Initial CPAP Settings

Starting Pressure

The American Academy of Sleep Medicine recommends starting CPAP at 4 cm H₂O for both pediatric and adult patients, regardless of age, based on consensus and supported by standard-level evidence including multiple Level I and II studies 1, 2, 3
Consider beginning at a higher pressure for patients with elevated body mass index (BMI) or those undergoing retitration studies, as CPAP requirements correlate with BMI (ρ = 0.32, p <0.001) 2, 3

The American Academy of Sleep Medicine recommends that maximum CPAP should not exceed 15 cm H₂O for patients <12 years 1, 2, 4
The American Academy of Sleep Medicine recommends that maximum CPAP should not exceed 20 cm H₂O for patients ≥12 years 1, 2, 4

Increase CPAP by at least 1 cm H₂O increments, waiting a minimum of 5 minutes between adjustments, with the goal of eliminating obstructive respiratory events 2, 3
Increase pressure if ≥2 obstructive apneas occur in patients ≥12 years (or ≥1 apnea in patients <12 years) 1, 2
Increase pressure if ≥3 hypopneas occur 2
Increase pressure if ≥5 respiratory effort-related arousals (RERAs) occur 2
Increase pressure if ≥3 minutes of loud or unambiguous snoring occurs in patients ≥12 years (or ≥1 minute in patients <12 years) 1, 2, 4

If the patient awakens complaining pressure is too high, immediately restart at a lower pressure that allows comfortable return to sleep, then resume gradual titration 1, 4, 5

Switch to BiPAP if obstructive events persist at 15 cm H₂O of CPAP or if the patient is intolerant of high CPAP pressures 4, 5

Begin with IPAP 8 cm H₂O and EPAP 4 cm H₂O for both pediatric and adult patients 4, 5, 6
Maintain a minimum IPAP-EPAP differential of 4 cm H₂O 5, 6

Do not increase CPAP by increments >2.5 cm H₂O, as there is insufficient evidence supporting larger jumps 2, 3
Do not wait <5 minutes between pressure adjustments, as this does not allow adequate time to assess response 2, 3
For split-night studies, consider using larger increments (2 or 2.5 cm H₂O) given the shorter titration duration, though the same algorithm otherwise applies 4, 5