A study advances a new “REPAP” protocol and finds that patients with co-occurring psychiatric symptoms fared better on advanced PAP therapies, especially after multiple titrations.

 When people in the sleep community talk about improving CPAP compliance (which hovers at a measly 50%1, by some estimates) they often use words like “education,” “motivation,” and “responsibility.” Attempts to boost compliance2 have experimented with encouraging mobile apps, motivational interviews, and educational videos. These approaches suggest that the bottleneck in treating obstructive sleep apnea (OSA) can be traced to patient unwillingness to stick to a prescribed course of treatment. Indeed, such interventions have worked for some patients. But poor compliance might sometimes reflect not on the patient but on the device, according to research published recently in the journal Respiratory Care.3

The research team, led by Barry Krakow, MD, medical director at the Maimonides Sleep Arts and Science Ltd, in New Mexico and member of the Sleep Review editorial advisory board, examined the outcome of what Krakow has dubbed the “REPAP (repeat, rescue, re-titration)” protocol. The protocol embraces targeted retitrations (sometimes multiple procedures in the same patient) and generally eschews CPAP in favor of more advanced and adjustable PAP machines like auto bilevel PAP (ABPAP) or adaptive servo-ventilation (ASV). In a chart review of 273 patients treated with this method at Krakow’s sleep center between 2006 and 2013, 196 went on to use the newly prescribed PAP therapy even though they had failed CPAP previously prescribed at a different institution. (The team judged which patients were “users” based on renewal of PAP supplies and continued contact with staff.)

Krakow acknowledged to Sleep Review this research flies in the face of two assumptions commonly held by sleep practitioners: one, that CPAP should be the default choice for OSA patients and two, that patients who fail to use CPAP sufficiently are simply not motivated enough.

“Most sleep centers have developed this constrained, one size fits all mentality that CPAP must work for everybody. And then if CPAP doesn’t work for someone, then either the patient presumably isn’t trying hard enough or there are no other options,” he says.

He recalls a recent conversation with the medical director of a major insurance carrier that often directs patients to home sleep testing rather than in-lab testing.

“This medical director said, ‘Well, the patient you have is only using the PAP machine two hours a night so he’s probably not trying hard enough. That’s his problem. So we’re not going to let him go back to the sleep lab.’…Well, what if he can’t try harder? What if he’s got claustrophobia, what if he’s got panic attacks, what if he’s got [expiratory pressure intolerance] and can’t breathe out and he rips the mask off in the middle of the night without knowing it? What about all those things that are preventing him from ‘trying harder?’”

Krakow specializes in treating patients with psychiatric comorbidities; about 70% of the patients in this study reported mental illness such as depression, PTSD, anxiety, or claustrophobia. These patients may be more likely to feel anxious when breathing out against the higher pressures needed to meet the American Academy of Sleep Medicine (AASM) mandated standards to eliminate all breathing events, including respiratory effort related arousals (RERAs), Krakow says. Sleep technologists following the REPAP protocol adjust the expiratory pressure down if the patient can’t tolerate it while maintaining a high enough inspiratory pressure to decrease breathing events. That’s where the more advanced machines come in. When using an auto-device like the ABPAP, the techs override the automatic algorithm and tweak the settings in response to the patient’s performance in the lab.

Patients in the study came back for re-titrations as many as four times, with about 9 months on average between sleep studies. Those who underwent multiple titrations were more likely to end up as users.

Krakow acknowledges this approach might be more expensive than the home sleep testing (HST) approach or single-visit titrations preferred by many insurance companies, but is doubtful that HSTs could pick up on the needs of a patient pool like the one in this study. Plus, the long-term savings of treating OSA patients effectively could make up for the up-front cost of multiple sleep studies, he says.

In a commentary published alongside Krakow’s research this month,4 Belgian researchers Dries Testelmans, MD PhD, and Bertien Buyse, MD, PhD, agreed with this assessment and expressed dismay that many of the patients in Krakow’s study reported inadequate follow-up from the first sleep center they had visited.

Krakow’s team’s results are “intriguing,” Testelmans and Buyse said, but they called for more research.

“[M]ore tools are needed to select those patients who really need to be switched to another PAP mode and to better guide the initial PAP mode (to minimalize the number of re-titrations necessary,)” they wrote. “Meanwhile, it is the duty of every physician involved with patients receiving PAP to closely evaluate and follow up their patients and maximally address any adverse effects.”

Rose Rimler is associate editor of Sleep Review.


  1. Wolkove N, et al. Long-term compliance in patients with obstructive sleep apnea. Canadian Respiratory Journal. 15 (7): 365-69.

  2. Chiner E et al. “The use of ambulatory strategies for the diagnosis and treatment of obstructive sleep apnea in adults.” Expert Review of Respiratory Medicine 7(3):259-73.

  3. Krakow B, et al. Reversal of PAP failure with the REPAP protocol. Respiratory Care. 2017. 62(4)

  4. Testelmans D, Buyse B. CPAP adherence: a matter of perfect airflow curves? Respiratory Care. 62 (4) 515-6.