Critical assessment of instrumental therapy of sleep-related breathing disorders

The administration of therapy with positive airway pressure (PAP) represents the standard option in the treatment of sleep-related breathing disorders (SRBD). Several modifications of continuous positive airway pressure (CPAP) have been developed in order to improve patient adherence, to most precisely address defined phenotypes of SRBD and to optimally focus on combinations of different disorders. The use of the different algorithms and devices requires a clear discrimination of phenotypes of SRBDs to avoid insufficient, inadequate and false therapies. As a first step, the physician has to define if the prevailing breathing disturbance has to be treated at all which depends on limitations of the quality of life, increased risk of accidents and any existing or imminent comorbidities. Although automatic CPAP (APAP) or bilevel PAP (BPAP) in spontaneous mode are not generally superior to CPAP, they allow individual treatment approaches. A short-term treatment trial with CPAP is indicated in most patients with cen-tral breathing disturbances; however, adaptive servoventilation or BPAP in spontaneous-timed mode or non-invasive ventilation have proven to be more efficient in treating patients with Cheyne-Stokes respiration, hypoventilation syndromes, coexisting obstructive and central sleep apnea, complex sleep apnea or atactic breathing. During the stay in the sleep laboratory, devices and interfaces are individually selected according to the specific requirements of the patient. Treatment pressure is titrated and the patient is educated in the use and care of the device. As the first days of therapy are of crucial importance for long-term adherence, any delay in the supply of the device, changes of the device for non-medical reasons and insufficient follow-up have to be avoided.