Advanced Positive Airway Pressure Modalities

Auto-adjusting positive airway pressure (PAP) devices are increasingly becoming the first line treatment for obstructive sleep apnea (OSA). More complex sleep- disordered breathing such as Cheyne-Stokes respirations and central sleep apnea related to heart failure as well as complex sleep-disordered breathing related to chronic hypoventilation syndromes may require the use of advanced positive airway pressure modalities such as automated servo ventilation (ASV) and volume targeted pressure limited ventilation. Identifying patients with complex sleep-disordered breathing that will benefit from treatment with advanced modalities re- mains an area of active investigation. A recent and surprising development found ASV to be associated with an increased risk of sudden cardiac death when used to treat central sleep apnea in patients with symptomatic systolic heart failure and an ejection fraction less than 45 %. The optimal treatment of central sleep apnea in heart failure and the role of ASV are currently in question. The following chapter is intended to provide the clinician with a description of newer PAP modal- ities; a review of evidence supported indications for use as well as provide a framework for managing patients with ad- vanced positive airway pressure therapy.