PEEP Calculation for CPAP in Obese Patients

Initial PEEP Settings

• The American Academy of Sleep Medicine recommends a minimum starting CPAP of 4 cmH2O for all patients, but a higher starting pressure may be selected for patients with elevated BMI 1
• For patients with BMI of 45, consider starting at 8-10 cmH2O due to the correlation between BMI and required CPAP pressure 1, 3
• The maximum recommended CPAP is 20 cmH2O for adult patients; if this pressure is insufficient, consider transitioning to BPAP 1, 3

Titration Protocol

• Increase CPAP by at least 1 cmH2O with the goal of eliminating obstructive respiratory events 1
• For patients with high BMI, consider larger increments (2-2.5 cmH2O) especially during split-night studies due to time constraints 3
• Continue increasing pressure until obstructive apneas, hypopneas, RERAs, and snoring are eliminated 1, 2

Special Considerations

• If the patient is uncomfortable or intolerant of high CPAP pressures, or if obstructive events persist at 15 cmH2O, consider switching to BPAP 2, 3
• For BPAP in obese patients, start with IPAP of 8 cmH2O and EPAP of 4 cmH2O, and maintain an IPAP-EPAP differential between 4-10 cmH2O 3
• Maximum IPAP for adults should be 30 cmH2O 3

Monitoring and Adjustment

• Aim for at least 30 minutes without breathing events and at least 15 minutes in supine REM sleep at the final pressure setting 1
• Monitor for potential cardiovascular effects of high PEEP, particularly in patients with cardiac conditions 4