Is Positive Airway Pressure Lab-Titration Always Necessary to Start Noninvasive Respiratory Support in Infants?

Background: Continuous Positive Airway Pressure (CPAP) initiation should ideally be conducted through CPAP titration in a sleep laboratory according to the American Academy of sleep Medicine recommendations. The objective of this retrospective study was to evaluate the efficacy of two continuous positive airway pressure (CPAP) titration methods-short-supervised in-sleep-laboratory titration and longer, unsupervised hospitalization-based titration-in children under 2 years requiring noninvasive ventilation (NIV) for severe obstructive sleep apnea syndrome (OSAS).

Methods: The participants were allocated based on sleep laboratory availability, with the short-supervised procedure involving in-lab nap polysomnography and pressure adjustments, while the long-unsupervised approach involved hospitalization, the ventilator's built-in software analysis, and overnight gas exchange-based guidance.

Results: The study included 46 infants between January 2022 and November 2024. Both groups were similar in terms of OSAS severity, achieved similar pressure levels at discharge, and demonstrated comparable outcomes in home nocturnal gas exchange (HNGE), including oxygen saturation and CO levels. Adherence was higher in the long-unsupervised group, potentially due to a higher number of therapeutic education sessions afforded by the longer hospitalization. Importantly, no significant differences were observed in the primary outcome of HNGE, with failure of titration observed in two patients (8%) in the short-supervised titration group and four patients (19%) in the long-unsupervised titration group (p = 0.390).

Conclusion: The findings suggest that both titration procedures are feasible and equally effective for initial CPAP/NIV management in infants. Therefore, the choice of method can be tailored to clinical settings and resource availability, with the longer hospital-based titration offering an acceptable alternative to traditional laboratory titration, potentially reducing medical supervision demands while maintaining treatment efficacy.