Is Positive Airway Pressure Lab‐Titration Always Necessary to Start Noninvasive Respiratory Support in Infants?

ABSTRACT

Background

Continuous Positive Airway Pressure (CPAP) initiation should ideally be conducted through CPAP titration in a sleep laboratory according to the American Academy of sleep Medicine recommendations. The objective of this retrospective study was to evaluate the efficacy of two continuous positive airway pressure (CPAP) titration methods—short‐supervised in‐sleep‐laboratory titration and longer, unsupervised hospitalization‐based titration—in children under 2 years requiring noninvasive ventilation (NIV) for severe obstructive sleep apnea syndrome (OSAS).

Methods

The participants were allocated based on sleep laboratory availability, with the short‐supervised procedure involving in‐lab nap polysomnography and pressure adjustments, while the long‐unsupervised approach involved hospitalization, the ventilator's built‐in software analysis, and overnight gas exchange‐based guidance.

Results

The study included 46 infants between January 2022 and November 2024. Both groups were similar in terms of OSAS severity, achieved similar pressure levels at discharge, and demonstrated comparable outcomes in home nocturnal gas exchange (HNGE), including oxygen saturation and CO₂ levels. Adherence was higher in the long‐unsupervised group, potentially due to a higher number of therapeutic education sessions afforded by the longer hospitalization. Importantly, no significant differences were observed in the primary outcome of HNGE, with failure of titration observed in two patients (8%) in the short‐supervised titration group and four patients (19%) in the long‐unsupervised titration group (p = 0.390).

Conclusion

The findings suggest that both titration procedures are feasible and equally effective for initial CPAP/NIV management in infants. Therefore, the choice of method can be tailored to clinical settings and resource availability, with the longer hospital‐based titration offering an acceptable alternative to traditional laboratory titration, potentially reducing medical supervision demands while maintaining treatment efficacy.

1. Introduction

In the past few decades, there has been a significant increase in the number of children receiving noninvasive continuous positive airway pressure (CPAP) therapy at home [1]. CPAP therapy can be successfully used in children of all ages for a variety of indications. The European Respiratory Society (ERS) statement on pediatric long‐term noninvasive respiratory support provides a comprehensive overview of all indications for CPAP found in the literature [2]. In infants (aged < 24 months) with moderate‐to‐severe obstructive sleep apnea syndrome (OSAS), who are not candidates for or do not improve after adenotonsillectomy or other surgical interventions, CPAP initiated at 4–6 cmH₂O and titrated up to 10 cmH₂O is an effective and well‐tolerated treatment [3]. However, there are currently no validated criteria for CPAP initiation in children, and very few studies have reported data on the effectiveness and tolerance of CPAP therapy in that particular population [4, 5, 6]. According to the American Academy of Sleep Medicine (AASM) recommendations, CPAP initiation should ideally be conducted through CPAP titration in a sleep laboratory [7]. However, this is often impractical due to the time‐consuming nature of such procedures and the limited number of pediatric sleep laboratories. In a laboratory setting, titration involves a doctor or technician adjusting pressure based on residual events under ventilation, whether during a nap or overnight (short‐supervised titration). Another approach to CPAP initiation has been reported involving 2–3 days of hospitalization without the “usual” titration but using built‐in software data analysis and nocturnal gas exchange recording [8]. Data acquired from CPAP devices are clinically useful, providing objective information regarding adherence, leak, and efficacy of CPAP therapy [9]. The reasons and rationale for CPAP treatment are explained to the caregivers on the first day, followed by a CPAP trial during a nap with pressure adjustments based on clinical indicators. Infants then sleep with CPAP during the first night. Potential issues, such as mask leaks, are addressed, and a manual analysis of the ventilator's built‐in software data along with the nocturnal gas exchange recording can be used to adjust the settings—a process termed long‐unsupervised titration. These two procedures, paired with therapeutic education sessions, are offered in our hospital, with the long‐unsupervised titration method requiring less medical supervision. To date, no studies have compared the different CPAP initiation procedures. In France, follow‐up is standardized, and nocturnal gas exchange monitoring may be carried out by a home care provider trained in pediatric noninvasive ventilation (NIV). Children benefit from a home nocturnal gas exchange (HNGE) evaluation to ensure effective treatment [10].

This retrospective study analyzed the clinical and physiological sleep data of children requiring CPAP/NIV after undergoing (nap)polysomnography, nocturnal gas exchange, or experiencing weaning difficulties. The primary objective of our study was to compare nocturnal gas exchange at the first HNGE following either short‐supervised or long‐unsupervised titration. The secondary objective was to evaluate adherence to treatment between these two titration methods.

2. Methods

The study was conducted at the Robert Debré Hospital's Sleep Unit in Paris, France, and included children under 2 years who needed CPAP. The study was conducted between January 2022 and November 2024. The CPAP device was chosen according to the manufacturer's recommendations—that is, based on a minimal weight. This choice was made to avoid an underestimation of objective compliance due to a low flow rate in young children, as previously reported [11]. CPAP or NIV initiation was considered when the apnea‐hypopnea index (AHI) exceeded 10 events/h despite upper airway surgery, when surgery was not indicated, or due to weaning difficulties in the pediatric intensive care unit (PICU) with or without hypoventilation (indicated by more than 25% of total sleep time spent with CO₂ levels over 50 mmHg). This study received approval from the Local Ethics Committee (PHENOSAS: N° 2018‐416), and data collection was registered with the French regulatory agency (CNIL). The parents of the participants were informed of the use of their data for research and were provided an opt‐out option, consistent with French law on noninterventional observational research. The study aligns with the STROBE guidelines for reporting observational studies.

Group allocation was determined by the availability of sleep laboratory facilities and/or technical staff. When resources were available, a short‐supervised titration study was conducted.

3. Diagnostic In‐Laboratory Polysomnography

Nap polysomnography (PSG) was performed for infants younger than 6 months, while an overnight PSG was recommended for older infants to ensure sufficient sleep. Nap PSG studies were conducted during spontaneous morning sleep. A minimum of two sleep cycles was set as the required duration. An Alice 6 LDx PSG system (Philips, Murrysville, PA) recorded the following parameters: chest and abdominal wall motion using respiratory inductance plethysmography, heart rate by electrocardiogram, arterial oxygen saturation (SpO₂) by pulse oximetry, transcutaneous PCO₂ (PtcCO₂) using the SenTec Digital Monitor (SenTec Inc., Therwil, Switzerland), airflow using a three‐pronged thermistor, nasal pressure by a pressure transducer, sleep using electroencephalographic leads (C3/A2, C4/A1, F3A2, F4A1, O1/A2, O2/A1), left and right electrooculograms, and submental electromyogram. The study participants were also recorded using an infrared video camera. Respiratory events, including apneas and hypopneas, were scored based on the AASM Scoring Manual (Version 2.4) [12] by experienced pediatric sleep physicians. The sleep stages were categorized as active sleep (equivalent to rapid eye movement [REM] sleep) or quiet sleep (equivalent to non‐REM sleep) for infants under 2 months at the time of the PSG, as recommended [13].

For overnight PSG, standard criteria were applied [14].

3.1. CPAP Lab Titration, Short‐Supervised

Following an OSAS diagnosis, a second in‐lab nap PSG was performed under the close supervision of a physician to establish the efficacy of the therapy and to allow any practical problems with mask fitting or attachment to be corrected.

CPAP was increased from a minimum starting point of 4 cmH₂O until obstructive respiratory events (apneas, hypopneas, and snoring) were eliminated, with increments of at least 1 cmH₂O applied no less than every 5 min [7]. In practice, there was a notable change in the child's breathing pattern as soon as an effective pressure was reached. Breathing became less labored, snoring stopped, arousals diminished, and SpO₂ stabilized. CPAP could only be classed as successful if it was shown to be effective in both quiet sleep (approximating to deep sleep stages) and active sleep (including REM sleep periods). The time taken to achieve a decision on CPAP efficacy was 2–4 h with CPAP in place. It depended on the level of CPAP required and the pattern of the sleep states of the infant. The children for whom CPAP was accepted and found to be effective were sent home with the appropriate equipment. The parents received a detailed explanation about obstructive sleep apnea, the need for treatment, and how the CPAP system works. Telephone support for any problems arising or for equipment replacement parts was also given to the families.

The infants who were discharged at home were treated with the pressure level that was determined during the titration study, and the parents were asked to administer CPAP to their infants during all sleeping periods, including daytime naps.

Bilevel positive airway pressure ventilation was considered for persistent sleep hypoventilation whenever PtcCO₂ levels exceeded 50 mmHg [12]. The minimum inspiratory positive airway pressure was set at 8 cmH₂O, with an inspiratory–expiratory positive airway pressure differential ranging from 4 to 10 cmH₂O.

3.2. Long‐Unsupervised Titration During Hospitalization

This method allows for CPAP/NIV initiation over a short hospitalization period of two to three nights, utilizing the detailed built‐in software analysis data. The initial CPAP levels were determined by OSAS severity and applied during a nap without PSG. The initial pressure was set between 4 and 9 cmH₂O depending on the clinical signs, such as snoring and retractions, with increases of 1 cmH₂O allowed every 5 min. For patients transitioning from PICU, the ventilator settings mirrored those used in the intensive care unit. Postinitiation adjustments were made based on nocturnal gas exchange and breath‐by‐breath analysis using the data recorded by the built‐in software of the CPAP device [15]. On the next day, CPAP was increased by at least 1 cmH₂O if apneas, hypopneas, or airflow limitations (Figure 1) were seen in the detailed data and/or overnight oxycapnography highlighted oxygen desaturation clusters [16] (Figure 2).

Figure 1.

Breath‐by‐breath tracings of an infant treated by constant CPAP. A 1‐min epoch of respiratory events, airway pressure, airflow, and unintentional leaks. Note the occurrence of obstructive events (arrow). [Color figure can be viewed at wileyonlinelibrary.com]

Figure 2.

Nocturnal gas exchange tracing report during hospitalization. Due to cluster desaturation (arrows), CPAP pressure was increased from 7 to 8 cmH₂O. [Color figure can be viewed at wileyonlinelibrary.com]

3.3. Home Nocturnal Gas Exchange

Under French law, follow‐up care is structured with reimbursement, including scheduled visits at 1 week, 1 month, 3 months, and then at least every 6 months after NIV/CPAP initiation. A home care provider trained in pediatric NIV performed an overnight recording of SpO₂ and PtcCO₂ using the SenTec Digital Monitor within the first month following hospital discharge. The key metrics recorded included median and maximum PtcCO₂ and percent time over 50 mmHg, alongside median and minimum SpO₂, and percent time spent with a SpO₂ < 90%. During the follow‐up visit, HNGE results and detailed data from the ventilator's built‐in software were used to determine whether adjustments for effective CPAP pressure were needed.

3.4. Adherence Data

Adherence data were downloaded from the ventilators' built‐in software during hospital and home visits, focusing on the last month of use coinciding with the HNGE. These adherence metrics were normalized against age‐specific recommended sleep durations per the National Sleep Foundation [17].

3.5. Sample Size

Sample size determination was guided by the literature, using prior [4, 5] studies reporting CPAP effectiveness in infants with obstructive sleep apnea. In these articles, the authors reported that nadir SpO₂ values observed in infants before CPAP treatment were 78% ± 12% [5] and 81% (with 25th–75th percentile of 75%–86%) [4]. While on CPAP, the nadir SpO₂ improved to 83% ± 6.75% and 91% (with 25th–75th percentile of 88%–93%), respectively. A power calculation for a noninferiority trial with a binary outcome was performed, aiming for 80% power with a 5% type I error, anticipating a success rate of 90% in both groups and a noninferiority margin of 25%. The criterion for a successful titration trial was defined as achieving a nadir SpO₂ ≥ 80% while on CPAP therapy. This threshold corresponds to the 10th percentile of the combined nadir SpO₂ observed across participants on CPAP in the two studies. This resulted in a minimal requirement of 18 children/group.

3.6. Statistical Analyses

Data are reported as medians with interquartile ranges (25th–75th percentiles). Comparisons of continuous variables between groups were performed using the t‐test or the Wilcoxon test when data violated assumptions of normality. Categorical variables were compared using the χ ² test or Fisher's test as appropriate. Normality was checked using the Shapiro–Wilk test. Additional statistical analyses are described in the text. A p < 0.05 was considered statistically significant. Analyses were conducted using StatView software from SAS Institute (Cary, North Carolina) and R 4.5.0.

4. Results

A total of 46 patients were included: 25 children undergoing short‐supervised titration and 21 children undergoing long‐unsupervised titration. In total, 32 participants underwent PSG, showing severe OSAS (5 overnight PSG and 27 nap PSG). Nine participants underwent overnight nocturnal gas exchange recording using a Sentec monitor; the results showed oxygen desaturation clusters or hypoventilation episodes with PtcCO₂ exceeding 50 mmHg more than 25% of their total sleep time. Five participants experienced weaning difficulties in the PICU before starting CPAP/NIV. The most common diagnosis was laryngomalacia (n = 14) followed by Down syndrome (n = 8). Other characteristics of the subjects are described in Table 1. OSAS severity and respiratory parameters in the diagnostic sleep study were comparable between the two groups (Table 1).

Table 1.

Characteristics of the 46 patients.

	Total population	Short‐supervised titration N = 25	Long‐unsupervised titration N = 21	p
Male/female, n	29/17	16/9	13/8	> 0.999
Age at initiation (months)	3.0 [1.8; 5.3]	3.1 [1.7; 7.0]	3.0 [2.3; 4.7]	0.886
Associated disorders, n (%)
– Down syndrome	8 (17)	8 (32)	0 (0)
– Laryngomalacia	14 (30)	6 (24)	8 (38)
– Pierre Robin sequence	4 (9)	3 (12)	1 (5)
– Polymalformative syndrome	5 (11)	1 (4)	4 (19)
– 22q11 deletion	1 (2)	1 (4)	0 (0)
– Prader–Willi syndrome	2 (4)	1 (4)	1 (5)
– Persistent OSA after AT	2 (4)	1 (4)	2 (10)
– Pharyngeal hypotonia from neurological origin	3 (7)	2 (8)	1 (5)
– Otherb	6 (13)	2 (8)	4 (19)
Type of sleep study performed
Nap polysomnography	27	13	14
Overnight polysomnography	5	4	1
Overnight SpO2 and PtcCO2 recording	9	5	4
Weaning difficulties	5	3	2
Sleep data (n = 32)
TST (min)	110 [88;143]	129 [83;196]	106 [92; 135]	0.527
Non‐REM sleep, %	63 [47; 72]	64 [47; 72]	63 [47; 72]	0.627
REM sleep, %	36 [27; 52]	36 [27; 53]	34 [27; 47]	0.522
Arousal (events:hours)	17.6 [10.8; 24.7]	17.9 [15.4; 25.1]	15.0 [9.6; 23.2]	0.635
Respiratory events
AHI (events:hours)	33.5 [25.0; 51.7]	29.5 [17.0; 53.2]	36.1 [27.4; 45.2]	0.710
Central AI (events:hours)	1.0 [0.6; 1.6]	1.1 [0.7; 1.5]	0.8 [0; 1.5]	0.320
Obstructive AI (events:hours)	13.8 [3.8; 28.2]	7.9 [5.2; 21.4]	16.9 [3.5; 33.6]	0.502
Hypopnea index (events:hours)	18.1 [10.5; 24.3]	19.4 [10.0; 26.0]	17.6 [10.8; 23.6]	0.852
Nocturnal gas exchange (n = 41)a
Median SpO2 (%)	96.0 [95.0; 97.0]	96.0 [95.0; 98.0]	95.5 [95.0; 97.0]	0.554
Minimal SpO2 (%)	80.0 [70.5; 86.0]	80.0 [71.0; 85.5]	80.0 [68.0; 86.0]	> 0.999
% of sleep time with SpO2 < 90% (%)	2.5 [0.3; 6.2]	2.5 [0.3; 6.3]	2.5 [0.4; 6.1]	0.946
3% oxygen desaturation index (events/h)	34.7 [22.7; 55.1]	30.9 [22.2; 47.9]	37.9 [28.8; 65.1]	0.341
Median PtcCO2 (mmHg)	41.6 [38.0; 47.0]	41.6 [39.5; 45.9]	41.5 [38.0; 48.1]	0.807
Maximal PtcCO2 (mmHg)	50.0 [44.0; 56.0]	50.8 [44.5; 53.0]	49.6 [44.8; 56.0]	> 0.999
% of sleep time with PtcCO2 > 50 mmHg (%)	0.0 [0.0; 10.0]	0.2 [0.0; 9.0]	0.0 [0.0; 17.0]	0.817

Note: Data are presented as median [25e; 75e p].

Abbreviations: AHI, apnea‐hypopnea index; AI, apnea index; SpO₂, pulse oximetry; PtcCO₂, transcutaneous carbon dioxide pressure.

^a Five patients had weaning difficulties and were ventilated in the PICU without prior sleep study.

^b Other syndromes were: ‐ for the group with short‐supervised titration: Simpson–Golabi–Behmel syndrome (one patient) and achondroplasia (one patient); for the group with long‐unsupervised titration: Moebius syndrome (one patient), Binder syndrome (one patient), subglottic stenosis (one patient), tracheobronchomalacia with interstitial lung disease (one patient).

The children with initiated CPAP/NIV were at a similar age in both groups (3.1 [1.7; 7.0] vs. 3.0 [2.3; 4.7] months, p = 0.886). Only three patients needed NIV, with two in the long‐unsupervised titration group. The median CPAP values were not different at hospital discharge in the two groups: 7.0 [6.0; 8.0] cmH₂O in the short‐supervised titration group versus 7.0 [6.5; 8.0] cmH₂O in the long‐unsupervised titration group (p = 0.722). The ventilator devices, types of interfaces, and the pressures used are reported in Table 2.

Table 2.

Nocturnal gas exchange and noninvasive respiratory support data following the titration.

	Short‐supervised titration N = 25	Long‐unsupervised titration N = 21	p
Noninvasive respiratory support data
NIV/CPAP, n	1/24	2/19
– CPAP	24	19
– ST mode	1	0
– PAC mode	0	2
Settings
– Median CPAP, cmH2O	7.0 [6.0; 8.0]	7.0 [6.5; 8.0]	0.722
– Initial pressure, cmH2O	4.0 [4.0; 4.0]	6.0 [6.0; 7.0]	< 10−4
Ventilator device, n
– Astral 150, RESMED	5	6
– Luisa, LOWENSTEIN	9	11
– Stellar 150, RESMED	3	1
– Vivo 45, BREAS	3	1
– Trilogy 100 or Evo, PHILIPS	5	2
Nasal mask/facial mask, n	25/0	20/1
Home nocturnal gas exchange (HNGE)
Delay between initiation and HNGE (months)	1.3 [1.0; 3.5]	1.4 [1.0; 6.0]	0.965
Median SpO2 (%)	97.0 [96.0; 98.0]	97.0 [95.0; 99.0]	0.737
Minimal SpO2 (%)	88.0 [85.0; 90.0]	85.0 [81; 90.0]	0.216
% of sleep time with SpO2 < 90% (%)	0.0 [0.0; 0.0]	0.0 [0.0; 0.0]	0.772
3% oxygen desaturation index (events/h)	7.5 [4.0; 15.8]	9.5 [4.0; 12.3]	0.944
Median PtcCO2 (mmHg)	41.2 [39.4; 42.9]	42.8 [38.7; 46.8]	0.374
Maximal PtcCO2 (mmHg)	45.5 [44.2; 49.9]	48.7 [43.6; 50.1]	0.587
% of sleep time with PtcCO2 > 50 mmHg (%)	0.0 [0.0; 0.0]	0.0 [0.0; 1.0]	0.313
Adherence data
Average use per night (h)	6.4 [3.7; 8.5]	9.8 [8.1; 11.5]	0.005
Average use per night corrected sleep need, %	51 [27; 65]	72 [60; 85]	0.006
Number of therapeutic education sessions, n	2 [0; 3]	5 [3; 5]	0.001

Note: Data are presented as median [25e; 75e p]. Bold values are statistically significant.

Abbreviations: AHI, apnea‐hypopnea index; CPAP, continuous positive airway pressure; SpO₂, pulse oximetry; PtcCO₂, transcutaneous carbon dioxide pressure; NIV, noninvasive ventilation; NRS, noninvasive respiratory support; HNGE, home nocturnal gas exchange.

At home, the children in the short‐supervised titration group demonstrated lower average use per night than the long‐unsupervised group: 6.4 [3.7; 8.5] versus 9.8 [8.1; 11.5] h (p = 0.005), respectively. They also had lower adherence when adjusted for sleep needs according to age: 51% [27; 65] versus 72% [60; 85] (p = 0.006). Fewer therapeutic education sessions were provided to the short‐supervised titration group than the long‐unsupervised titration group: 2 [0; 3] versus 5 [3; 5] (p = 0.001).

HNGE parameters, such as median SpO₂, minimal SpO₂, time spent with SpO₂ < 90%, oxygen desaturation index (ODI), median PtcCO₂, maximal PtcCO₂, and time spent over 50 mmHg, were not different between the two groups (Table 2). The time interval between the hospital discharge and the overnight recording of HNGE was similar for both groups: 1.3 months [1.0; 3.5] versus 1.4 months [1.0; 6.0] (p = 0.965). Five infants had their effective CPAP pressure adapted after the visit following the HNGE recording by the consulting physician (two children in the short‐supervised titration group and three in the long‐unsupervised titration group).

Two children in the short‐supervised titration group (8%) versus four in the long‐unsupervised titration (19%) had nadir SpO₂ under 80% (p = 0.390) (Fisher's exact test). After accounting for the underlying condition by including it as a random effect in a Bayesian mixed model, the titration allocation group remained unassociated with treatment failure (p = 0.149).

5. Discussion

Our study did not identify any significant differences in HNGE between the two titration procedures of CPAP therapy in infants with severe OSAS, with both groups showing nondifferent gas exchanges and comparable pressure levels. The short‐supervised titration procedure, described in international guidelines [7], was performed in infants and younger children who underwent PSG and were scheduled for nap titration based on staff and sleep laboratory availability. When sleep laboratory facilities were unavailable, the longer titration was performed during hospitalization. The allocation to each treatment group was primarily based on a random factor (sleep laboratory availability), which is reflected by the comparability of the groups in terms of clinical diagnosis. We aimed to determine whether these two procedures yielded similar results in follow‐up HNGE assessments. It is logical to assume that longer hospital stays, which included more therapeutic education sessions, could lead to better adherence. Importantly, the long‐unsupervised titration produced results—regarding required pressure and hematosis—that were not significantly different from those achieved with the recommended short‐supervised titration, which deserved to be demonstrated. Thus, either of the two titration procedures can be utilized, depending on the patient's setting.

Other researchers have compared the effectiveness and barriers to adherence of CPAP treatment in infants and school‐aged children with OSAS, demonstrating that CPAP is effective in most infants with pressure requirements similar to those of older children [4].

Initiating CPAP/NIV during short hospitalization using detailed built‐in software analysis requires less medical supervision and is less demanding in terms of time. However, in France, laboratory titration requires continuous medical supervision throughout the procedure to adjust pressures based on residual respiratory events such as apneas, hypopneas, and snoring. Home initiation of treatment for older children following outpatient consultations is also feasible. As demonstrated by another French team, adherence to this outpatient approach can be satisfactory and was similar to our results [8].

Objective adherence should be checked on the built‐in software of the CPAP device at every visit. However, no minimal CPAP utilization has been validated in children. It has been proposed that a minimal use of more than 4 h/night for at least 70% of the nights over a 30‐day period [18] or more than 50% of the total sleep time [15] may be sufficient to efficiently counteract the deleterious effects of OSAS. However, use during the entire sleep time seems the best target. In this study, we observed that most infants had a CPAP utilization above the threshold of 50% of recommended sleep time (Table 2). The differences in adherence observed between the groups may be partly explained by a higher number of therapeutic education sessions provided to children who did not undergo laboratory titration.

In adults with severe OSAS, one study found no difference in CPAP outcomes between starting at 10 cmH₂O and performing a titration, suggesting that fixed pressures can often be used empirically [19]. A similar approach could probably be proposed in children and infants as we found a median CPAP pressure of 7 cmH₂O [6; 8] to be efficient, which closely mirrors the final CPAP titration level reported by Cielo et al. [4], that is, 7 cmH₂O [5; 8]. However, other authors found lower median CPAP pressures from titration studies in infants: 5.7 cmH₂O [4–8] [5] or 4.6 ± 0.2 cmH₂O [20]. In older children, a CPAP level of 8 cmH₂O seems to be a reasonable choice, as reported by two large‐scale studies [5, 21].

Our study has some limitations. First, the longer hospital stays involved more therapeutic education sessions, which may have contributed to better adherence in our cohort. Second, almost all the infants had nap PSG for the diagnostic study, which is a potential limitation [22] as daytime nap PSG applied in infants and children with Down syndrome underestimates sleep‐disordered breathing severity [23]. Nevertheless, Singh and colleagues found that polysomnographic sleep parameters and the number of treatments prescribed were equivalent whether the PSG was performed during daytime or nighttime in a group of children aged < 6 months [24] who were evaluated for sleep‐disordered breathing. Other limitations include the single‐center data, a small sample size, and the retrospective nature of the study design.

In conclusion, this study confirms that initiating CPAP in infants under 2 years old, either with or without traditional laboratory titration, is feasible and effective. The outcomes of HNGE are comparable between the short‐supervised lab titration and the long‐unsupervised titration using the built‐in ventilator software data.

Author Contributions

Benjamin Dudoignon: conceptualization, investigation, writing – original draft, methodology, validation, visualization, writing – review and editing, supervision. Rim Abdelkarim: visualization, writing – review and editing, validation, methodology, formal analysis. Christophe Delclaux: methodology, writing – review and editing, conceptualization, visualization, validation. Plamen Bokov: writing – review and editing, methodology, validation, visualization, investigation, writing – original draft, conceptualization.

Ethics Statement

Ethical approval was obtained from our local Ethical Committee for collecting data from this cohort.

Consent

Consent obtained from parents.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.