Yes, PAP devices can be used in the pediatric population. A sleep medicine expert shares important information on implementation, titration, and maximizing outcomes.

According to the National Sleep Foundation, the prevalence of obstructive sleep apnea (OSA) in children is about 2% to 3% and as high as 10% to 20% in those with habitual snoring.1 Children may have a family history of OSA, present with obesity or special needs, or experience persistent snoring and apneas after adenotonsillectomy.2 Positive airway pressure (PAP) therapy is a common noninvasive treatment option for OSA that delivers a constant pressure to prevent upper airway collapse. Although the majority of OSA patients on PAP therapy are adults, PAP is increasingly utilized within the pediatric age group.

PAP Therapy Implementation

Utilizing a team approach is important to achieving the desired results for all parts of the PAP therapy implementation process.3 Members of the sleep team may include the pediatric sleep technologist, psychologist, behavioral sleep specialist, registered nurse, physician assistant, and board-certified physician in sleep medicine. Patients should have an initial evaluation by their physician and receive PAP therapy education, hands-on demonstration, and careful mask fitting, allowing adequate time for acclimation to the device prior to overnight titration.4 It is essential to gain the trust of the patient and caregiver and not to treat these patients as little adults. Remember that they are also part of the sleep team.

It can be challenging to select an appropriately sized mask and get the child to actually tolerate PAP therapy on a nightly basis.5 The selection of masks made specifically for the pediatric age group is limited. It is not uncommon for small adult masks to be used off label. Using an adult-sized mask on a child may increase mask leak and require smaller headgear for proper fit.2 Since noncompliance is a major concern, techniques to acclimate the child are handled best using a multidisciplinary approach. Allowing the child to get accustomed to sleeping with PAP therapy at home, known as the desensitization process, may take days or weeks prior to the in-lab sleep study depending on the involvement of the caregiver and the child’s tolerance.4

Titration Process and Guidelines

The overnight titration study should be performed in a facility accredited by the American Academy of Sleep Medicine (AASM) according to the guidelines set forth by the AASM PAP Titration Task Force in February 2008. The titration process consists of collecting data recording the effects and tolerance of various pressures on the patient. The data assists the sleep physician with providing the appropriate treatment recommendations.

The PAP Titration Task Force provides guidelines on the minimum pressure required and how to increase pressure during titration. For patients less than 12 years of age, the recommended starting pressure is a CPAP of 4 cm H2O and maximum pressure of 15 cm H2O. An increase of a minimum of 1 cm H2O for an interval of no less than 5 minutes is indicated when 1 obstructive apnea, 1 hypopnea, 3 respiratory effort-related arousals (RERAs), or 1 minute of loud snoring occurs. For patients 12 years of age and older, the recommended starting pressure is the same as above but the maximum pressure is 20 cm H2O. A 1 cm H2O increase for a minimum of 5 minutes is indicated when 2 obstructive apneas, 3 hypopneas, 5 RERAs, or 3 minutes of loud snoring occurs. For split-night studies where PAP therapy is added during the middle of the study, PAP pressures can be increased by a minimum of 2 cm H2O with at least 5 minutes at each pressure due to the limited time to obtain optimal results. Split-night studies are not recommended for children under 12 years of age due to lack of research support.4

The use of bilevel positive airway pressure (BPAP) might be considered when CPAP is not tolerated at high pressures or if pressures during a CPAP titration are greater than 15 cm H2O with persistent respiratory events. If a child has elevated CO2 levels/hypoventilation, the sleep physician may choose to order a BPAP study since the continuous nature of CPAP may further elevate CO2 levels. This is often seen in children who have neuromuscular diseases. Increasing the inspiratory component (IPAP) and keeping the expiratory component (EPAP) lower than the IPAP value by a minimum of 4 cm H2O may allow time for the patient to eliminate the elevated CO2 levels.4

The PAP Titration Task Force also provides guidelines for BPAP therapy. The starting EPAP pressure, or beginning CPAP pressure at which the obstructive respiratory events are eliminated, is recommended at 4 cm H2O. For children less than 12 years of age, initial IPAP pressures should be set at 8 cm H2O and 4 cm H2O for EPAP with maximum IPAP of 20 cm H2O. The minimum I/E difference is recommended at 4 cm H2O and maximum I/E difference at 10 cm H2O. Both the IPAP and EPAP should be increased by at least 1 cm H2O for a minimum of 5 minutes if 1 obstructive apnea occurs. IPAP only should be increased in this manner after 1 hypopnea, 3 RERAs, or 1 minute of loud snoring. For patients 12 years of age and older, the starting pressures as well as minimum and maximum I/E difference are the same as for those under 12, but a maximum IPAP of 30 cm H2O is recommended. Additionally, the process for increasing pressure is similar, although IPAP and EPAP should be increased by 1 cm H2O after 2 obstructive apneas and only IPAP increased when 3 hypopneas, 5 RERAs, or 3 minutes of loud snoring is observed.4

Titration Grading Criteria

After completing the overnight study, classification of the titration quality can occur. The titration is considered optimal when the respiratory disturbance index (RDI) is less than 5 per hour for a minimum of 15 minutes with acceptable mask leak. Additionally, SpO2 must be greater than 90% and supine REM without arousals or awakenings must be achieved. The term RDI encompasses the number of apneas, hypopneas, and RERAs per hour. A good titration is an RDI less than 10 per hour (or the RDI was reduced by half if the baseline RDI was less than 15) for a minimum of 15 minutes. Mask leak must be low and SpO2 greater than 90% with continuous supine REM. Adequate titration is defined when the RDI is not less than 10 per hour, but the number of respiratory events is reduced by 75% from baseline, meeting the same criteria as optimal and good with no supine REM. A titration is considered unacceptable if the final results do not meet any of the mentioned criteria with less than 3 hours of titration time. Unacceptable titrations tend to occur more often with children and may require a repeat study.4 These guidelines are from the AASM task force scale, but some physicians may use different parameters.

Maximizing Titration Outcomes

Since a successful titration can only occur if the child is asleep, an experienced pediatric sleep technologist trained in working with children of various ages and illnesses can increase the likelihood of success. Sleep physicians will determine therapeutic pressures based on the data collected by the sleep technologist. Therefore, it is extremely important that the sleep technologist has the foundational knowledge and problem-solving skills for accurate data collection with children specifically. If the patient wakes up, or even complains of the pressures being too high, the pressures should be lowered to facilitate sleep.4 Excessive mouth breathing, increased air leak from the mask, or an improperly fitted mask should be documented and remedied since these problems can prevent the child from falling asleep.4

Techniques for increasing and decreasing pressures should be used during CPAP and BPAP titrations to facilitate sleep. The PAP Titration Task Force mentions increasing PAP or IPAP pressures by 2 to 5 cm H2O greater than the pressure at which respiratory events are eliminated. In contrast, down titration may be considered following a minimum of 30 minutes of recording time without obstructive events. A reduction of 1 cm H2O with a minimum of 10 minutes until obstructive events reappear is recommended for PAP and IPAP titrations. Once obstructive events are noticed, the pressures can be increased by 1 cm H2O with a minimum of 5-minute intervals until the obstructive events are resolved.4


Research studies have shown that PAP therapy for the treatment of pediatric OSA is highly effective but associated with a poor adherence rate. A study published in Pediatrics linked PAP therapy with a high dropout rate even in compliant children.5 In the Journal of Clinical Sleep Medicine, a prospective study was performed of possible predictors of PAP therapy adherence in children. Some key barriers identified were low maternal education, African American race, older patient age, and lack of family support. The highest predictive factor for PAP therapy adherence was education level of the mother.6



The physician’s decision on how to treat a child with OSA is made on an individualized basis.2 PAP therapy is a viable treatment option when adenotonsillectomy has already been performed or a nonsurgical approach to airway patency is being considered.2 It is encouraged to utilize the AASM PAP Titration Task Force guidelines combined with a multidisciplinary team approach throughout the treatment process. A sleep technologist who is confident in performing pediatric studies is a critical team member to ensure the validity of the study. Applying the recommendations outlined in this article can assist with early diagnosis and successful implementation of PAP therapy to optimize outcomes.

Joel Porquez, BS, RPSGT/RST, CCSH, is the founder and principal of He works for Children’s Healthcare of Atlanta and is a member of Sleep Review’s editorial advisory board.


1. Sleep apnea. National Sleep Foundation. Accessed July 8, 2015.

2. Paruthi S. Management of obstructive sleep apnea in children. UptoDate. March 31, 2015. Accessed July 8, 2015.

3. Flint K, D’Andrea LA. Best practices for pediatric PAP therapy. Advance for Respiratory Care and Sleep Medicine. Sept 13, 2010. Accessed July 8, 2015.

4. Positive Airway Pressure Task Force of the American Academy of Sleep Medicine. Clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea. J Clin Sleep Med. 2008;4(2):157-71.

5. Marcus CL, Rosen G, Ward SL, et al. Adherence to and effectiveness of positive airway pressure therapy in children with obstructive sleep apnea. Pediatrics. 2006;117(3):e442-51.

6. DiFeo N, Meltzer LJ, Beck SE, et al. Predictors of positive airway pressure therapy adherence in children: a prospective study. J Clin Sleep Med. 2012;11(6):279-86.