MD1
1Center for Sleep Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; 2Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona; 3Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota

Study Objectives:

At the sleep laboratory, noninvasive positive pressure ventilation titration protocols in patients with neuromuscular disease (NMD) are based on standard pressure cycle devices in a spontaneous/timed mode (BPAP-ST). Experience integrating protocols on average volume-assured pressure support (AVAPS) mode is limited, prompting us to develop a practical single-night titration protocol that provides information to assist clinicians and patients as they decide between BPAP-ST and AVAPS modes.


We implemented a sequential titration protocol of BPAP-ST followed by AVAPS during a single-night polysomnography study in patients with NMD and reported polysomnographic and clinical metrics.


There were 27 patients who completed the protocol: 14 (52%) were male with median and interquartile range (IQR) 64 (59 to 70) years of age and body mass index of 29.6 (25.6–32) kg/m2. They had median (IQR) maximal percent predicted inspiratory and expiratory pressures, and percent vital capacity of 33 (24 to 54), 34 (22 to 47) and 60 (47 to 74), respectively. At final titration of each device, average tidal volume and nadir non-rapid eye movement sleep oxyhemoglobin saturation (SpO2) were higher and respiratory rate/tidal volume, transcutaneous CO2, and arousal index were lower on AVAPS (P < .05) in comparison with BPAP-ST. Full face mask was used in 23 patients (85%). None of the other ventilatory or sleep parameters differed significantly between BPAP-ST and AVAPS (P > .05) sessions.


A practical single-night split-titration protocol with BPAP-ST and AVAPS can successfully be implemented in patients with NMD, assisting clinicians and patients with the decision on initial treatment modalities and settings.


Patel SI, Gay P, Morgenthaler TI, Olson EJ, Shamoun FE, Kashyap R, Herold D, McNamara S, Selim B. Practical implementation of a single-night split-titration protocol with BPAP-ST and AVAPS in patients with neuromuscular disease. J Clin Sleep Med. 2018;14(12):2031–2035.

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