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Teixeira RCP, Cahali MB. In-Laboratory Polysomnography Worsens Obstructive Sleep Apnea by Changing Body Position Compared to Home Testing. SENSORS (BASEL, SWITZERLAND) 2024; 24:2803. [PMID: 38732909 PMCID: PMC11086251 DOI: 10.3390/s24092803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 04/24/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024]
Abstract
(1) Background: Home sleep apnea testing, known as polysomnography type 3 (PSG3), underestimates respiratory events in comparison with in-laboratory polysomnography type 1 (PSG1). Without head electrodes for scoring sleep and arousal, in a home environment, patients feel unfettered and move their bodies more naturally. Adopting a natural position may decrease obstructive sleep apnea (OSA) severity in PSG3, independently of missing hypopneas associated with arousals. (2) Methods: Patients with suspected OSA performed PSG1 and PSG3 in a randomized sequence. We performed an additional analysis, called reduced polysomnography, in which we blindly reassessed all PSG1 tests to remove electroencephalographic electrodes, electrooculogram, and surface electromyography data to estimate the impact of not scoring sleep and arousal-based hypopneas on the test results. A difference of 15 or more in the apnea-hypopnea index (AHI) between tests was deemed clinically relevant. We compared the group of patients with and without clinically relevant differences between lab and home tests (3) Results: As expected, by not scoring sleep, there was a decrease in OSA severity in the lab test, similar to the home test results. The group of patients with clinically relevant differences between lab and home tests presented more severe OSA in the lab compared to the other group (mean AHI, 42.5 vs. 20.2 events/h, p = 0.002), and this difference disappeared in the home test. There was no difference between groups in the shift of OSA severity by abolishing sleep scoring in the lab. However, by comparing lab and home tests, there were greater variations in supine AHI and time spent in the supine position in the group with a clinically relevant difference, either with or without scoring sleep, showing an impact of the site of the test on body position during sleep. These variations presented as a marked increase or decrease in supine outcomes according to the site of the test, with no particular trend. (4) Conclusions: In-lab polysomnography may artificially increase OSA severity in a subset of patients by inducing marked changes in body position compared to home tests. The location of the sleep test seems to interfere with the evaluation of patients with more severe OSA.
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Affiliation(s)
- Raquel Chartuni Pereira Teixeira
- Department of Otolaryngology, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, sala 6167, São Paulo 05403-000, SP, Brazil;
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2
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Portable evaluation of obstructive sleep apnea in adults: A systematic review. Sleep Med Rev 2023; 68:101743. [PMID: 36657366 DOI: 10.1016/j.smrv.2022.101743] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 12/10/2022] [Accepted: 12/23/2022] [Indexed: 01/07/2023]
Abstract
Obstructive sleep apnea (OSA) is a significant healthcare burden affecting approximately one billion people worldwide. The prevalence of OSA is rising with the ongoing obesity epidemic, a key risk factor for its development. While in-laboratory polysomnography (PSG) is the gold standard for diagnosing OSA, it has significant drawbacks that prevent widespread use. Portable devices with different levels of monitoring are available to allow remote assessment for OSA. To better inform clinical practice and research, this comprehensive systematic review evaluated diagnostic performances, study cost and patients' experience of different levels of portable sleep studies (type 2, 3, and 4), as well as wearable devices and non-contact systems, in adults. Despite varying study designs and devices used, portable diagnostic tests are found to be sufficient for initial screening of patients at risk of OSA. Future studies are needed to evaluate cost effectiveness with the incorporation of portable diagnostic tests into the diagnostic pathway for OSA, as well as their application in patients with chronic respiratory diseases and other comorbidities that may affect test performance.
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Nassi TE, Ganglberger W, Sun H, Bucklin AA, Biswal S, van Putten MJAM, Thomas RJ, Westover MB. Automated Scoring of Respiratory Events in Sleep with a Single Effort Belt and Deep Neural Networks. IEEE Trans Biomed Eng 2021; 69:2094-2104. [PMID: 34928786 DOI: 10.1109/tbme.2021.3136753] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Automatic detection and analysis of respiratory events in sleep using a single respiratory effort belt and deep learning. METHODS Using 9,656 polysomnography recordings from the Massachusetts General Hospital (MGH), we trained a neural network (WaveNet) to detect obstructive apnea, central apnea, hypopnea and respiratory-effort related arousals. Performance evaluation included event-based analysis and apnea-hypopnea index (AHI) stratification. The model was further evaluated on a public dataset, the Sleep-Heart-Health-Study-1, containing 8,455 polysomnographic recordings. RESULTS For binary apnea event detection in the MGH dataset, the neural network obtained a sensitivity of 68%, a specificity of 98%, a precision of 65%, a F1-score of 67%, and an area under the curve for the receiver operating characteristics curve and precision-recall curve of 0.93 and 0.71, respectively. AHI prediction resulted in a mean difference of 0.417.8 and a r2 of 0.90. For the multiclass task, we obtained varying performances: 84% of all labeled central apneas were correctly classified, whereas this metric was 51% for obstructive apneas, 40% for respiratory effort related arousals and 23% for hypopneas. CONCLUSION Our fully automated method can detect respiratory events and assess the AHI accurately. Differentiation of event types is more difficult and may reflect in part the complexity of human respiratory output and some degree of arbitrariness in the criteria used during manual annotation. SIGNIFICANCE The current gold standard of diagnosing sleep-disordered breathing, using polysomnography and manual analysis, is time-consuming, expensive, and only applicable in dedicated clinical environments. Automated analysis using a single effort belt signal overcomes these limitations.
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Gupta M, Ish P, Chakrabarti S, Sen MK, Mishra P, Suri JC. Diagnostic accuracy and feasibility of portable sleep monitoring in patients with obstructive sleep apnea: Re-exploring the utility in the current COVID-19 pandemic. Monaldi Arch Chest Dis 2021; 92. [PMID: 34523322 DOI: 10.4081/monaldi.2021.1818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 08/03/2021] [Indexed: 11/23/2022] Open
Abstract
Portable sleep monitoring (PSM) is a promising alternative diagnostic tool for Obstructive Sleep Apnea (OSA) especially in high burden resource limited settings. We aimed to determine the diagnostic accuracy and feasibility of PSM device-based studies in patients presenting for evaluation of OSA at a tertiary care hospital in North-India. PSM studies (using a Type-III PSM device) were compared for technical reliability and diagnostic accuracy with the standard laboratory-based Type-I polysomnography (PSG). Patients were also interviewed about their experience on undergoing an unsupervised PSM studies. Fifty patients (68% males) were enrolled in the study, of which only 30% patients expressed their concerns about undergoing unsupervised PSM studies which included safety issues, ease of use, diagnostic accuracy, etc. Technical acceptability criteria were easily met by the PSM studies with signal loss in 12% studies (complete data loss and inaccessible data in 6% studies), warranting repetition sleep studies in four patients. The overall sensitivity of PSM device (AHI ≥5) was 93.5% (area under curve; AUC: 0.87). The diagnostic accuracy was 68.5%, 80%, and 91.4% for mild, moderate, and severe cases of OSA, respectively. An overall strong correlation was observed between PSM-AHI (apnoea-hypopnoea index) and PSG (r>0.85, p≤0.001), especially in severe OSA. The observed sensitivity was >90% for AHI>20 (clinically significant OSA), with high specificity of 91% for severe OSA (AUC: 0.94, 0.97 for AHI>20, AHI>30 respectively). The overall Bland-Altman concordance analysis also demonstrated only a small dispersion for PSM studies with a Cronbach's coefficient of 0.95. Therefore, there is good diagnostic accuracy as well as feasibility of home-based portable sleep studies in Indian patients. It can be promoted for widespread use in high burden countries like India for diagnosing and managing appropriately selected stable patients with high clinical probability of OSA, especially during the ongoing crises of COVID-19 pandemic.
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Affiliation(s)
- Mansi Gupta
- Department of Pulmonary Medicine, Sanjay Gandhi Post-graduate Institute of Medical sciences, Lucknow.
| | - Pranav Ish
- Department of Pulmonary, Critical Care and Sleep Medicine, Vardhmaan Mahavir Medical College and Safdarjung Hospital, New Delhi.
| | - Shibdas Chakrabarti
- Department of Pulmonary, Critical Care and Sleep Medicine, Vardhmaan Mahavir Medical College and Safdarjung Hospital, New Delhi.
| | - Manas Kamal Sen
- Department of Pulmonary, Critical Care and Sleep Medicine, Vardhmaan Mahavir Medical College and Safdarjung Hospital, New Delhi.
| | - Prabhakar Mishra
- Department of Biostatistics, Sanjay Gandhi Post-graduate Institute of Medical Sciences, Lucknow.
| | - Jagdish Chander Suri
- Department of Pulmonary, Critical Care and Sleep Medicine, Vardhmaan Mahavir Medical College and Safdarjung Hospital, New Delhi.
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Tiron R, Lyon G, Kilroy H, Osman A, Kelly N, O'Mahony N, Lopes C, Coffey S, McMahon S, Wren M, Conway K, Fox N, Costello J, Shouldice R, Lederer K, Fietze I, Penzel T. Screening for obstructive sleep apnea with novel hybrid acoustic smartphone app technology. J Thorac Dis 2020; 12:4476-4495. [PMID: 32944361 PMCID: PMC7475565 DOI: 10.21037/jtd-20-804] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Obstructive sleep apnea (OSA) has a high prevalence, with an estimated 425 million adults with apnea hypopnea index (AHI) of ≥15 events/hour, and is significantly underdiagnosed. This presents a significant pain point for both the sufferers, and for healthcare systems, particularly in a post COVID-19 pandemic world. As such, it presents an opportunity for new technologies that can enable screening in both developing and developed countries. In this work, the performance of a non-contact OSA screener App that can run on both Apple and Android smartphones is presented. Methods The subtle breathing patterns of a person in bed can be measured via a smartphone using the "Firefly" app technology platform [and underpinning software development kit (SDK)], which utilizes advanced digital signal processing (DSP) technology and artificial intelligence (AI) algorithms to identify detailed sleep stages, respiration rate, snoring, and OSA patterns. The smartphone is simply placed adjacent to the subject, such as on a bedside table, night stand or shelf, during the sleep session. The system was trained on a set of 128 overnights recorded at a sleep laboratory, where volunteers underwent simultaneous full polysomnography (PSG), and "Firefly" smartphone app analysis. A separate independent test set of 120 recordings was collected across a range of Apple iOS and Android smartphones, and withheld for performance evaluation by a different team. An operating point tuned for mid-sensitivity (i.e., balancing sensitivity and specificity) was chosen for the screener. Results The performance on the test set is comparable to ambulatory OSA screeners, and other smartphone screening apps, with a sensitivity of 88.3% and specificity of 80.0% [with receiver operating characteristic (ROC) area under the curve (AUC) of 0.92], for a clinical threshold for the AHI of ≥15 events/hour of detected sleep time. Conclusions The "Firefly" app based sensing technology offers the potential to significantly lower the barrier of entry to OSA screening, as no hardware (other than the user's personal smartphone) is required. Additionally, multi-night analysis is possible in the home environment, without requiring the wearing of a portable PSG or other home sleep test (HST).
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Affiliation(s)
- Roxana Tiron
- ResMed Sensor Technologies, NexusUCD, Dublin, Ireland
| | - Graeme Lyon
- ResMed Sensor Technologies, NexusUCD, Dublin, Ireland
| | - Hannah Kilroy
- ResMed Sensor Technologies, NexusUCD, Dublin, Ireland
| | - Ahmed Osman
- ResMed Sensor Technologies, NexusUCD, Dublin, Ireland
| | - Nicola Kelly
- ResMed Sensor Technologies, NexusUCD, Dublin, Ireland
| | | | - Cesar Lopes
- ResMed Sensor Technologies, NexusUCD, Dublin, Ireland
| | - Sam Coffey
- ResMed Sensor Technologies, NexusUCD, Dublin, Ireland
| | | | - Michael Wren
- ResMed Sensor Technologies, NexusUCD, Dublin, Ireland
| | - Kieran Conway
- ResMed Sensor Technologies, NexusUCD, Dublin, Ireland
| | - Niall Fox
- ResMed Sensor Technologies, NexusUCD, Dublin, Ireland
| | - John Costello
- ResMed Sensor Technologies, NexusUCD, Dublin, Ireland
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Punjabi NM, Patil S, Crainiceanu C, Aurora RN. Variability and Misclassification of Sleep Apnea Severity Based on Multi-Night Testing. Chest 2020; 158:365-373. [PMID: 32081650 DOI: 10.1016/j.chest.2020.01.039] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 01/20/2020] [Accepted: 01/24/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Portable monitoring is a convenient means for diagnosing sleep apnea. However, data on whether one night of monitoring is sufficiently precise for the diagnosis of sleep apnea are limited. RESEARCH QUESTION The current study sought to determine the variability and misclassification in disease severity over three consecutive nights in a large sample of patients referred for sleep apnea. METHODS A sample of 10,340 adults referred for sleep apnea testing was assessed. A self-applied type III monitor was used for three consecutive nights. The apnea-hypopnea index (AHI) was determined for each night, and a reference AHI was computed by using data from all 3 nights. Pairwise correlations and the proportion misclassified regarding disease severity were computed for each of the three AHI values against the reference AHI. RESULTS Strong correlations were observed between the AHI from each of the 3 nights (r = 0.87-0.89). However, substantial within-patient variability in the AHI and significant misclassification in sleep apnea severity were observed based on any 1 night of monitoring. Approximately 93% of the patients with a normal study on the first night and 87% of those with severe sleep apnea on the first night were correctly classified compared with the reference derived from all three nights. However, approximately 20% of the patients with mild and moderate sleep apnea on the first night were misdiagnosed either as not having sleep apnea or as having mild disease, respectively. CONCLUSIONS In patients with mild to moderate sleep apnea, one night of portable testing can lead to misclassification of disease severity given the substantial night-to-night variability in the AHI.
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Affiliation(s)
- Naresh M Punjabi
- Department of Medicine, Johns Hopkins University, Baltimore, MD; Department of Epidemiology, Johns Hopkins University, Baltimore, MD.
| | - Susheel Patil
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | | | - R Nisha Aurora
- Department of Medicine, Johns Hopkins University, Baltimore, MD
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Veauthier C, Ryczewski J, Mansow-Model S, Otte K, Kayser B, Glos M, Schöbel C, Paul F, Brandt AU, Penzel T. Contactless recording of sleep apnea and periodic leg movements by nocturnal 3-D-video and subsequent visual perceptive computing. Sci Rep 2019; 9:16812. [PMID: 31727918 PMCID: PMC6856090 DOI: 10.1038/s41598-019-53050-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 10/23/2019] [Indexed: 11/24/2022] Open
Abstract
Contactless measurements during the night by a 3-D-camera are less time-consuming in comparison to polysomnography because they do not require sophisticated wiring. However, it is not clear what might be the diagnostic benefit and accuracy of this technology. We investigated 59 persons simultaneously by polysomnography and 3-D-camera and visual perceptive computing (19 patients with restless legs syndrome (RLS), 21 patients with obstructive sleep apnea (OSA), and 19 healthy volunteers). There was a significant correlation between the apnea hypopnea index (AHI) measured by polysomnography and respiratory events measured with the 3-D-camera in OSA patients (r = 0.823; p < 0.001). The receiver operating characteristic curve yielded a sensitivity of 90% for OSA with a specificity of 71.4%. In RLS patients 72.8% of leg movements confirmed by polysomnography could be detected by 3-D-video and a significant moderate correlation was found between PLM measured by polysomnography and by the 3-D-camera (RLS: r = 0.654; p = 0.004). In total, 95.4% of the sleep epochs were correctly classified by the machine learning approach, but only 32.5% of awake epochs. Further studies should investigate, if this technique might be an alternative to home sleep testing in persons with an increased pre-test probability for OSA.
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Affiliation(s)
- Christian Veauthier
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Interdisciplinary Center of Sleep Medicine, Berlin, Germany.
| | - Juliane Ryczewski
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Interdisciplinary Center of Sleep Medicine, Berlin, Germany.,Department of Neurology, Bundeswehr-Krankenhaus, 10115, Berlin, Germany
| | | | - Karen Otte
- Motognosis GmbH, Berlin, Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, NeuroCure Clinical Research Center, Berlin, Germany
| | | | - Martin Glos
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Interdisciplinary Center of Sleep Medicine, Berlin, Germany
| | - Christoph Schöbel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Interdisciplinary Center of Sleep Medicine, Berlin, Germany
| | - Friedemann Paul
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, NeuroCure Clinical Research Center, Berlin, Germany.,Clinical and Experimental Multiple Sclerosis Research Center, Department of Neurology, Charité University Medicine Berlin, and Experimental and Clinical Research Center, Max Delbrück Center for Molecular Medicine and Charité University Medicine Berlin, Berlin, Germany
| | - Alexander U Brandt
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, NeuroCure Clinical Research Center, Berlin, Germany.,Clinical and Experimental Multiple Sclerosis Research Center, Department of Neurology, Charité University Medicine Berlin, and Experimental and Clinical Research Center, Max Delbrück Center for Molecular Medicine and Charité University Medicine Berlin, Berlin, Germany.,Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Thomas Penzel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Interdisciplinary Center of Sleep Medicine, Berlin, Germany.,International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic
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Sowho MO, Patil S, Schneider H, MacCarrick G, Kirkness JP, Wolfe LF, Sterni L, Cistulli PA, Neptune ER. Sleep disordered breathing in Marfan syndrome: Value of standard screening questionnaires. Mol Genet Genomic Med 2019; 8:e1039. [PMID: 31707771 PMCID: PMC6978263 DOI: 10.1002/mgg3.1039] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 09/16/2019] [Accepted: 10/16/2019] [Indexed: 12/12/2022] Open
Abstract
Background A high prevalence of sleep disordered breathing (SDB) has been reported in persons with Marfan syndrome (MFS), a single gene disorder of connective tissue resulting in premature death from aortic rupture. The burden of SDB and accompanying hemodynamic stress could warrant broad screening in this population. Our goal was to assess the utility of traditional SDB screening tools in our sample of persons with MFS. Methods Participants were recruited during an annual Marfan Foundation meeting and Marfan status confirmed using the Ghent criteria. Screening questionnaires were administered and SDB assessed by home sleep testing. We assessed accuracy of screening tools using receiver‐operating characteristic curve analyses. Results The prevalence of moderate‐severe SDB was 32% in our sample of 31 MFS participants. The Stop‐Bang questionnaire had the highest positive predictive value (PPV) of 60% and the highest negative predictive value (NPV) of 100% using the high‐ and moderate‐risk cut‐offs, respectively, and the Berlin questionnaire had a PPV of 50% and an NPV of 92.3% at the high‐risk cut‐off. When those with mild SDB were included, the Stop‐Bang and the Sleep Apnea Clinical Score (SACS) questionnaires demonstrated useful screening accuracies with PPVs of 94.7% and 92.9%, and NPVs of 63.6% and 47.1%, respectively, at the moderate‐risk cut‐offs. Conclusion A survey of SDB in a sample of persons with MFS reveals not only a high burden of SDB but also that conventional screening instruments have utility if adapted appropriately. Future studies should validate the utility of these screening tools given concerns that SDB may contribute to progression of aortic pathology in MFS.
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Affiliation(s)
- Mudiaga O Sowho
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Susheel Patil
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Hartmut Schneider
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Gretchen MacCarrick
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jason P Kirkness
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Lisa F Wolfe
- Pulmonary Division, Northwestern University, Chicago, IL, USA
| | - Laura Sterni
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Peter A Cistulli
- Charles Perkins Centre, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Department of Respiratory Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Enid R Neptune
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
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9
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Distance to Specialist Medical Care and Diagnosis of Obstructive Sleep Apnea in Rural Saskatchewan. Can Respir J 2019; 2019:1683124. [PMID: 30733845 PMCID: PMC6348862 DOI: 10.1155/2019/1683124] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 12/23/2018] [Indexed: 12/18/2022] Open
Abstract
Obstructive sleep apnea (OSA) is the most common sleep-disordered breathing condition. Patients with OSA symptoms are often not diagnosed clinically, which is a concern, given the health and safety risks associated with unmanaged OSA. The availability of fewer practicing medical specialists combined with longer travel distances to access health care services results in barriers to diagnosis and treatment in rural communities. This study aimed to (1) determine whether the proportion of adults reporting OSA symptoms in the absence of a sleep apnea diagnosis in rural populations varied by travel distance to specialist medical care and (2) assess whether any distance-related patterns were attributable to differences in the frequency of diagnosis among adults who likely required this specialist medical care. We used a cross-sectional epidemiologic study design, augmented by analysis of follow-up survey data. Our study base included adults who completed a 2010 baseline questionnaire for the Saskatchewan Rural Health Study. Follow-up occurred until 2015. 6525 adults from 3731 households constituted our sample. Statistical models used log-binomial regression. Rural adults who reported the largest travel distances (≥250 km) to specialist medical care were 1.17 (95% CI: 1.07, 1.29) times more likely to report OSA symptoms in the absence of a sleep apnea diagnosis than those who reported the smallest (<100 km; referent) distances. However, the proportion of sleep apnea diagnoses was low and unaffected by reported travel distance among adults who likely required this specialist medical care. Our findings suggest factors other than travel distance may be contributing to the low sleep apnea diagnostic rate. This remains important as undiagnosed and untreated OSA has serious implications on the health of people and populations, but effective treatments are available. Health care access barriers to the diagnosis and treatment of OSA require evaluation to inform health care planning and delivery.
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Bhat S, Gupta D, Akel O, Polos PG, DeBari VA, Akhtar S, McIntyre A, Ming SX, Upadhyay H, Chokroverty S. The relationships between improvements in daytime sleepiness, fatigue and depression and psychomotor vigilance task testing with CPAP use in patients with obstructive sleep apnea. Sleep Med 2018; 49:81-89. [PMID: 30093261 DOI: 10.1016/j.sleep.2018.06.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 06/22/2018] [Accepted: 06/25/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The purpose of this study was to determine if the subjective improvements in daytime sleepiness, fatigue and depression experienced by patients with obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) therapy predict an objective improvement in vigilance, and whether patients with mild-to-moderate OSA differ from patients with severe OSA in this regard. METHODS A total of 182 patients underwent psychomotor vigilance task (PVT) testing and measurements of subjective daytime sleepiness, fatigue and depression at baseline and after a minimum of one month of adherent CPAP use at an adequate pressure. RESULTS Patients with both mild-to-moderate (n = 92) and severe (n = 90) OSA experienced improvements in subjective daytime sleepiness, fatigue and depression, but objective improvement in vigilance was only seen in patients with severe OSA. In patients with severe OSA, while a correlation was found between improvements in daytime sleepiness and some PVT parameters, changes in subjective daytime sleepiness, fatigue and depression scores were not predictive of objective improvement in vigilance while controlling for all these subjective symptoms and for age, gender, body mass index, apnea-hypopnea index/respiratory event index and total sleep time/total recording time with pulse oximetry below 90%. CONCLUSIONS We found no predictive relationship between subjective improvements in daytime sleepiness, fatigue and depression and objective vigilance with CPAP use in patients with OSA. These results suggest that subjective complaints of daytime impairment and objective measures of vigilance in patients with OSA should be assessed separately while evaluating the efficacy of CPAP therapy on daytime functioning.
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Affiliation(s)
- Sushanth Bhat
- JFK Neuroscience Institute, Hackensack Meridian Health-JFK Medical Center, Edison, NJ 08818, USA.
| | - Divya Gupta
- JFK Neuroscience Institute, Hackensack Meridian Health-JFK Medical Center, Edison, NJ 08818, USA
| | - Omar Akel
- JFK Neuroscience Institute, Hackensack Meridian Health-JFK Medical Center, Edison, NJ 08818, USA
| | - Peter G Polos
- JFK Neuroscience Institute, Hackensack Meridian Health-JFK Medical Center, Edison, NJ 08818, USA
| | | | - Shaista Akhtar
- JFK Neuroscience Institute, Hackensack Meridian Health-JFK Medical Center, Edison, NJ 08818, USA
| | - Anna McIntyre
- JFK Neuroscience Institute, Hackensack Meridian Health-JFK Medical Center, Edison, NJ 08818, USA
| | - Sue X Ming
- Rutgers University-New Jersey Medical School, Newark, NJ, USA
| | | | - Sudhansu Chokroverty
- JFK Neuroscience Institute, Hackensack Meridian Health-JFK Medical Center, Edison, NJ 08818, USA
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Esbensen AJ, Hoffman EK, Stansberry E, Shaffer R. Convergent validity of actigraphy with polysomnography and parent reports when measuring sleep in children with Down syndrome. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2018; 62:281-291. [PMID: 29314419 PMCID: PMC5847446 DOI: 10.1111/jir.12464] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 11/07/2017] [Accepted: 11/29/2017] [Indexed: 05/10/2023]
Abstract
BACKGROUND There is a need for rigorous measures of sleep in children with Down syndrome as sleep is a substantial problem in this population and there are barriers to obtaining the gold standard polysomnography (PSG). PSG is cost-prohibitive when measuring treatment effects in some clinical trials, and children with Down syndrome may not cooperate with undergoing a PSG. Minimal information is available on the validity of alternative methods of assessing sleep in children with Down syndrome, such as actigraphy and parent ratings. Our study examined the concurrent and convergent validity of different measures of sleep, including PSG, actigraphy and parent reports of sleep among children with Down syndrome. METHOD A clinic (n = 27) and a community (n = 47) sample of children with Down syndrome were examined. In clinic, children with Down syndrome wore an actigraph watch during a routine PSG. In the community, children with Down syndrome wore an actigraph watch for a week at home at night as part of a larger study on sleep and behaviour. Their parent completed ratings of the child's sleep during that same week. RESULTS Actigraph watches demonstrated convergent validity with PSG when measuring a child with Down syndrome's total amount of sleep time, total wake time after sleep onset and sleep period efficiency. In contrast, actigraph watches demonstrated poor correlations with parent reports of sleep, and with PSG when measuring the total time in bed and total wake episodes. Actigraphy, PSG and parent ratings of sleep demonstrated poor concurrent validity with clinical diagnosis of obstructive sleep apnoea. CONCLUSION Our current data suggest that actigraph watches demonstrate convergent validity and are sensitive to measuring certain sleep constructs (duration, efficiency) in children with Down syndrome. However, parent reports, such as the Children's Sleep Habits Questionnaire, may be measuring other sleep constructs. These findings highlight the importance of selecting measures of sleep related to target concerns.
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Affiliation(s)
- A J Esbensen
- Division of Developmental and Behavioral Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - E K Hoffman
- Division of Developmental and Behavioral Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - E Stansberry
- Division of Developmental and Behavioral Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - R Shaffer
- Division of Developmental and Behavioral Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Mendonça F, Mostafa SS, Ravelo-García AG, Morgado-Dias F, Penzel T. Devices for home detection of obstructive sleep apnea: A review. Sleep Med Rev 2018; 41:149-160. [PMID: 30149930 DOI: 10.1016/j.smrv.2018.02.004] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 01/16/2018] [Accepted: 02/09/2018] [Indexed: 01/15/2023]
Abstract
One of the most common sleep-related disorders is obstructive sleep apnea, characterized by a reduction of airflow while breathing during sleep and cause significant health problems. This disorder is mainly diagnosed in sleep labs with polysomnography, involving high costs and stress for the patient. To address this situation multiple systems have been proposed to conduct the examination and analysis in the patient's home, using sensors to detect physiological signals that are examined by algorithms. The objective of this research is to review publications that show the performance of different devices for ambulatory diagnosis of sleep apnea. Commercial systems that were examined by an independent research group and validated research projects were selected. In total 117 articles were analysed, including a total of 50 commercial devices. Each article was evaluated according to diagnostic elements, level of automatisation implemented and the deducted level of evidence and quality rating. Each device was categorized using the SCOPER categorization system, including an additional proposed category, and a final comparison was performed to determine the sensors that provided the best results.
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Affiliation(s)
- Fábio Mendonça
- Madeira Interactive Technologies Institute, Portugal; Universidade de Lisboa, Instituto Superior Técnico, Portugal
| | - Sheikh Shanawaz Mostafa
- Madeira Interactive Technologies Institute, Portugal; Universidade de Lisboa, Instituto Superior Técnico, Portugal
| | - Antonio G Ravelo-García
- Universidad de Las Palmas de Gran Canaria, Institute for Technological Development and Innovation in Communications, Spain.
| | - Fernando Morgado-Dias
- Madeira Interactive Technologies Institute, Portugal; Universidade da Madeira, Portugal
| | - Thomas Penzel
- Charité Universitatsmedizin, Sleep Center, Germany; International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic
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13
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Corral J, Sánchez-Quiroga MÁ, Carmona-Bernal C, Sánchez-Armengol Á, de la Torre AS, Durán-Cantolla J, Egea CJ, Salord N, Monasterio C, Terán J, Alonso-Alvarez ML, Muñoz-Méndez J, Arias EM, Cabello M, Montserrat JM, De la Peña M, Serrano JC, Barbe F, Masa JF. Conventional Polysomnography Is Not Necessary for the Management of Most Patients with Suspected Obstructive Sleep Apnea. Noninferiority, Randomized Controlled Trial. Am J Respir Crit Care Med 2017. [PMID: 28636405 DOI: 10.1164/rccm.201612-2497oc] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Home respiratory polygraphy may be a simpler alternative to in-laboratory polysomnography for the management of more symptomatic patients with obstructive sleep apnea, but its effectiveness has not been evaluated across a broad clinical spectrum. OBJECTIVES To compare the long-term effectiveness (6 mo) of home respiratory polygraphy and polysomnography management protocols in patients with intermediate-to-high sleep apnea suspicion (most patients requiring a sleep study). METHODS A multicentric, noninferiority, randomized controlled trial with two open parallel arms and a cost-effectiveness analysis was performed in 12 tertiary hospitals in Spain. Sequentially screened patients with sleep apnea suspicion were randomized to respiratory polygraphy or polysomnography protocols. Moreover, both arms received standardized therapeutic decision-making, continuous positive airway pressure (CPAP) treatment or a healthy habit assessment, auto-CPAP titration (for CPAP indication), health-related quality-of-life questionnaires, 24-hour blood pressure monitoring, and polysomnography at the end of follow-up. The main outcome was the Epworth Sleepiness Scale measurement. The noninferiority criterion was -2 points on the Epworth scale. MEASUREMENTS AND MAIN RESULTS In total, 430 patients were randomized. The respiratory polygraphy protocol was noninferior to the polysomnography protocol based on the Epworth scale. Quality of life, blood pressure, and polysomnography were similar between protocols. Respiratory polygraphy was the most cost-effective protocol, with a lower per-patient cost of 416.7€. CONCLUSIONS Home respiratory polygraphy management is similarly effective to polysomnography, with a substantially lower cost. Therefore, polysomnography is not necessary for most patients with suspected sleep apnea. This finding could change established clinical practice, with a clear economic benefit. Clinical trial registered with www.clinicaltrials.gov (NCT 01752556).
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Affiliation(s)
- Jaime Corral
- 1 San Pedro de Alcántara Hospital, Cáceres, Spain.,2 Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Maria-Ángeles Sánchez-Quiroga
- 2 Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,3 Virgen del Puerto Hospital, Plasencia, Cáceres, Spain
| | | | | | - Alicia Sánchez de la Torre
- 2 Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,5 Arnau de Vilanova y Santa María Hospital, Lleida, Spain
| | - Joaquín Durán-Cantolla
- 2 Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,6 Organización Sanitaria Integrada Araba University Hospital, Bioaraba Research Institute, Vitoria, Spain
| | - Carlos J Egea
- 2 Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,6 Organización Sanitaria Integrada Araba University Hospital, Bioaraba Research Institute, Vitoria, Spain
| | - Neus Salord
- 2 Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,7 Bellvitge Hospital, Hospitalet de Llobregat, Barcelona, Spain
| | - Carmen Monasterio
- 2 Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,7 Bellvitge Hospital, Hospitalet de Llobregat, Barcelona, Spain
| | - Joaquín Terán
- 2 Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,8 Burgos University Hospital, Burgos, Spain
| | - M Luz Alonso-Alvarez
- 2 Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,8 Burgos University Hospital, Burgos, Spain
| | | | | | | | - Josep M Montserrat
- 2 Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,11 Clinic Hospital, Barcelona, Spain
| | - Mónica De la Peña
- 2 Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,12 Son Espases Hospital, Mallorca, Spain; and
| | | | - Ferran Barbe
- 2 Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,5 Arnau de Vilanova y Santa María Hospital, Lleida, Spain
| | - Juan F Masa
- 1 San Pedro de Alcántara Hospital, Cáceres, Spain.,2 Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
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Methodological strategies in using home sleep apnea testing in research and practice. Sleep Breath 2017; 22:569-577. [PMID: 29139016 DOI: 10.1007/s11325-017-1593-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 11/03/2017] [Accepted: 11/08/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE Home sleep apnea testing (HSAT) has increased due to improvements in technology, accessibility, and changes in third party reimbursement requirements. Research studies using HSAT have not consistently reported procedures and methodological challenges. This paper had two objectives: (1) summarize the literature on use of HSAT in research of adults and (2) identify methodological strategies to use in research and practice to standardize HSAT procedures and information. METHODS Search strategy included studies of participants undergoing sleep testing for OSA using HSAT. MEDLINE via PubMed, CINAHL, and Embase with the following search terms: "polysomnography," "home," "level III," "obstructive sleep apnea," and "out of center testing." RESULTS Research articles that met inclusion criteria (n = 34) inconsistently reported methods and methodological challenges in terms of: (a) participant sampling; (b) instrumentation issues; (c) clinical variables; (d) data processing; and (e) patient acceptability. Ten methodological strategies were identified for adoption when using HSAT in research and practice. CONCLUSIONS Future studies need to address the methodological challenges summarized in this paper as well as identify and report consistent HSAT procedures and information.
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15
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Investigating Cost Implications of Incorporating Level III At-Home Testing into a Polysomnography Based Sleep Medicine Program Using Administrative Data. Can Respir J 2017; 2017:8939461. [PMID: 28790878 PMCID: PMC5534303 DOI: 10.1155/2017/8939461] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 06/08/2017] [Indexed: 11/25/2022] Open
Abstract
Objective Obstructive sleep apnea is a common problem, requiring expensive in-lab polysomnography for proper diagnosis. Home monitoring can provide an alternative to in-lab testing for a subset of OSA patients. The objective of this project was to investigate the effect of incorporating home testing into an OSA program at a large, tertiary sleep disorders centre. Methods The Sleep Disorders Centre in Saskatoon, Canada, has been incorporating at-home testing into their diagnostic pathways since 2006. Administrative data from 2007 to 2013 were extracted (10030 patients) and the flow of patients through the program was followed from diagnosis to treatment. Costs were estimated using 2014 pricing and were stratified by disease attributes and sensitivity analysis was applied. Results The overall costs per patient were $627.40, with $419.20 for at-home testing and $746.20 for in-lab testing. The cost of home management would rise to $515 if all negative tests were required to be confirmed by an in-lab PSG. Discussion Our review suggests that at-home testing can be cost-effective alternative to in-lab testing when applied to the correct population, specifically, those with a high pretest probability of obstructive sleep apnea and an absence of significant comorbidities.
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Hunsaker DH, Riffenburgh RH. Snoring Significance in Patients Undergoing Home Sleep Studies. Otolaryngol Head Neck Surg 2016; 134:756-60. [PMID: 16647530 DOI: 10.1016/j.otohns.2006.01.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2005] [Accepted: 01/25/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE: To analyze the impact of snoring, independent of obstructive sleep apnea syndrome on patients referred for home sleep studies and to report a new technology for the reporting of snoring, using sophisticated sound collection and noise-canceling technology. STUDY DESIGN AND SETTING: A retrospective statistical review of consecutive anonymous data compiled from questionnaires and digital data of snoring loudness and duration measured at the upper lip during unattended home sleep studies in 4,860 patients referred for snoring and sleep-disturbed breathing. RESULTS: A strong relationship exists between a history of snoring and complaints of daytime sleepiness (80%), obesity (73%), and chronic fatigue (78%) (all yield P < 0.001). By contrast, only 42% to 48% of patients without these symptoms complain of snoring. In 3 multiple-regression analyses, the percent of time snoring, average loudness, and peak loudness are all significantly predicted by the apnea hypopnea index (all P < 0.003), body mass index (all P < 0.001), and age ( P = 0.014). Daytime sleepiness was strongly predicted by percent time snoring ( P = 0.014), weakly by average loudness ( P = 0.046), and not at all by peak loudness (P = 0.303). CONCLUSION: By using a pair of microphones placed at the upper lip, one that samples breath sounds and the other ambient sound and artifact noise, the NovaSOM QSG measures snoring while canceling ambient noise. The clinical impact of snoring on the patient as well as the bed partner, independent of obstructive sleep apnea syndrome, is an unrecognized factor in sleep-disturbed breathing. SIGNIFICANCE: Measurable criteria to define snoring are suggested. Snoring loudness is not measured in most laboratory Polysomnograms. EBM rating: B-3b
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Affiliation(s)
- Darrell H Hunsaker
- Department of Otolaryngology, Naval Medical Center San Diego, San Diego, California 92109, USA.
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17
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Nonaka R, Emoto T, Abeyratne UR, Jinnouchi O, Kawata I, Ohnishi H, Akutagawa M, Konaka S, Kinouchi Y. Automatic snore sound extraction from sleep sound recordings via auditory image modeling. Biomed Signal Process Control 2016. [DOI: 10.1016/j.bspc.2015.12.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Krishnaswamy U, Aneja A, Kumar RM, Kumar TP. Utility of portable monitoring in the diagnosis of obstructive sleep apnea. J Postgrad Med 2016; 61:223-9. [PMID: 26440391 PMCID: PMC4943369 DOI: 10.4103/0022-3859.166509] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Obstructive sleep apnea (OSA) is a common but underdiagnosed sleep disorder, which is associated with systemic consequences such as hypertension, stroke, metabolic syndrome, and ischemic heart disease. Nocturnal laboratory-based polysomnography (PSG) is the gold standard test for diagnosis of OSA. PSG consists of a simultaneous recording of multiple physiologic parameters related to sleep and wakefulness including electroencephalography (EEG), electrooculography (EOG), surface electromyography (EMG), airflow measurement using thermistor and nasal pressure transducer, pulse oximetry and respiratory effort (thoracic and abdominal). Multiple alternative and simpler methods that record respiratory parameters alone for diagnosing OSA have been developed in the past two decades. These devices are called portable monitors (PMs) and enable performing sleep studies at a lower cost with shorter waiting times. It has been observed and reported that comprehensive sleep evaluation coupled with the use of PMs can fulfill the unmet need for diagnostic testing in various out-of-hospital settings in patients with suspected OSA. This article reviews the available medical literature on PMs in order to justify the utility of PMs in the diagnosis of OSA, especially in resource-poor, high-disease burden settings. The published practice parameters for the use of these devices have also been reviewed with respect to their relevance in the Indian setting.
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Affiliation(s)
| | - A Aneja
- Department of Respiratory Medicine, MS Ramaiah Medical College, Bangalore, Karnataka, India
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Comparative Study between Sequential Automatic and Manual Home Respiratory Polygraphy Scoring Using a Three-Channel Device: Impact of the Manual Editing of Events to Identify Severe Obstructive Sleep Apnea. SLEEP DISORDERS 2015; 2015:314534. [PMID: 26347825 PMCID: PMC4549605 DOI: 10.1155/2015/314534] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 07/28/2015] [Indexed: 11/18/2022]
Abstract
Objective. According to current guidelines, autoscoring of respiratory events in respiratory polygraphy requires manual scoring. The aim of this study was to evaluate the agreement between automatic analysis and manual scoring to identify patients with suspected OSA. Methods. This retrospective study analyzed 791 records from respiratory polygraphy (RP) performed at home. The association grade between automatic scoring and manual scoring was evaluated using Kappa coefficient and the agreement using Bland and Altman test and intraclass correlation coefficient (CCI). To determine the accuracy in the identification of AHI ≥ 30 eV/h, the ROC curve analysis was used. Results. The population analyzed consisted of 493 male (62.3%) and 298 female patients, with an average age of 54.7 ± 14.20 years and BMI of 32.7 ± 8.21 kg/m2. There was no significant difference between automatic and manual apnea/hypopnea indexes (aAHI, mAHI): aAHI 17.25 (SD: 17.42) versus mAHI 21.20 ± 7.96 (p; NS). The agreement between mAHI and aAHI to AHI ≥ 30 was 94%, with a Kappa coefficient of 0.83 (p < 0.001) and a CCI of 0.83. The AUC-ROC, sensitivity, and specificity were 0.99 (CI 95%: 0.98-0.99, p < 0.001), 86% (CI 95%: 78.7–91.4), and 97% (CI 95%: 96–98.3), respectively. Conclusions. We observed good agreement between automatic scoring and sequential manual scoring to identify subjects with AHI ≥ 30 eV/h.
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Ward KL, McArdle N, James A, Bremner AP, Simpson L, Cooper MN, Palmer LJ, Fedson AC, Mukherjee S, Hillman DR. A Comprehensive Evaluation of a Two-Channel Portable Monitor to "Rule in" Obstructive Sleep Apnea. J Clin Sleep Med 2015; 11:433-44. [PMID: 25580606 PMCID: PMC4365457 DOI: 10.5664/jcsm.4600] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 11/18/2014] [Indexed: 02/02/2023]
Abstract
STUDY OBJECTIVES We hypothesized that a dual-channel portable monitor (PM) device could accurately identify patients who have a high pretest probability of obstructive sleep apnea (OSA), and we evaluated factors that may contribute to variability between PM and polysomnography (PSG) results. METHODS Consecutive clinic patients (N = 104) with possible OSA completed a home PM study, a PM study simultaneous with laboratory PSG, and a second home PM study. Uniform data analysis methods were applied to both PM and PSG data. Primary outcomes of interest were the positive likelihood ratio (LR+) and sensitivity of the PM device to "rule-in" OSA, defined as an apnea-hypopnea index (AHI) ≥ 5 events/h on PSG. Effects of different test environment and study nights, and order of study and analysis methods (manual compared to automated) on PM diagnostic accuracy were assessed. RESULTS The PM has adequate LR+ (4.8), sensitivity (80%), and specificity (83%) for detecting OSA in the unattended home setting when benchmarked against laboratory PSG, with better LR+ (> 5) and specificity (100%) and unchanged sensitivity (80%) in the simultaneous laboratory comparison. There were no significant night-night (all p > 0.10) or study order effects (home or laboratory first, p = 0.08) on AHI measures. Manual PM data review improved case finding accuracy, although this was not statistically significant (all p > 0.07). Misclassification was more frequent where OSA was mild. CONCLUSIONS Overall performance of the PM device is consistent with current recommended criteria for an "acceptable" device to confidently "rule-in" OSA (AHI ≥ 5 events/h) in a high pretest probability clinic population. Our data support the utility of simple two-channel diagnostic devices to confirm the diagnosis of OSA in the home environment. COMMENTARY A commentary on this article appears in this issue on page 411.
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Affiliation(s)
- Kim L. Ward
- School of Population Health, The University of Western Australia, Perth, Australia
- Western Australian Sleep Disorders Research Institute, Queen Elizabeth Medical Centre, Perth, Australia
| | - Nigel McArdle
- Western Australian Sleep Disorders Research Institute, Queen Elizabeth Medical Centre, Perth, Australia
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Alan James
- Western Australian Sleep Disorders Research Institute, Queen Elizabeth Medical Centre, Perth, Australia
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Perth, Australia
- School of Medicine and Pharmacology, The University of Western Australia, Perth, Australia
| | - Alexandra P. Bremner
- School of Population Health, The University of Western Australia, Perth, Australia
| | - Laila Simpson
- School of Anatomy and Human Biology, The University of Western Australia, Perth, Australia
| | - Matthew N. Cooper
- Telethon Kids Institute, The University of Western Australia, Subiaco, Australia
| | - Lyle J. Palmer
- The Joanna Briggs Institute and School of Translational Health Science, University of Adelaide, Adelaide, Australia
| | - Annette C. Fedson
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania, PA
| | - Sutapa Mukherjee
- Western Australian Sleep Disorders Research Institute, Queen Elizabeth Medical Centre, Perth, Australia
| | - David R. Hillman
- Western Australian Sleep Disorders Research Institute, Queen Elizabeth Medical Centre, Perth, Australia
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Perth, Australia
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O’Brien LM, Bullough AS, Chames MC, Shelgikar AV, Armitage R, Guilleminualt C, Sullivan CE, Johnson TRB, Chervin RD. Hypertension, snoring, and obstructive sleep apnoea during pregnancy: a cohort study. BJOG 2014; 121:1685-93. [PMID: 24888772 PMCID: PMC4241143 DOI: 10.1111/1471-0528.12885] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2014] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To assess the frequency of obstructive sleep apnoea among women with and without hypertensive disorders of pregnancy. DESIGN Cohort study. SETTING Obstetric clinics at an academic medical centre. POPULATION Pregnant women with hypertensive disorders (chronic hypertension, gestational hypertension, or pre-eclampsia) and women who were normotensive. METHODS Women completed a questionnaire about habitual snoring and underwent overnight ambulatory polysomnography. MAIN OUTCOME MEASURES The presence and severity of obstructive sleep apnoea. RESULTS Obstructive sleep apnoea was found among 21 of 51 women with hypertensive disorders (41%), but in only three of 16 women who were normotensive (19%, chi-square test, P=0.005). [Author correction added on 16 June 2014, after first online publication: Results mentioned in the abstract were amended.] Non-snoring women with hypertensive disorders typically had mild obstructive sleep apnoea, but >25% of snoring women with hypertensive disorders had moderate to severe obstructive sleep apnoea. Among women with hypertensive disorders, the mean apnoea/hypopnoea index was substantially higher in snorers than in non-snorers (19.9±34.1 versus 3.4±3.1, P=0.013), and the oxyhaemoglobin saturation nadir was significantly lower (86.4±6.6 versus 90.2±3.5, P=0.021). Among women with hypertensive disorders, after stratification by obesity, the pooled relative risk for obstructive sleep apnoea in snoring women with hypertension compared with non-snoring women with hypertension was 2.0 (95% CI 1.4-2.8). CONCLUSIONS Pregnant women with hypertension are at high risk for unrecognised obstructive sleep apnoea. Although longitudinal and intervention studies are urgently needed, given the known relationship between obstructive sleep apnoea and hypertension in the general population, it would seem pertinent that hypertensive pregnant women who snore should be tested for obstructive sleep apnoea, a condition believed to cause or promote hypertension.
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Affiliation(s)
- Louise M. O’Brien
- Sleep Disorders Center and Department of Neurology, University of Michigan, Ann Arbor, MI
- Department of Obstetrics & Gynecology, University of Michigan, Ann Arbor, MI
- Department of Oral & Maxillofacial Surgery, University of Michigan, Ann Arbor, MI
| | | | - Mark C. Chames
- Department of Obstetrics & Gynecology, University of Michigan, Ann Arbor, MI
| | - Anita V. Shelgikar
- Sleep Disorders Center and Department of Neurology, University of Michigan, Ann Arbor, MI
| | | | | | - Colin E. Sullivan
- Department of Respiratory Medicine, University of Sydney, Sydney, Australia
| | | | - Ronald D. Chervin
- Sleep Disorders Center and Department of Neurology, University of Michigan, Ann Arbor, MI
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Guerrero A, Embid C, Isetta V, Farre R, Duran-Cantolla J, Parra O, Barbé F, Montserrat JM, Masa JF. Management of sleep apnea without high pretest probability or with comorbidities by three nights of portable sleep monitoring. Sleep 2014; 37:1363-73. [PMID: 25083017 DOI: 10.5665/sleep.3932] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) diagnosis using simplified methods such as portable sleep monitoring (PM) is only recommended in patients with a high pretest probability. The aim is to determine the diagnostic efficacy, consequent therapeutic decision-making, and costs of OSA diagnosis using polysomnography (PSG) versus three consecutive studies of PM in patients with mild to moderate suspicion of sleep apnea or with comorbidity that can mask OSA symptoms. DESIGN AND SETTING Randomized, blinded, crossover study of 3 nights of PM (3N-PM) versus PSG. The diagnostic efficacy was evaluated with receiver operating characteristic (ROC) curves. Therapeutic decisions to assess concordance between the two different approaches were performed by sleep physicians and respiratory physicians (staff and residents) using agreement level and kappa coefficient. The costs of each diagnostic strategy were considered. PATIENTS AND RESULTS Fifty-six patients were selected. Epworth Sleepiness Scale was 10.1 (5.3) points. Bland-Altman plot for apnea-hypopnea index (AHI) showed good agreement. ROC curves showed the best area under the curve in patients with PSG AHI ≥ 5 [0.955 (confidence interval = 0.862-0.993)]. For a PSG AHI ≥ 5, a PM AHI of 5 would effectively exclude and confirm OSA diagnosis. For a PSG AHI ≥ 15, a PM AHI ≥ 22 would confirm and PM AHI < 7 would exclude OSA. The best agreement of therapeutic decisions was achieved by the sleep medicine specialists (81.8%). The best cost-diagnostic efficacy was obtained by the 3N-PM. CONCLUSIONS Three consecutive nights of portable monitoring at home evaluated by a qualified sleep specialist is useful for the management of patients without high pretest probability of obstructive sleep apnea or with comorbidities. CLINICAL TRIAL REGISTRATION http://www.clinicaltrials.gov, registration number: NCT01820156. CITATION Guerrero A, Embid C, Isetta V, Farre R, Duran-Cantolla J, Parra O, Barbé F, Montserrat JM, Masa JF. Management of sleep apnea without high pretest probability or with comorbidities by three nights of portable sleep monitoring.
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Affiliation(s)
- Arnoldo Guerrero
- Pulmonary and Critical Care Service. Dr. José Eleuterio González University Hospital. UANL. Monterrey, México ; Pulmonary Service. Clínic Hospital. UB-IDIBAPS. Barcelona, Spain
| | - Cristina Embid
- Pulmonary Service. Clínic Hospital. UB-IDIBAPS. Barcelona, Spain ; CIBER de enfermedades respiratorias (CIBERES). Madrid, Spain
| | - Valentina Isetta
- CIBER de enfermedades respiratorias (CIBERES). Madrid, Spain ; Unit of Biophysics and Bioengineering. Faculty of Medicine. IDIBAPS. University of Barcelona. Barcelona, Spain
| | - Ramón Farre
- CIBER de enfermedades respiratorias (CIBERES). Madrid, Spain ; Unit of Biophysics and Bioengineering. Faculty of Medicine. IDIBAPS. University of Barcelona. Barcelona, Spain
| | - Joaquin Duran-Cantolla
- CIBER de enfermedades respiratorias (CIBERES). Madrid, Spain ; Bio-Araba Research Institute and Clinical Research Unit, Hospital Universitario Araba. Vitoria, Spain
| | - Olga Parra
- CIBER de enfermedades respiratorias (CIBERES). Madrid, Spain ; Pulmonary Service. Sagrat Cor Hospital. Barcelona, Spain
| | - Ferran Barbé
- CIBER de enfermedades respiratorias (CIBERES). Madrid, Spain ; Respiratory Dept. IRBLleida. Lleida, Spain
| | - Josep M Montserrat
- Pulmonary Service. Clínic Hospital. UB-IDIBAPS. Barcelona, Spain ; CIBER de enfermedades respiratorias (CIBERES). Madrid, Spain
| | - Juan F Masa
- CIBER de enfermedades respiratorias (CIBERES). Madrid, Spain ; Pulmonary Service. Hospital San Pedro de Alcantara. Cáceres. Spain
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Chiner E, Andreu AL, Sancho-Chust JN, Sánchez-de-la-Torre A, Barbé F. The use of ambulatory strategies for the diagnosis and treatment of obstructive sleep apnea in adults. Expert Rev Respir Med 2014; 7:259-73. [DOI: 10.1586/ers.13.19] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Seetho IW, Wilding JPH. Screening for obstructive sleep apnoea in obesity and diabetes--potential for future approaches. Eur J Clin Invest 2013; 43:640-55. [PMID: 23586795 DOI: 10.1111/eci.12083] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 03/07/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND It is recognised that sleep-disordered breathing (SDB), in particular, obstructive sleep apnoea (OSA) is associated with obesity and diabetes. The complications of OSA include dysregulation of metabolic and cardiovascular homeostasis. With the growing population of diabetes and obesity globally, it is becoming apparent that identifying and screening patients who are at risk is becoming increasingly crucial. Many patients may remain unaware of the potential diagnosis and continue to be undiagnosed. The high prevalence of OSA poses a demanding challenge to healthcare providers in order to provide sufficient resources and facilities for patient diagnosis and treatment. DESIGN In this article, we review the evidence in favour of screening populations deemed to be at increased risk of OSA, with particular reference to patients with obesity and diabetes. We consider the recent advances in potential screening methods that may allow new prognostic and predictive tools to be developed. A detailed search of Medline and Web of Science electronic databases for relevant articles in English was performed. RESULTS Apart from the use of screening tools such as questionnaires and clinical decision models, there is increasing evidence to suggest that there are differences in biological parameters in patients with OSA. Although further studies are required, there may be potential for such biomarkers to contribute to and augment the screening process. However, the significance of such biological tools remains to be elucidated. CONCLUSIONS A fundamental role for improved screening in patients with conditions such as obesity and diabetes can enable early interventions that may improve health outcomes relating to the adverse consequences of OSA. The future will see further research being carried out in the development of potential screening methods with emphasis on the selection of patients at risk of sleep disorders, thereby allowing more detailed physiological studies to be carried out where needed.
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Affiliation(s)
- Ian W Seetho
- Department of Obesity & Endocrinology, University of Liverpool, Clinical Sciences Centre, University Hospital Aintree, Liverpool, UK.
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Patil SP. Preoperative Evaluation of Obstructive Sleep Apnea. Sleep Med Clin 2013. [DOI: 10.1016/j.jsmc.2012.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Masa JF, Corral J, Gomez de Terreros J, Duran-Cantolla J, Cabello M, Hernández-Blasco L, Monasterio C, Alonso A, Chiner E, Aizpuru F, Zamorano J, Cano R, Montserrat JM, Garcia-Ledesma E, Pereira R, Cancelo L, Martinez A, Sacristan L, Salord N, Carrera M, Sancho-Chust JN, Embid C. Significance of including a surrogate arousal for sleep apnea-hypopnea syndrome diagnosis by respiratory polygraphy. Sleep 2013; 36:249-57. [PMID: 23372273 DOI: 10.5665/sleep.2384] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
RATIONALE Respiratory polygraphy is an accepted alternative to polysomnography (PSG) for sleep apnea/hypopnea syndrome (SAHS) diagnosis, although it underestimates the apnea-hypopnea index (AHI) because respiratory polygraphy cannot identify arousals. OBJECTIVES We performed a multicentric, randomized, blinded crossover study to determine the agreement between home respiratory polygraphy (HRP) and PSG, and between simultaneous respiratory polygraphy (respiratory polygraphy with PSG) (SimultRP) and PSG by means of 2 AHI scoring protocols with or without hyperventilation following flow reduction considered as a surrogate arousal. METHODS We included suspected SAHS patients from 8 hospitals. They were assigned to home and hospital protocols at random. We determined the agreement between respiratory polygraphy AHI and PSG AHI scorings using Bland and Altman plots and diagnostic agreement using receiver operating characteristic (ROC) curves. The agreement in therapeutic decisions (continuous positive airway pressure treatment or not) between HRP and PSG scorings was done with likelihood ratios and post-test probability calculations. RESULTS Of 366 randomized patients, 342 completed the protocol. AHI from HRP scorings (with and without surrogate arousal) had similar agreement with PSG. AHI from SimultRP with surrogate arousal scoring had better agreement with PSG than AHI from SimultRP without surrogate arousal. HRP with surrogate arousal scoring had slightly worse ROC curves than HRP without surrogate arousal, and the opposite was true for SimultRP scorings. HRP with surrogate arousal showed slightly better agreement with PSG in therapeutic decisions than for HRP without surrogate arousal. CONCLUSION Incorporating a surrogate arousal measure into HRP did not substantially increase its agreement with PSG when compared with the usual procedure (HRP without surrogate arousal).
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Affiliation(s)
- Juan F Masa
- San Pedro de Alcantara Hospital, Caceres, Spain.
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Zhang C, Berger M, Malhotra A, Kales SN. Portable diagnostic devices for identifying obstructive sleep apnea among commercial motor vehicle drivers: considerations and unanswered questions. Sleep 2012; 35:1481-9. [PMID: 23115397 PMCID: PMC3466795 DOI: 10.5665/sleep.2194] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Obstructive sleep apnea (OSA), a syndrome defined by breathing abnormalities during sleep, can lead to fatigue and excessive daytime sleepiness (EDS) with an increased risk of motor vehicle crashes. Identifying commercial motor vehicle operators with unrecognized OSA is a major public health priority. Portable monitors (PMs) are being actively marketed to trucking firms as potentially lower-cost and more accessible alternatives to the reference standard of in-laboratory polysomnography (PSG) in the diagnosis of OSA among commercial motor vehicle operators. Several factors regarding PMs remain uncertain in this unique patient population: their sensitivity and specificity; the cost-benefit ratio of the PMs versus PSG; potential barriers from human factors; and evolving technologic advancement. Human factors that alter test accuracy are a major concern among commercial drivers motivated to gain/maintain employment. Current available data using PMs as a diagnostic tool among CMV operators indicate relatively high data loss and high loss to follow-up. Loss to follow-up has also been an issue using PSG in commercial motor vehicle operators. Furthermore, PM testing and PM results interpretation protocols may have no sleep specialist oversight, and sometimes minimal physician oversight and involvement. Additional studies comparing unattended and unmonitored PMs directly against full in-laboratory PSG are needed to provide evidence for their efficacy among commercial motor vehicle operators.
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Affiliation(s)
- Chunbai Zhang
- Environmental and Occupational Medicine and Epidemiology, Harvard School of Public Health, Boston, MA
- Division of Sleep Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Mark Berger
- Precision Pulmonary Diagnostics, 8275 El Rio Street, Houston, TX
| | - Atul Malhotra
- Division of Sleep Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Stefanos N. Kales
- Environmental and Occupational Medicine and Epidemiology, Harvard School of Public Health, Boston, MA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA
- Employee and Industrial Medicine, Cambridge Health Alliance, Cambridge, MA
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Oliveira MG, Nery LE, Santos-Silva R, Sartori DE, Alonso FF, Togeiro SM, Tufik S, Bittencourt L. Is portable monitoring accurate in the diagnosis of obstructive sleep apnea syndrome in chronic pulmonary obstructive disease? Sleep Med 2012; 13:1033-8. [PMID: 22841038 DOI: 10.1016/j.sleep.2012.06.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 05/09/2012] [Accepted: 06/14/2012] [Indexed: 01/11/2023]
Abstract
BACKGROUND No scientific evidence supports the use of portable devices to diagnose obstructive sleep apnea syndrome (OSAS) in patients with co-morbities. Our aim was to evaluate the accuracy of a portable monitoring device (Stardust - STD) in the detection of patients with chronic obstructive pulmonary disease (COPD). METHODS Patients with COPD and clinical suspicion of OSAS were recruited for a prospective randomized study. The STD was used on two different nights: (1) at home (STDHome) and (2) at the sleep laboratory simultaneous with polysomnography (PSG-STDLab). RESULTS A total of 72 patients underwent the proposed recordings. Forty-six volunteers were excluded due to recording problems, and data from 26 subjects were analyzed. The mean age was (mean±SD) 62.8±8.5 years, 50% were male, and the mean forced expiratory volume in the first second was 55±11%. Significant intraclass correlation was observed between apnea-hypopnea index (AHI)-PSG vs. AHI-STDLab (r=0.61, p<0.0001) and AHI-STDHome (r=0.47, p<0.007). Kappa analysis also showed a significant agreement for severe group. CONCLUSION Despite the agreement found in a small number of patients between AHI, a large number of failures in the recording limits the use of this portable device for the diagnosis of OSAS in patients with COPD.
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Affiliation(s)
- Marcia Gonçalves Oliveira
- Disciplina de Pneumologia, Departamento de Clínica Médica, Universidade Federal de Sao Paulo - UNIFESP, Sao Paulo/SP, Brazil
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Validity of sheet-type portable monitoring device for screening obstructive sleep apnea syndrome. Sleep Breath 2012; 17:589-95. [PMID: 22707086 DOI: 10.1007/s11325-012-0725-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 05/21/2012] [Accepted: 05/23/2012] [Indexed: 10/28/2022]
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Collop NA, Tracy SL, Kapur V, Mehra R, Kuhlmann D, Fleishman SA, Ojile JM. Obstructive sleep apnea devices for out-of-center (OOC) testing: technology evaluation. J Clin Sleep Med 2012; 7:531-48. [PMID: 22003351 DOI: 10.5664/jcsm.1328] [Citation(s) in RCA: 251] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Guidance is needed to help clinicians decide which out-of-center (OOC) testing devices are appropriate for diagnosing obstructive sleep apnea (OSA). A new classification system that details the type of signals measured by these devices is presented. This proposed system categorizes OOC devices based on measurements of Sleep, Cardiovascular, Oximetry, Position, Effort, and Respiratory (SCOPER) parameters.Criteria for evaluating the devices are also presented, which were generated from chosen pre-test and post-test probabilities. These criteria state that in patients with a high pretest probability of having OSA, the OOC testing device has a positive likelihood ratio (LR+) of 5 or greater coinciding with an in-lab-polysomnography (PSG)-generated apnea hypopnea index (AHI) ≥ 5, and an adequate sensitivity (at least 0.825).Since oximetry is a mandatory signal for scoring AHI using PSG, devices that do not incorporate oximetry were excluded. English peer-reviewed literature on FDA-approved devices utilizing more than 1 signal was reviewed according to the above criteria for 6 questions. These questions specifically addressed the adequacy of different respiratory and effort sensors and combinations thereof to diagnose OSA. In summary, the literature is currently inadequate to state with confidence that a thermistor alone without any effort sensor is adequate to diagnose OSA; if a thermal sensing device is used as the only measure of respiration, 2 effort belts are required as part of the montage and piezoelectric belts are acceptable in this context; nasal pressure can be an adequate measurement of respiration with no effort measure with the caveat that this may be device specific; nasal pressure may be used in combination with either 2 piezoelectric or respiratory inductance plethysmographic (RIP) belts (but not 1 piezoelectric belt); and there is insufficient evidence to state that both nasal pressure and thermistor are required to adequately diagnose OSA. With respect to alternative devices for diagnosing OSA, the data indicate that peripheral arterial tonometry (PAT) devices are adequate for the proposed use; the device based on cardiac signals shows promise, but more study is required as it has not been tested in the home setting; for the device based on end-tidal CO(2) (ETCO(2)), it appears to be adequate for a hospital population; and for devices utilizing acoustic signals, the data are insufficient to determine whether the use of acoustic signals with other signals as a substitute for airflow is adequate to diagnose OSA.Standardized research is needed on OOC devices that report LR+ at the appropriate AHI (≥ 5) and scored according to the recommended definitions, while using appropriate research reporting and methodology to minimize bias.
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Mäuser WS, Sandrock S, Kotzott L, Bonnemeier H. [Screening for sleep apnea in cardiovascular patients in clinical routine]. Herzschrittmacherther Elektrophysiol 2012; 23:27-32. [PMID: 22395802 DOI: 10.1007/s00399-012-0169-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Sleep apnea syndromes (SAS) are highly prevalent in cardiovascular patients. Because diagnostics are cost and labor intensive, these patients often remain undiagnosed. For this reason, simple screening methods for SAS in daily clinical practice are very important. Standardized questionnaires are one way to screen patients, i.e., simple standardized questionnaires have been shown to be highly predictive in OSA, but not in CSA patients. Simple ambulatory screening devices use oxymetry and/or nasal flow to determine the apnea-hypopnea index (AHI). These devices have been shown to be highly effective in screening for OSA and CSA. In addition, algorithms that calculate the electrocardiography (ECG)-derived AHI using heart rate variability and/or QRS morphology from Holter ECG recordings are also promising. Especially the latter method could become a simple tool for cardiologists to screen for SAS in clinical routine.
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Affiliation(s)
- W S Mäuser
- Universitätsklinikum Schleswig-Holstein, Campus Kiel, Klinik für Innere Medizin III, Kardiologie und Angiologie, Arnold-Heller-Str. 3, 24105, Kiel, Deutschland.
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Hesselbacher S, Mattewal A, Hirshkowitz M, Sharafkhaneh A. Classification, Technical Specifications, and Types of Home Sleep Testing Devices for Sleep-Disordered Breathing. Sleep Med Clin 2011. [DOI: 10.1016/j.jsmc.2011.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Masa JF, Corral J, Pereira R, Duran-Cantolla J, Cabello M, Hernández-Blasco L, Monasterio C, Alonso A, Chiner E, Zamorano J, Aizpuru F, Montserrat JM. Therapeutic decision-making for sleep apnea and hypopnea syndrome using home respiratory polygraphy: a large multicentric study. Am J Respir Crit Care Med 2011; 184:964-71. [PMID: 21737584 DOI: 10.1164/rccm.201103-0428oc] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Home respiratory polygraphy (HRP) is an alternative to polysomnography (PSG) for sleep apnea-hypopnea syndrome (SAHS) diagnosis. However, therapeutic decision-making is a different process than diagnosis. OBJECTIVES This study aimed to determine the agreement between HRP and in-hospital PSG for therapeutic decision-making in a large sample. METHODS Patients with an intermediate or high SAHS suspicion were included in a multicenter study (eight sleep centers) and assigned to home and hospital protocols in a random order. Therapeutic decisions (continuous positive airway pressure, no continuous positive airway pressure, or impossible decision) were made by an investigator in each center, based on using either HRP or PSG and a single set of auxiliary clinical variables. Patients and diagnostic methods (HRP and PSG) were assessed in random order using an electronic database. After a month the same therapeutic decision-making procedure was repeated with the same method. MEASUREMENTS AND MAIN RESULTS Of 366 randomized patients, 348 completed the protocol. The "impossible decision" case was not observed with either PSG or HRP. Therapeutic decisions using HRP had a sensitivity of 73%, a specificity of 77%, and an agreement level (sum of true positives and negatives) of 76%. Patients with higher HRP apnea-hypopnea index (AHI) scores (≥ 30; 41% of the total sample) had a sensitivity of 94%, a specificity of 44%, and the agreement level was 91%. CONCLUSIONS The HRP-based therapeutic decision was adequate when AHI was high, but deficient in the large population of patients with mild to moderate AHI. Therefore, both selecting patients with a high suspicion and severity of SAHS and future prospective cost-effectiveness studies are necessary.
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Affiliation(s)
- Juan F Masa
- San Pedro de Alcántara Hospital, Cáceres, Spain.
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Pietzsch JB, Garner A, Cipriano LE, Linehan JH. An integrated health-economic analysis of diagnostic and therapeutic strategies in the treatment of moderate-to-severe obstructive sleep apnea. Sleep 2011; 34:695-709. [PMID: 21629357 DOI: 10.5665/sleep.1030] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) is a common disorder associated with substantially increased cardiovascular risks, reduced quality of life, and increased risk of motor vehicle collisions due to daytime sleepiness. This study evaluates the cost-effectiveness of three commonly used diagnostic strategies (full-night polysomnography, split-night polysomnography, unattended portable home-monitoring) in conjunction with continuous positive airway pressure (CPAP) therapy in patients with moderate-to-severe OSA. DESIGN A Markov model was created to compare costs and effectiveness of different diagnostic and therapeutic strategies over a 10-year interval and the expected lifetime of the patient. The primary measure of cost-effectiveness was incremental cost per quality-adjusted life year (QALY) gained. PATIENTS OR PARTICIPANTS Baseline computations were performed for a hypothetical average cohort of 50-year-old males with a 50% pretest probability of having moderate-to-severe OSA (apnea-hypopnea index [AHI] ≥ 15 events per hour). MEASUREMENTS AND RESULTS For a patient with moderate-to-severe OSA, CPAP therapy has an incremental cost-effectiveness ratio (ICER) of $15,915 per QALY gained for the lifetime horizon. Over the lifetime horizon in a population with 50% prevalence of OSA, full-night polysomnography in conjunction with CPAP therapy is the most economically efficient strategy at any willingness-to-pay greater than $17,131 per-QALY gained because it dominates all other strategies in comparative analysis. CONCLUSIONS Full-night polysomnography (PSG) is cost-effective and is the preferred diagnostic strategy for adults suspected to have moderate-to-severe OSA when all diagnostic options are available. Split-night PSG and unattended home monitoring can be considered cost-effective alternatives when full-night PSG is not available.
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Maurer JT. Early diagnosis of sleep related breathing disorders. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2010; 7:Doc03. [PMID: 22073090 PMCID: PMC3199834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Obstructive sleep apnea (OSA) being the most frequent sleep related breathing disorder results in non-restorative sleep, an increased cardiovascular morbidity and mortality as well as an elevated number of accidents. In Germany at least two million people have to be expected. If obstructive sleep apnea is diagnosed early enough then sleep may regain its restorative function, daytime performance may be improved and accident risk as well as cardiovascular risk may be normalised. This review critically evaluates anamnestic parameters, questionnaires, clinical findings and unattended recordings during sleep regarding their diagnostic accurracy in recognising OSA. There are numerous tools with insufficient results or too few data disqualifying them for screening for OSA. Promising preliminary results are published concerning neural network analysis of a high number of clinical parameters and non-linear analysis of oximetry itself or in combination with heart rate. Nasal pressure recordings can be used for risk estimation even without expertise in sleep medicine. More data is needed. Unattended portable monitoring used by qualified physicians is the gold standard procedure when screening methods for OSA are compared. It has a very high sensitivity and specificity well documented by several meta-analyses.
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Affiliation(s)
- Joachim T. Maurer
- Sleep Disorders Centre, University Dept. of Otorhinolaryngology, Head and Neck Surgery Mannheim, Medical Faculty Mannheim of the Ruprecht-Karls-University Heidelberg, Mannheim, Germany,*To whom correspondence should be addressed: Joachim T. Maurer, Sleep Disorders Centre, University Dept. of Otorhinolaryngology, Head and Neck Surgery Mannheim, Medical Faculty Mannheim of the Ruprecht-Karls-University Heidelberg, 68135 Mannheim, Germany, Telephone: +49 (0)621 383 1600, Telefax: +49 (0)621 383 1972, E-mail:
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Tiihonen P, Hukkanen T, Tuomilehto H, Mervaala E, Pääkkönen A, Töyräs J. Accuracy of automatic analysis of ambulatory recordings of nocturnal breathing disorders is significantly instrumentation dependent. J Med Eng Technol 2009; 33:386-93. [PMID: 19440918 DOI: 10.1080/03091900902739999] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Obstructive sleep apnoea (OSA) is generally diagnosed with ambulatory recordings. Although reliability of automated analysis has been investigated, suitability of one single analysis software for use with different devices is unclear. Here, validity of automatic analysis of recordings with two ambulatory devices and reliability of automatic analysis in detection of mixed and central apnoeas are investigated through 100 and 167 recordings with Venla and Embletta devices, respectively. Recordings were analysed automatically with Somnologica 3.2 and compared to manual analysis. Significant differences were seen between devices in classification of the severity of OSA when automatic analysis was applied. 65.4% and 11.4% of patients with mild obstructive sleep apnoea received false negative diagnosis with Venla and Embletta, respectively. Further, as automatic analysis was seen to have major difficulty in detection and classification of central and mixed apnoeas, manual analysis is suggested when these forms of disease are suspected.
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Affiliation(s)
- P Tiihonen
- Department of Clinical Neurophysiology, Kuopio University Hospital, Kuopio, Finland.
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Santos-Silva R, Sartori DE, Truksinas V, Truksinas E, Alonso FFFD, Tufik S, Bittencourt LRA. Validation of a portable monitoring system for the diagnosis of obstructive sleep apnea syndrome. Sleep 2009; 32:629-36. [PMID: 19480230 PMCID: PMC2675898 DOI: 10.1093/sleep/32.5.629] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
STUDY OBJECTIVE To evaluate if a portable monitor could accurately measure the apnea-hypopnea index (AHI) in patients with a suspicion of obstructive sleep apnea (OSA). DESIGN Prospective and randomized. SETTING Sleep laboratory. PARTICIPANTS 80 participants: 70 patients with clinical OSA suspicion and 10 subjects without suspicion of OSA. INTERVENTIONS N/A. MEASUREMENTS AND RESULTS Three-order randomized evaluations were performed: (1) STD (Stardust II) used at the participants' home (STD home), (2) STD used simultaneously with PSG in the sleep lab (STD+PSG lab), and (3) PSG performed without the STD (PSG lab). Four AHI values were generated and analyzed: (a) STD home; (b) STD from STD+PSG lab; (c) PSG from STD+PSG (named PSG+STD lab); and (d) PSG lab. Two technicians, blinded to study details, performed the analyses of all evaluations. There was a strong correlation between AHI from the STD and PSG recordings for all 4 AHI values (all correlations above 0.87). Sensitivity, specificity, and positive and negative predictive values at AHI cut-off values of 5, 15, and 30 events/hour were calculated. AHI values from the PSG lab and PSG+STD lab were compared to STD home and STD+PSG lab and showed the best results when STD and PSG were performed simultaneously. In all analyses, the area under ROC curve was at least 0.90. With multiple comparisons, diagnostic agreement was between 91% and 75%. The Bland Altman analyses showed strong agreement between AHI values from the STD and PSG recordings, especially when comparing the AHI from simultaneous STD and PSG recordings. CONCLUSION These data suggest that the STD is accurate in confirming the diagnosis of OSA where there is a suspicion of the disorder. Better agreement occurred during simultaneous recordings.
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Affiliation(s)
- Rogerio Santos-Silva
- Discipline of Medicine and Biology of Sleep, Psychobiology Department, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Denis E. Sartori
- Discipline of Medicine and Biology of Sleep, Psychobiology Department, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Viviane Truksinas
- Discipline of Medicine and Biology of Sleep, Psychobiology Department, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Eveli Truksinas
- Discipline of Medicine and Biology of Sleep, Psychobiology Department, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Fabiana F. F. D Alonso
- Discipline of Medicine and Biology of Sleep, Psychobiology Department, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Sergio Tufik
- Discipline of Medicine and Biology of Sleep, Psychobiology Department, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Lia R. A. Bittencourt
- Discipline of Medicine and Biology of Sleep, Psychobiology Department, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
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de Oliveira ACT, Martinez D, Vasconcelos LFT, Cadaval Gonçalves S, do Carmo Lenz M, Costa Fuchs S, Gus M, de Abreu-Silva EO, Beltrami Moreira L, Danni Fuchs F. Diagnosis of obstructive sleep apnea syndrome and its outcomes with home portable monitoring. Chest 2009; 135:330-336. [PMID: 19201709 DOI: 10.1378/chest.08-1859] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The use of portable respiratory monitoring (PM) has been proposed for the diagnosis of obstructive sleep apnea syndrome (OSAS), but most studies that validate PM accuracy have not followed the best standards for diagnostic test validation. The objective of the present study was to evaluate the accuracy of PM performed at home to diagnose OSAS and its outcomes after first validating PM in the laboratory setting by comparing it to polysomnography (PSG). METHODS Patients with suspected OSAS were submitted, in random order, to PM at the sleep laboratory concurrently with PSG (lab-PM) or at home-PM. The diagnostic performance was assessed by sensitivity, specificity, positive and negative predictive values, positive likelihood ratio (+LR), negative likelihood ratio (-LR), intraclass correlation coefficients, kappa statistic, and Bland-Altman plot. RESULTS One hundred fifty-seven subjects (73% men, mean age +/- SD, 45 +/- 12 yr) with an apnea-hypopnea index (AHI) of 31 (SD +/- 29) events/h were studied. Excluding inadequate recordings, 149 valid comparisons with lab-PM and 121 with unattended home-PM were obtained. Compared to PSG for detecting AHI > 5, the lab-PM demonstrated sensitivity of 95.3%, specificity of 75%, +LR of 3.8, and -LR of 0.11; the home-PM exhibited sensitivity of 96%, specificity of 64%, +LR of 2.7, and -LR of 0.05. Kappa statistics indicated substantial correlation between PSG and PM results. Bland-Altman plot showed smaller dispersion for lab-PM than for home-PM. Pearson product moment correlation coefficients among the three AHIs and clinical outcomes were similar, denoting comparable diagnostic ability. CONCLUSIONS This study used all available comparison methods to demonstrate accuracy of PM in-home recordings similar to that of repeated PSGs. PM increases the possibility of correctly diagnosing and effectively treating OSAS in populations worldwide.
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Affiliation(s)
| | - Denis Martinez
- Clinica do Sono Sleep Clinic, Porto Alegre, RS, Brazil; Cardiology Unit, Hospital de Clinicas de Porto Alegre, Porto Alegre, RS, Brazil; Graduate Program in Medical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.
| | - Luiz Felipe T Vasconcelos
- Graduate Program in Medical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Sandro Cadaval Gonçalves
- Graduate Program in Medical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | - Sandra Costa Fuchs
- Programa de Pós-graduação em Epidemiologia, Faculdade de Medicina, Porto Alegre, RS, Brazil; Cardiology Unit, Hospital de Clinicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Miguel Gus
- Cardiology Unit, Hospital de Clinicas de Porto Alegre, Porto Alegre, RS, Brazil; Graduate Program in Medical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | - Leila Beltrami Moreira
- Graduate Program in Medical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil; Cardiology Unit, Hospital de Clinicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Flávio Danni Fuchs
- Cardiology Unit, Hospital de Clinicas de Porto Alegre, Porto Alegre, RS, Brazil; Graduate Program in Medical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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Redmond SJ, de Chazal P, O'Brien C, Ryan S, McNicholas WT, Heneghan C. Sleep staging using cardiorespiratory signals. SOMNOLOGIE 2007. [DOI: 10.1007/s11818-007-0314-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Patel MR, Davidson TM. Home Sleep Testing in the Diagnosis and Treatment of Sleep Disordered Breathing. Otolaryngol Clin North Am 2007; 40:761-84. [PMID: 17606022 DOI: 10.1016/j.otc.2007.04.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Sleep-disordered breathing is a growing public health concern and an integral part of head and neck surgery. Multichannel home sleep testing is a cost-effective, patient-friendly, scientifically valid technique of evaluating patients who present with symptoms of sleep-disordered breathing, typically snoring or daytime sleepiness. Home sleep tests can be dispensed from the physician's office. They have a 95% successful recording rate. Scoring can be autoscore or manual score. There are several protocols that can be followed based on diagnostic outcomes.
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Affiliation(s)
- Minal R Patel
- University of California, San Diego, San Diego, CA, USA
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43
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García-Díaz E, Quintana-Gallego E, Ruiz A, Carmona-Bernal C, Sánchez-Armengol Á, Botebol-Benhamou G, Capote F. Respiratory polygraphy with actigraphy in the diagnosis of sleep apnea-hypopnea syndrome. Chest 2007; 131:725-732. [PMID: 17356086 DOI: 10.1378/chest.06-1604] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE To determine the utility and reliability of a respiratory polygraphy (RP) device with actigraphy (Apnoescreen II; Erich Jaeger GMBH & CoKg; Wuerzburg, Germany) in the diagnosis of sleep apnea-hypopnea syndrome (SAHS). DESIGN A prospective randomized study with blinded analysis. PATIENTS Sixty-two patients with suspected SAHS. MEASUREMENTS the following two RP studies were performed: one in the sleep laboratory (sleep laboratory RP [LRP]), simultaneously with polysomnography; and the other at home (home RP [HRP]). To study the interobserver reliability of RP, two manual analyses were carried out by two different researchers. RESULTS In LRP, when the respiratory disturbance index was calculated using the total sleep time estimated by actigraphy (RDI) as a denominator, the sensitivity ranged between 94.6% and 100%, and the specificity between 88% and 96.7% for the different cutoff points of the apnea-hypopnea indexes studied. When the respiratory disturbance index was calculated according to the total recording time (RDITRT), the sensitivity was slightly lower (91.6 to 96.9%) and the specificity was similar (92 to 96.7%). In HRP, the sensitivity of the RDI ranged between 83.8% and 95.8%, and the specificity between 92% and 100%, whereas, when the RDITRT was used, the sensitivity was between 83.8% and 87.5%, and the specificity was between 94.7% and 100%. With regard to interobserver reliability, the intraclass correlation coefficient for the RDI of the two analyses of the RP was 0.99 for both LPR and HPR. CONCLUSION HPR is an effective and reliable technique for the diagnosis of SAHS, although it is less sensitive than LRP. Wrist actigraphy improves the results of HRP only slightly.
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Affiliation(s)
- Emilio García-Díaz
- Departments of Critical Care and Emergency, Hospitales Universitarios Virgen del Rocío, Sevilla, Spain.
| | | | - Aránzazu Ruiz
- Pneumology, Hospitales Universitarios Virgen del Rocío, Sevilla, Spain
| | | | | | | | - Francisco Capote
- Pneumology, Hospitales Universitarios Virgen del Rocío, Sevilla, Spain
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45
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Ghegan MD, Angelos PC, Stonebraker AC, Gillespie MB. Laboratory versus portable sleep studies: a meta-analysis. Laryngoscope 2006; 116:859-64. [PMID: 16735890 DOI: 10.1097/01.mlg.0000214866.32050.2e] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of this meta-analysis study was to compare the accuracy of home sleep studies with laboratory polysomnography in the diagnosis of obstructive sleep apnea (OSA). METHODS Eligible studies included prospective cohort studies of portable and in-laboratory sleep studies performed on the same groups of patients. A comparison of respiratory disturbance index (RDI), mean low oxygen saturation levels, sleep time, rate of inadequate studies, and average cost per examination was made between portable and in-laboratory sleep studies. A total of 18 papers were identified in two independent Medline searches. RESULTS RDI values on portable sleep studies were 10% lower on average compared with laboratory studies (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.87-0.92). There was no significant difference in the mean low oxygen saturation on portable versus laboratory studies (OR, 1.0; 95% CI, 0.94-1.10). Recorded sleep time was significantly higher by 13% for laboratory compared with portable studies (OR, 0.87; 95% CI, 0.86-0.89), and portable studies were significantly more likely to give a poor recording when compared with laboratory examinations (P = .0001). The cost of home studies ranged from 35% to 88% lower than laboratory studies across a number of countries. CONCLUSION Home sleep studies provide similar diagnostic information to laboratory polysomnograms in the evaluation of sleep-disordered breathing but may underestimate sleep apnea severity. The lower cost of home sleep studies makes it a viable screening tool for patients with suspected OSA; however, these lower costs are partially offset by the higher rate of inadequate examinations.
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Affiliation(s)
- Mark D Ghegan
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina 29425, USA
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46
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Redmond SJ, Heneghan C. Cardiorespiratory-based sleep staging in subjects with obstructive sleep apnea. IEEE Trans Biomed Eng 2006; 53:485-96. [PMID: 16532775 DOI: 10.1109/tbme.2005.869773] [Citation(s) in RCA: 158] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
A cardiorespiratory-based automatic sleep staging system for subjects with sleep-disordered breathing is described. A simplified three-state system is used: Wakefulness (W), rapid eye movement (REM) sleep (R), and non-REM sleep (S). The system scores the sleep stages in standard 30-s epochs. A number of features associated with the epoch RR-intervals, an inductance plethysmography estimate of rib cage respiratory effort, and an electrocardiogram-derived respiration (EDR) signal were investigated. A subject-specific quadratic discriminant classifier was trained, randomly choosing 20% of the subject's epochs (in appropriate proportions of W, S and R) as the training data. The remaining 80% of epochs were presented to the classifier for testing. An estimated classification accuracy of 79% (Cohen's kappa value of 0.56) was achieved. When a similar subject-independent classifier was trained, using epochs from all other subjects as the training data, a drop in classification accuracy to 67% (kappa = 0.32) was observed. The subjects were further broken in groups of low apnoea-hypopnea index (AHI) and high AHI and the experiments repeated. The subject-specific classifier performed better on subjects with low AHI than high AHI; the performance of the subject-independent classifier is not correlated with AHI. For comparison an electroencephalograms (EEGs)-based classifier was trained utilizing several standard EEG features. The subject-specific classifier yielded an accuracy of 87% (kappa = 0.75), and an accuracy of 84% (kappa = 0.68) was obtained for the subject-independent classifier, indicating that EEG features are quite robust across subjects. We conclude that the cardiorespiratory signals provide moderate sleep-staging accuracy, however, features exhibit significant subject dependence which presents potential limits to the use of these signals in a general subject-independent sleep staging system.
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Affiliation(s)
- Stephen J Redmond
- Department of Electronic Engineering, University College Dublin, Belfield D4, Ireland.
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Yin M, Miyazaki S, Ishikawa K. Evaluation of type 3 portable monitoring in unattended home setting for suspected sleep apnea: factors that may affect its accuracy. Otolaryngol Head Neck Surg 2006; 134:204-9. [PMID: 16455365 DOI: 10.1016/j.otohns.2005.10.019] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2005] [Indexed: 11/23/2022]
Abstract
OBJECTIVE This study evaluates the reliability of type 3 portable monitoring (PM) in a home setting. STUDY DESIGN AND SETTING Prospective study in sleep laboratory. Type 3 device (Stardust II) was evaluated in comparison with standard polysomnography (PSG) among patients with obstructive sleep apnea. Quality of recorded data and agreement between PM and PSG results were evaluated. RESULTS Low quality of recorded data was observed only in 5 cases. Pattern of disordered breathing was recognized correctly by PM. Apnea/hypopnea index (AHI) correlated well with a mean bias of 3.7 +/- 13.1/h. High sensitivity of PM was observed generally, whereas specificity was lower in mild patients. AHI, record time, and sleep position were found to be the main factors that would affect the accuracy of PM. CONCLUSION Type 3 PM is feasible in unattended home-setting for routine examination. Influence of the factors above should be comprehensively considered especially for mild patients.
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Affiliation(s)
- Min Yin
- Department of Otorhinolaryngology, Akita University School of Medicine, Akita, Japan
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48
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Pang KP, Terris DJ. Screening for obstructive sleep apnea: an evidence-based analysis. Am J Otolaryngol 2006; 27:112-8. [PMID: 16500475 DOI: 10.1016/j.amjoto.2005.09.002] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2005] [Indexed: 11/22/2022]
Abstract
Sleep disordered breathing is a spectrum of diseases that includes snoring, upper airway resistance syndrome, and obstructive sleep apnea (OSA). Obstructive sleep apnea is a common sleep disorder and is estimated to have an incidence of 24% in men and 9% in women. However, many authors believe that up to 93% of women and 82% of men with moderate to severe OSA remain undiagnosed. There is a strong link between sleep disordered breathing and hypertension, believed to be due to sleep fragmentation, intermittent hypoxemia, and increased sympathetic tone, which results in a higher mortality and morbidity rate among these patients. It is therefore desirable to attempt to diagnose all patients with OSA, to institute early treatment intervention, and to prevent development of cardiovascular complications. The gold standard for diagnosing OSA remains the attended overnight level I polysomnogram. However, in view of the limited resources, including limited number of recording beds, high cost, long waiting lists, and labor requirements, many authors have explored the use of clinical predictors or questionnaires that may help to identify higher-risk patients. Screening devices in the form of single or multiple channel monitoring systems have also been introduced and may represent an alternative method to diagnose OSA. The ideal screening device should be cheap, readily accessible, easily used with minimal instructions, have no risk or side effects to the patient, and be safe and accurate. We review a variety of clinical predictive formulae and several screening devices available for the diagnosis of OSA.
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Affiliation(s)
- Kenny P Pang
- Department of Otolaryngology-Head and Neck Surgery, Medical College of Georgia, Augusta, GA, USA.
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49
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Foo JYA. Pulse transit time in paediatric respiratory sleep studies. Med Eng Phys 2006; 29:17-25. [PMID: 16495120 DOI: 10.1016/j.medengphy.2006.01.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2005] [Revised: 11/15/2005] [Accepted: 01/17/2006] [Indexed: 11/23/2022]
Abstract
Pulse transit time (PTT) has emerged over the recent decades as a simple and non-invasive measure to quantify inspiratory effort changes in adults with sleep disordered breathing (SDB). Hence, this shows promise to be an effective screening tool for the paediatrics. However, little is known about its utility and suitability until recent studies has been provided quantitative knowledge about its relevance in clinical investigations. In this review, the origins, normative values, current uses and technical issues in its application to paediatric monitoring, particularly during sleep are discussed. Preliminary findings from these investigations suggest favourably its potential as an important element to screen SDB in the children population.
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Affiliation(s)
- Jong Yong A Foo
- Biomedical Engineering Research Centre, Nanyang Technological University, 50 Nanyang Drive, Research Techno Plaza, 6th Storey, Xfrontiers Block, Singapore 637553, Singapore.
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50
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Westbrook PR, Levendowski DJ, Cvetinovic M, Zavora T, Velimirovic V, Henninger D, Nicholson D. Description and validation of the apnea risk evaluation system: a novel method to diagnose sleep apnea-hypopnea in the home. Chest 2005; 128:2166-75. [PMID: 16236870 DOI: 10.1378/chest.128.4.2166] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES To evaluate the accuracy and practicality of the Apnea Risk Evaluation System (ARES; Advanced Brain Monitoring; Carlsbad, CA), a limited-channel system for diagnosing sleep apnea/hypopnea in the home. DESIGN Prospective randomized study with blinded analysis. SETTINGS Two independent, community-based, sleep-disorders centers and the participants' homes. PARTICIPANTS Two hundred ninety-nine subjects were recruited, including 210 consecutive willing patients referred by community physicians to the centers because of suspected sleep apnea; 36 "general medical" patients recruited from community physicians' offices; and 53 "presumably healthy" subjects recruited from community centers. MEASUREMENTS AND RESULTS Manual scoring of attended in-laboratory full-night or split-night polysomnography by trained technologists supervised by physicians board certified in sleep medicine, and automated scoring of the limited-channel system used attended in the laboratory and unattended at home. The definition of the polysomnography apnea-hypopnea index (AHI) and the ARES respiratory disturbance index was the total number of events divided by the study duration in hours. Two hundred eighty-four valid comparisons of in-laboratory simultaneous polysomnography and ARES and 187 valid comparisons of in-laboratory polysomnography with a separate 2 nights of unattended self-applied ARES Unicorder (Advanced Brain Monitoring) were obtained. A diagnostic AHI cutoff of > 10 was used to establish the accuracy and validity of the ARES. The concurrent in-laboratory comparison yielded a sensitivity of 97.4, a specificity of 85.6, a positive predictive value of 93.6, and a negative predictive value of 93.9; in-home comparison sensitivity, specificity, positive predictive value, and negative predictive value were 91.5, 85.7, 91.5, and 85.7, respectively. CONCLUSIONS The ARES demonstrated consistently high sensitivity and specificity for both in-laboratory and in-home recordings. In patients at risk for sleep apnea who do not a priori need an attended study, the ARES could provide a low-cost alternative to traditional polysomnography.
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Affiliation(s)
- Philip R Westbrook
- Advanced Brain Monitoring, Inc., 2850 Pio Pico Dr, Suite A, Carlsbad, CA 92008, usa.
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