The NAMES assessment: a novel combined-modality screening tool for obstructive sleep apnea

Diagnosis of Obstructive Sleep Apnea Using Feature Selection, Classification Methods, and Data Grouping Based Age, Sex, and Race

Obstructive sleep apnea (OSA) is a prevalent sleep disorder that affects approximately 3-7% of males and 2-5% of females. In the United States alone, 50-70 million adults suffer from various sleep disorders. OSA is characterized by recurrent episodes of breathing cessation during sleep, thereby leading to adverse effects such as daytime sleepiness, cognitive impairment, and reduced concentration. It also contributes to an increased risk of cardiovascular conditions and adversely impacts patient overall quality of life. As a result, numerous researchers have focused on developing automated detection models to identify OSA and address these limitations effectively and accurately. This study explored the potential benefits of utilizing machine learning methods based on demographic information for diagnosing the OSA syndrome. We gathered a comprehensive dataset from the Torr Sleep Center in Corpus Christi, Texas, USA. The dataset comprises 31 features, including demographic characteristics such as race, age, sex, BMI, Epworth score, M. Friedman tongue position, snoring, and more. We devised a novel process encompassing pre-processing, data grouping, feature selection, and machine learning classification methods to achieve the research objectives. The classification methods employed in this study encompass decision tree (DT), naive Bayes (NB), k-nearest neighbor (kNN), support vector machine (SVM), linear discriminant analysis (LDA), logistic regression (LR), and subspace discriminant (Ensemble) classifiers. Through rigorous experimentation, the results indicated the superior performance of the optimized kNN and SVM classifiers for accurately classifying sleep apnea. Moreover, significant enhancements in model accuracy were observed when utilizing the selected demographic variables and employing data grouping techniques. For instance, the accuracy percentage demonstrated an approximate improvement of 4.5%, 5%, and 10% with the feature selection approach when applied to the grouped data of Caucasians, females, and individuals aged 50 or below, respectively. Furthermore, a comparison with prior studies confirmed that effective data grouping and proper feature selection yielded superior performance in OSA detection when combined with an appropriate classification method. Overall, the findings of this research highlight the importance of leveraging demographic information, employing proper feature selection techniques, and utilizing optimized classification models for accurate and efficient OSA diagnosis.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

The value of nurse-led anthropometric and oropharyngeal measurements combined with STOP-Bang questionnaire in screening for obstructive sleep apnea in patients with acute coronary syndrome: a prospective cohort study

Background

Obstructive sleep apnea (OSA) is a modifiable risk factor for acute coronary syndrome (ACS), with high prevalence but low diagnostic rates. Therefore, it is particularly important to develop strategies for better screening for OSA in newly admitted ACS patients.

Methods

From March 2017 to October 2019, consecutive eligible patients with ACS underwent cardiorespiratory polygraphy during hospitalization. OSA was defined as an apnea–hypopnea index (AHI) ≥ 15 events/h. All anthropometric and oropharyngeal parameters are measured by specialist nurses.

Results

Finally, 761 ACS patients were recruited in the present study. Prevalence of moderate/severe OSA was 53.2% based on diagnostic criteria of AHI ≥ 15. Correlation analysis illustrated that AHI was positively correlated with anthropometric characteristics. In the multivariate model, only micrognathia (OR 2.02, 95% CI 1.02–4.00, P = 0.044), waist circumference (OR 1.08, 95% CI 1.04–1.11, P < 0.001), and STOP-BANG Questionnaire (SBQ) score (OR 1.45, 95% CI 1.27–1.66, P < 0.001) were independently associated with the prevalence of OSA. Receiver operating characteristic curve (ROC) analysis showed that the area under curve (AUC) of multivariable joint diagnosis (waist circumference, micrognathia combined with SBQ) was significantly better than the AUC of Epworth Sleepiness Scale (ESS) and SBQ (p < 0.0001 and p = 0.0002, respectively), and the results showed that AUC was 0.728. Under the optimal truncation value, the sensitivity was 73%, and the specificity was 61%, which was higher than the single index. Finally, we also constructed a nomogram model based on multiple logistic regression, to easily determine the probability of OSA in ACS patients.

Conclusions

The new screening tool has greater power than single questionnaire or measurements in screening of OSA among ACS patients.

Trial registration

Clinicaltrials.gov identifier NCT03362385, registered December 5, 2017.

BASAN index (Body mass index, Age, Sex, Arterial hypertension and Neck circumference) predicts severe apnoea in adults living at high altitude

OBJECTIVES

Obstructive sleep apnoea (OSA)/hypopnoea syndrome is associated with serious and major multiorgan morbidities, particularly in its most severe forms. However, no severe OSA screening instruments are available for high altitude residents that enable adequate identification and clinical prioritisation of such patients. We aimed at developing a severe OSA prediction tool based on the clinical characteristics and anthropometric measurements of a clinical referral cohort living at 2640 m.a.s.l.

DESIGN

Cohort-nested cross-sectional study.

SETTING

Sleep laboratory for standard polysomnography (PSG) in Colombia.

PARTICIPANTS

A predictive model was generated from 8718 participants referred to the PSG laboratory. Results were subsequently validated in a second cohort of 1898 participants.

PRIMARY OUTCOME

To identify clinical and anthropometric variables associated with severe OSA (>30 events/hour) and to include them in a binary logistic regression model.

RESULTS

The significant variables that were retained with the presence of severe OSA included Body mass index (BMI), Age, Sex, Arterial hypertension and Neck circumference (BASAN). The area under the receiver operating characteristic curvefor the BASAN index was 0.69 (95% CI: 0.68 to 0.70) in the derivation cohort and 0.67 (95% CI: 0.65 to 0.69) in the validation cohort, whereby a BASAN index ≥2 had a sensitivity of 95% and a specificity of 17% to detect severe OSA.

CONCLUSION

An objectively based approach to screen for the presence of severe OSA, the BASAN index, exhibits favourable sensitivity characteristics that should enable its operational use as a screening tool in a Hispanic population with a clinical suspicion of OSA and living at high altitude.

The No-apnea score vs. the other five questionnaires in screening for obstructive sleep apnea-hypopnea syndrome in patients with cerebral infarction

Background

Given the growing number of patients suspected of having obstructive sleep apnea-hypopnea syndrome (OSAHS), screening methods have become increasingly important for sleep clinics. We analyzed the clinical value of the No-apnea score which is used to diagnose OSAHS in patients with cerebral infarction, and compared the accuracy of the No-apnea score with the accuracy of the NoSAS score, the STOP-Bang questionnaire (SBQ), the Epworth Sleepiness Scale (ESS), the STOP questionnaire (STOP) and the Berlin questionnaire (BQ).

Methods

Between January 2014 and December 2018, a total of 221 cerebral infarction patients, suspected of having OSAHS, underwent the polysomnography (PSG) for one night at the sleep medical center of Guangdong Medical University Affiliated Second Hospital. The PSG data were collected and analyzed with the NoSAS score, the SBQ, the ESS, the STOP, the BQ, and patients' demographic information. Based on the apnea-hypopnea index (AHI), the patients were classified into four groups: the normal group (<5 events/h), mild OSAHS group (5-15 events/h), moderate OSAHS group (15-30 events/h) and severe OSAHS group (≥30 events/h). The sensitivity, specificity, positive predictive value, negative predictive value and areas under the curve (AUC) of the Receiver Operating Curve (ROC) were calculated for the five questionnaires to compare their relative efficacies for diagnosing OSAHS.

Results

When using the standard of AHI ≥5 for diagnosing OSAHS, the NoSAS score had an AUC of 0.831; the SBQ had an AUC of 0.730; the BQ had an AUC of 0.698; and the STOP had an AUC of 0.735, so these techniques are relatively accurate in diagnosing OSAHS. On the other hand, the No-apnea score and the ESS score are relatively less accurate comparing to the rest: the No-apnea had an AUC of 0.626, and the ESS had an AUC of 0.650. Using the NoSAS score to predict AHI ≥5 events/h, AHI ≥15 events/h and AHI ≥30 events/h, the sensitivity and specificity were 0.867 and 0.731, 0.888 and 0.476, 0.889 and 0.369, respectively; Using the SBQ to predict AHI ≥5 events/h, AHI 15 events/h and AHI ≥30 events/h, the sensitivity and specificity were 0.903 and 0.268, 0.914 and 0.200, 0.903 and 0.268, respectively; Using the STOP to predict AHI ≥5 events/h, AHI ≥15 events/h and AHI ≥30 events/h, the values were 0.830 and 0.500, 0.871 and 0.390, 0.875 and 0.302, respectively; and using the BQ to predict AHI ≥5 events/h, AHI ≥15 events/h and AHI ≥30 events/h, the values were 0.758 and 0.482, 0.810 and 0.429, 0.819 and 0.362, respectively.

Conclusions

The study concludes that the NoSAS score and the SBQ had a better predictive value for cerebral infarction patients suspected with OSAHS disease. These questionnaires can also effectively help clinicians quickly address nocturnal hypoxia in patients with cerebral infarction to control subsequent complications in patients with cerebral infarction. More studies are needed to evaluate the efficacy of the NoSAS score in screening for OSAHS in patients with cerebral infarction.

Evaluation of Clinical Tools to Screen and Assess for Obstructive Sleep Apnea

ABSTRACT

Obstructive sleep apnea (OSA) is a globally recognized medical condition, associated with development of long-term adverse health consequences, including cardiovascular disease, cerebrovascular disease, neurocognitive deficiencies, and vehicular and occupational accidents. OSA can be screened effectively, because it can be identified well before the manifestation of the aforementioned poor health and public safety consequences. Additionally, appropriate management of OSA includes an assessment of outcomes before and after therapeutic intervention initiation. OSA clinical screening and outcome assessment tools exist; however, a key existing knowledge gap is identifying which tools are most clinically relevant and efficient to use in clinical practice models. The American Academy of Sleep Medicine (AASM) commissioned a task force (TF) of sleep medicine experts to identify and evaluate current OSA screening and assessment tools for adult patients and determine if they are reliable, effective, and feasible for use in clinical settings. No single tool met all the TF's objective criteria and subjective evaluation for clinical validity and feasibility to be recommended by the AASM. The TF provides several suggestions for the development of new tools or modifications to existing tools that would enhance their functionality in adults.

Validity of the Berlin questionnaire in detecting obstructive sleep apnea: A systematic review and meta-analysis

We aimed to systematically review the Berlin questionnaire as a screening tool for obstructive sleep apnea. We systematically searched PubMed, Embase, and Scopus databases, reviewed articles reporting the Berlin questionnaire's diagnostic utility as measured against type-1 polysomnography, and performed meta-analyses where possible. Thirty five eligible articles showed that the Berlin questionnaire's diagnostic utility varied by study population, definition of hypopnea used, and apnea-hypopnea index threshold used. It had good sensitivity and specificity for detecting clinically relevant obstructive sleep apnea as well as any obstructive sleep apnea in the sleep clinic population. Despite limited evidence, it showed modest to high sensitivity for detecting clinically relevant obstructive sleep apnea or any obstructive sleep apnea in other clinical and general population subgroups. Its specificity was relatively low. Possible reasons for variability in reported diagnostic utility of the Berlin questionnaire are multifaceted. We conclude that the Berlin questionnaire is useful as a clinical screening test and epidemiological tool in the sleep clinic population. Despite limited evidence, it likely has potential clinical and research utility in other populations. Adopting more consistent methodological definitions and focussing more on the general population and specific clinical populations to determine its usefulness as a clinical or epidemiological screening tool are recommended.

Using the Berlin Questionnaire to Predict Obstructive Sleep Apnea in the General Population

STUDY OBJECTIVES

The Berlin questionnaire is a self-administered questionnaire that was developed to identify subjects with obstructive sleep apnea (OSA) in primary care settings. This study evaluated the performance of the questionnaire to predict OSA in the general population.

METHODS

A sample of 242 subjects in a population-based cohort completed a home-based sleep study with an Embletta device (type 3 monitor). Subjects completed the Berlin questionnaire on the evening just prior to the sleep study. The sleep studies were manually scored according to the 2012 American Academy of Sleep Medicine (AASM) criteria.

RESULTS

The prevalence of moderate-to-severe and severe OSA defined as apnea-hypopnea index (AHI) of ≥ 15 and ≥ 30 was 28.1% and 10.7%, respectively. Seventy-nine subjects (32.6%) were classified as high risk according to the Berlin questionnaire. The sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of the questionnaire to predict an AHI ≥ 15 was 58.8%, 77.6%, 82.9%, and 50.6%, respectively. The area under the receiving operator characteristic (ROC) curve for moderate-to-severe OSA was 0.682. When used to predict an AHI ≥ 30, the sensitivity of the questionnaire increased to 76.9% with a small drop in specificity to 72.7%. The corresponding NPV, PPV, and area under the ROC curve of the questionnaire to predict severe OSA were 96.3%, 25.3%, and 0.748, respectively.

CONCLUSIONS

The Berlin questionnaire may have utility in the general population setting as a screening tool for OSA in view of its good sensitivity and high NPV in ruling out severe OSA.

Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline

INTRODUCTION

This guideline establishes clinical practice recommendations for the diagnosis of obstructive sleep apnea (OSA) in adults and is intended for use in conjunction with other American Academy of Sleep Medicine (AASM) guidelines on the evaluation and treatment of sleep-disordered breathing in adults.

METHODS

The AASM commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence. The task force developed recommendations and assigned strengths based on the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use. In addition, the task force adopted foundational recommendations from prior guidelines as "good practice statements", that establish the basis for appropriate and effective diagnosis of OSA. The AASM Board of Directors approved the final recommendations.

RECOMMENDATIONS

The following recommendations are intended as a guide for clinicians diagnosing OSA in adults. Under GRADE, a STRONG recommendation is one that clinicians should follow under most circumstances. A WEAK recommendation reflects a lower degree of certainty regarding the outcome and appropriateness of the patient-care strategy for all patients. The ultimate judgment regarding propriety of any specific care must be made by the clinician in light of the individual circumstances presented by the patient, available diagnostic tools, accessible treatment options, and resources. Good Practice Statements: Diagnostic testing for OSA should be performed in conjunction with a comprehensive sleep evaluation and adequate follow-up. Polysomnography is the standard diagnostic test for the diagnosis of OSA in adult patients in whom there is a concern for OSA based on a comprehensive sleep evaluation.Recommendations: We recommend that clinical tools, questionnaires and prediction algorithms not be used to diagnose OSA in adults, in the absence of polysomnography or home sleep apnea testing. (STRONG). We recommend that polysomnography, or home sleep apnea testing with a technically adequate device, be used for the diagnosis of OSA in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA. (STRONG). We recommend that if a single home sleep apnea test is negative, inconclusive, or technically inadequate, polysomnography be performed for the diagnosis of OSA. (STRONG). We recommend that polysomnography, rather than home sleep apnea testing, be used for the diagnosis of OSA in patients with significant cardiorespiratory disease, potential respiratory muscle weakness due to neuromuscular condition, awake hypoventilation or suspicion of sleep related hypoventilation, chronic opioid medication use, history of stroke or severe insomnia. (STRONG). We suggest that, if clinically appropriate, a split-night diagnostic protocol, rather than a full-night diagnostic protocol for polysomnography be used for the diagnosis of OSA. (WEAK). We suggest that when the initial polysomnogram is negative and clinical suspicion for OSA remains, a second polysomnogram be considered for the diagnosis of OSA. (WEAK).

Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline

INTRODUCTION

This guideline establishes clinical practice recommendations for the diagnosis of obstructive sleep apnea (OSA) in adults and is intended for use in conjunction with other American Academy of Sleep Medicine (AASM) guidelines on the evaluation and treatment of sleep-disordered breathing in adults.

METHODS

The AASM commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence. The task force developed recommendations and assigned strengths based on the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use. In addition, the task force adopted foundational recommendations from prior guidelines as "good practice statements", that establish the basis for appropriate and effective diagnosis of OSA. The AASM Board of Directors approved the final recommendations.

RECOMMENDATIONS

The following recommendations are intended as a guide for clinicians diagnosing OSA in adults. Under GRADE, a STRONG recommendation is one that clinicians should follow under most circumstances. A WEAK recommendation reflects a lower degree of certainty regarding the outcome and appropriateness of the patient-care strategy for all patients. The ultimate judgment regarding propriety of any specific care must be made by the clinician in light of the individual circumstances presented by the patient, available diagnostic tools, accessible treatment options, and resources. Good Practice Statements: Diagnostic testing for OSA should be performed in conjunction with a comprehensive sleep evaluation and adequate follow-up. Polysomnography is the standard diagnostic test for the diagnosis of OSA in adult patients in whom there is a concern for OSA based on a comprehensive sleep evaluation.Recommendations: We recommend that clinical tools, questionnaires and prediction algorithms not be used to diagnose OSA in adults, in the absence of polysomnography or home sleep apnea testing. (STRONG). We recommend that polysomnography, or home sleep apnea testing with a technically adequate device, be used for the diagnosis of OSA in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA. (STRONG). We recommend that if a single home sleep apnea test is negative, inconclusive, or technically inadequate, polysomnography be performed for the diagnosis of OSA. (STRONG). We recommend that polysomnography, rather than home sleep apnea testing, be used for the diagnosis of OSA in patients with significant cardiorespiratory disease, potential respiratory muscle weakness due to neuromuscular condition, awake hypoventilation or suspicion of sleep related hypoventilation, chronic opioid medication use, history of stroke or severe insomnia. (STRONG). We suggest that, if clinically appropriate, a split-night diagnostic protocol, rather than a full-night diagnostic protocol for polysomnography be used for the diagnosis of OSA. (WEAK). We suggest that when the initial polysomnogram is negative and clinical suspicion for OSA remains, a second polysomnogram be considered for the diagnosis of OSA. (WEAK).

Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline

INTRODUCTION

This guideline establishes clinical practice recommendations for the diagnosis of obstructive sleep apnea (OSA) in adults and is intended for use in conjunction with other American Academy of Sleep Medicine (AASM) guidelines on the evaluation and treatment of sleep-disordered breathing in adults.

METHODS

The AASM commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence. The task force developed recommendations and assigned strengths based on the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use. In addition, the task force adopted foundational recommendations from prior guidelines as "good practice statements", that establish the basis for appropriate and effective diagnosis of OSA. The AASM Board of Directors approved the final recommendations.

RECOMMENDATIONS

The following recommendations are intended as a guide for clinicians diagnosing OSA in adults. Under GRADE, a STRONG recommendation is one that clinicians should follow under most circumstances. A WEAK recommendation reflects a lower degree of certainty regarding the outcome and appropriateness of the patient-care strategy for all patients. The ultimate judgment regarding propriety of any specific care must be made by the clinician in light of the individual circumstances presented by the patient, available diagnostic tools, accessible treatment options, and resources. Good Practice Statements: Diagnostic testing for OSA should be performed in conjunction with a comprehensive sleep evaluation and adequate follow-up. Polysomnography is the standard diagnostic test for the diagnosis of OSA in adult patients in whom there is a concern for OSA based on a comprehensive sleep evaluation.Recommendations: We recommend that clinical tools, questionnaires and prediction algorithms not be used to diagnose OSA in adults, in the absence of polysomnography or home sleep apnea testing. (STRONG). We recommend that polysomnography, or home sleep apnea testing with a technically adequate device, be used for the diagnosis of OSA in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA. (STRONG). We recommend that if a single home sleep apnea test is negative, inconclusive, or technically inadequate, polysomnography be performed for the diagnosis of OSA. (STRONG). We recommend that polysomnography, rather than home sleep apnea testing, be used for the diagnosis of OSA in patients with significant cardiorespiratory disease, potential respiratory muscle weakness due to neuromuscular condition, awake hypoventilation or suspicion of sleep related hypoventilation, chronic opioid medication use, history of stroke or severe insomnia. (STRONG). We suggest that, if clinically appropriate, a split-night diagnostic protocol, rather than a full-night diagnostic protocol for polysomnography be used for the diagnosis of OSA. (WEAK). We suggest that when the initial polysomnogram is negative and clinical suspicion for OSA remains, a second polysomnogram be considered for the diagnosis of OSA. (WEAK).

Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline

INTRODUCTION

This guideline establishes clinical practice recommendations for the diagnosis of obstructive sleep apnea (OSA) in adults and is intended for use in conjunction with other American Academy of Sleep Medicine (AASM) guidelines on the evaluation and treatment of sleep-disordered breathing in adults.

METHODS

The AASM commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence. The task force developed recommendations and assigned strengths based on the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use. In addition, the task force adopted foundational recommendations from prior guidelines as "good practice statements", that establish the basis for appropriate and effective diagnosis of OSA. The AASM Board of Directors approved the final recommendations.

RECOMMENDATIONS

The following recommendations are intended as a guide for clinicians diagnosing OSA in adults. Under GRADE, a STRONG recommendation is one that clinicians should follow under most circumstances. A WEAK recommendation reflects a lower degree of certainty regarding the outcome and appropriateness of the patient-care strategy for all patients. The ultimate judgment regarding propriety of any specific care must be made by the clinician in light of the individual circumstances presented by the patient, available diagnostic tools, accessible treatment options, and resources. Good Practice Statements: Diagnostic testing for OSA should be performed in conjunction with a comprehensive sleep evaluation and adequate follow-up. Polysomnography is the standard diagnostic test for the diagnosis of OSA in adult patients in whom there is a concern for OSA based on a comprehensive sleep evaluation.Recommendations: We recommend that clinical tools, questionnaires and prediction algorithms not be used to diagnose OSA in adults, in the absence of polysomnography or home sleep apnea testing. (STRONG). We recommend that polysomnography, or home sleep apnea testing with a technically adequate device, be used for the diagnosis of OSA in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA. (STRONG). We recommend that if a single home sleep apnea test is negative, inconclusive, or technically inadequate, polysomnography be performed for the diagnosis of OSA. (STRONG). We recommend that polysomnography, rather than home sleep apnea testing, be used for the diagnosis of OSA in patients with significant cardiorespiratory disease, potential respiratory muscle weakness due to neuromuscular condition, awake hypoventilation or suspicion of sleep related hypoventilation, chronic opioid medication use, history of stroke or severe insomnia. (STRONG). We suggest that, if clinically appropriate, a split-night diagnostic protocol, rather than a full-night diagnostic protocol for polysomnography be used for the diagnosis of OSA. (WEAK). We suggest that when the initial polysomnogram is negative and clinical suspicion for OSA remains, a second polysomnogram be considered for the diagnosis of OSA. (WEAK).

Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline

INTRODUCTION

This guideline establishes clinical practice recommendations for the diagnosis of obstructive sleep apnea (OSA) in adults and is intended for use in conjunction with other American Academy of Sleep Medicine (AASM) guidelines on the evaluation and treatment of sleep-disordered breathing in adults.

METHODS

The AASM commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence. The task force developed recommendations and assigned strengths based on the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use. In addition, the task force adopted foundational recommendations from prior guidelines as "good practice statements", that establish the basis for appropriate and effective diagnosis of OSA. The AASM Board of Directors approved the final recommendations.

RECOMMENDATIONS

The following recommendations are intended as a guide for clinicians diagnosing OSA in adults. Under GRADE, a STRONG recommendation is one that clinicians should follow under most circumstances. A WEAK recommendation reflects a lower degree of certainty regarding the outcome and appropriateness of the patient-care strategy for all patients. The ultimate judgment regarding propriety of any specific care must be made by the clinician in light of the individual circumstances presented by the patient, available diagnostic tools, accessible treatment options, and resources. Good Practice Statements: Diagnostic testing for OSA should be performed in conjunction with a comprehensive sleep evaluation and adequate follow-up. Polysomnography is the standard diagnostic test for the diagnosis of OSA in adult patients in whom there is a concern for OSA based on a comprehensive sleep evaluation.Recommendations: We recommend that clinical tools, questionnaires and prediction algorithms not be used to diagnose OSA in adults, in the absence of polysomnography or home sleep apnea testing. (STRONG). We recommend that polysomnography, or home sleep apnea testing with a technically adequate device, be used for the diagnosis of OSA in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA. (STRONG). We recommend that if a single home sleep apnea test is negative, inconclusive, or technically inadequate, polysomnography be performed for the diagnosis of OSA. (STRONG). We recommend that polysomnography, rather than home sleep apnea testing, be used for the diagnosis of OSA in patients with significant cardiorespiratory disease, potential respiratory muscle weakness due to neuromuscular condition, awake hypoventilation or suspicion of sleep related hypoventilation, chronic opioid medication use, history of stroke or severe insomnia. (STRONG). We suggest that, if clinically appropriate, a split-night diagnostic protocol, rather than a full-night diagnostic protocol for polysomnography be used for the diagnosis of OSA. (WEAK). We suggest that when the initial polysomnogram is negative and clinical suspicion for OSA remains, a second polysomnogram be considered for the diagnosis of OSA. (WEAK).

Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline

INTRODUCTION

This guideline establishes clinical practice recommendations for the diagnosis of obstructive sleep apnea (OSA) in adults and is intended for use in conjunction with other American Academy of Sleep Medicine (AASM) guidelines on the evaluation and treatment of sleep-disordered breathing in adults.

METHODS

The AASM commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence. The task force developed recommendations and assigned strengths based on the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use. In addition, the task force adopted foundational recommendations from prior guidelines as "good practice statements", that establish the basis for appropriate and effective diagnosis of OSA. The AASM Board of Directors approved the final recommendations.

RECOMMENDATIONS

The following recommendations are intended as a guide for clinicians diagnosing OSA in adults. Under GRADE, a STRONG recommendation is one that clinicians should follow under most circumstances. A WEAK recommendation reflects a lower degree of certainty regarding the outcome and appropriateness of the patient-care strategy for all patients. The ultimate judgment regarding propriety of any specific care must be made by the clinician in light of the individual circumstances presented by the patient, available diagnostic tools, accessible treatment options, and resources. Good Practice Statements: Diagnostic testing for OSA should be performed in conjunction with a comprehensive sleep evaluation and adequate follow-up. Polysomnography is the standard diagnostic test for the diagnosis of OSA in adult patients in whom there is a concern for OSA based on a comprehensive sleep evaluation.Recommendations: We recommend that clinical tools, questionnaires and prediction algorithms not be used to diagnose OSA in adults, in the absence of polysomnography or home sleep apnea testing. (STRONG). We recommend that polysomnography, or home sleep apnea testing with a technically adequate device, be used for the diagnosis of OSA in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA. (STRONG). We recommend that if a single home sleep apnea test is negative, inconclusive, or technically inadequate, polysomnography be performed for the diagnosis of OSA. (STRONG). We recommend that polysomnography, rather than home sleep apnea testing, be used for the diagnosis of OSA in patients with significant cardiorespiratory disease, potential respiratory muscle weakness due to neuromuscular condition, awake hypoventilation or suspicion of sleep related hypoventilation, chronic opioid medication use, history of stroke or severe insomnia. (STRONG). We suggest that, if clinically appropriate, a split-night diagnostic protocol, rather than a full-night diagnostic protocol for polysomnography be used for the diagnosis of OSA. (WEAK). We suggest that when the initial polysomnogram is negative and clinical suspicion for OSA remains, a second polysomnogram be considered for the diagnosis of OSA. (WEAK).

Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline

INTRODUCTION

This guideline establishes clinical practice recommendations for the diagnosis of obstructive sleep apnea (OSA) in adults and is intended for use in conjunction with other American Academy of Sleep Medicine (AASM) guidelines on the evaluation and treatment of sleep-disordered breathing in adults.

METHODS

The AASM commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence. The task force developed recommendations and assigned strengths based on the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use. In addition, the task force adopted foundational recommendations from prior guidelines as "good practice statements", that establish the basis for appropriate and effective diagnosis of OSA. The AASM Board of Directors approved the final recommendations.

RECOMMENDATIONS

The following recommendations are intended as a guide for clinicians diagnosing OSA in adults. Under GRADE, a STRONG recommendation is one that clinicians should follow under most circumstances. A WEAK recommendation reflects a lower degree of certainty regarding the outcome and appropriateness of the patient-care strategy for all patients. The ultimate judgment regarding propriety of any specific care must be made by the clinician in light of the individual circumstances presented by the patient, available diagnostic tools, accessible treatment options, and resources. Good Practice Statements: Diagnostic testing for OSA should be performed in conjunction with a comprehensive sleep evaluation and adequate follow-up. Polysomnography is the standard diagnostic test for the diagnosis of OSA in adult patients in whom there is a concern for OSA based on a comprehensive sleep evaluation.Recommendations: We recommend that clinical tools, questionnaires and prediction algorithms not be used to diagnose OSA in adults, in the absence of polysomnography or home sleep apnea testing. (STRONG). We recommend that polysomnography, or home sleep apnea testing with a technically adequate device, be used for the diagnosis of OSA in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA. (STRONG). We recommend that if a single home sleep apnea test is negative, inconclusive, or technically inadequate, polysomnography be performed for the diagnosis of OSA. (STRONG). We recommend that polysomnography, rather than home sleep apnea testing, be used for the diagnosis of OSA in patients with significant cardiorespiratory disease, potential respiratory muscle weakness due to neuromuscular condition, awake hypoventilation or suspicion of sleep related hypoventilation, chronic opioid medication use, history of stroke or severe insomnia. (STRONG). We suggest that, if clinically appropriate, a split-night diagnostic protocol, rather than a full-night diagnostic protocol for polysomnography be used for the diagnosis of OSA. (WEAK). We suggest that when the initial polysomnogram is negative and clinical suspicion for OSA remains, a second polysomnogram be considered for the diagnosis of OSA. (WEAK).

Using the Karolinska Sleep Questionnaire to identify obstructive sleep apnea syndrome in a sleep clinic population

INTRODUCTION

In Scandinavia, portable monitoring has virtually replaced standard polysomnography for diagnosis of obstructive sleep apnea syndrome (OSAS). Because waiting times for specialized OSAS care remain long, an accurate screening tool to exclude low-risk patients from diagnostic testing would be valuable.

OBJECTIVES

To examine the diagnostic accuracy of the Karolinska Sleep Questionnaire (KSQ) for OSAS.

METHODS

Consecutive patients, 30–66 years old, attending a large sleep clinic in Sweden for OSAS evaluation completed the KSQ and underwent in-home portable monitoring and medical history evaluation. OSAS was defined as apnea-hypopnea index ≥5 with symptoms of disease. We calculated sensitivity and specificity of apnea/snoring and sleepiness indices of the KSQ. Retrospectively, we combined six KSQ items (snoring, breathing cessations, disturbed sleep, etc.) and four clinical variables (age, sex, body mass index, smoking status) predictive of OSAS into a new instrument, which we also evaluated. Instrument score ranged between 0 and 21; a higher score indicated more severe symptoms.

RESULTS

Of 103 patients, 62 were diagnosed with OSAS. Sensitivity and specificity of the indices were 0.56 and 0.68 (apnea/snoring), and 0.37 and 0.71 (sleepiness). The new instrument performed optimally at a score of 9. Sensitivity was 0.76 (95% confidence interval 0.63–0.86) and specificity 0.88 (0.74–0.96). Between 19.4% and 50.5% of patients were unaware of having apnea/snoring symptoms.

CONCLUSIONS

Diagnostic accuracy of the apnea/snoring and sleepiness indices for OSAS was poor but could be improved by combining clinical and KSQ items. The usefulness of the apnea/snoring index and the combined instrument was questionable because of extensive symptom unawareness.

Role of preoperative screening for adult patients for obstructive sleep apnea

Obstructive sleep apnea (OSA) is a chronic disease with increasing prevalence. Underdiagnosed in the surgical population, OSA can reach a prevalence of up to 70% in bariatric surgery, and be associated with difficult airways and postoperative cardiopulmonary adverse events. Despite its association with escalation of care, increased health care resource utilization, and length of hospital stay, < 25% of health care institutions in the United States have OSA perioperative protocols to improve patient safety. This is explained in part by a lack of studies that support a widely accepted systematic approach to preoperative screening and risk stratification. This review evaluates the role of preoperative screening tools for adult patients with suspected OSA.

Obstructive sleep apnea in the perioperative setting: complications and management strategies

Obstructive sleep apnea (OSA) is frequently encountered in an undiagnosed, untreated state in perioperative patients. It increases the risk of respiratory, cardiac, and infectious complications following surgical procedures. Patients with OSA may require additional monitoring, unplanned escalations in care, and prolonged hospitalization. It is important to identify patients at risk for OSA during the preoperative assessment so that appropriate anesthesia, postsurgical monitoring, and pain control can be planned. Herein, we discuss data regarding perioperative outcomes in patients with OSA, methods to quickly identify patients at high risk for OSA, and implementation of clinical safeguards to minimize OSA-associated complications. An algorithm is provided to guide the perioperative management of patients with OSA.

Diabetes, sleep apnea, obesity and cardiovascular disease: Why not address them together?

Obesity, sleep apnea, diabetes and cardiovascular diseases are some of the most common diseases encountered by the worldwide population, with high social and economic burdens. Significant emphasis has been placed on obtaining blood pressure, body mass index, and placing importance on screening for signs and symptoms pointing towards cardiovascular disease. Symptoms related to sleep, or screening for sleep apnea has been overlooked by cardiac, diabetic, pulmonary and general medicine clinics despite recommendations for screening by several societies. In recent years, there is mounting data where obesity and obstructive sleep apnea sit at the epicenter and its control can lead to improvement and prevention of diabetes and cardiovascular complications. This editorial raises questions as to why obstructive sleep apnea screening should be included as yet another vital sign during patient initial inpatient or outpatient visit.

Are diabetic patients being screened for sleep related breathing disorder?

Prevalence of both diabetes mellitus and obstructive sleep apnea (OSA) is high among general population. Both of these conditions are associated with significant morbidity. OSA affects approximately 25% of men and 9% of women, and its prevalence is even higher among obese, Hispanics, African American and diabetic patients. Diabetes on the other hand besides having high prevalence in general population has even higher prevalence among ethnic populations as Hispanics and African American. Despite the availability of several simple screening tools for OSA, as Berlin questionnaire, STOP-BANG questionnaire, NAMES Criteria, the utility for screening of OSA among the diabetic population remains marginal. This in turn can lead to significant morbidity and complications related to OSA as well as worsening of diabetes mellitus and increase in diabetic complications due to untreated sleep related breathing disorder. It is therefore imperative for the primary care giver to screen for OSA among the diabetic population as a part of their routine evaluation to prevent worsening of diabetes, and its cardiovascular, renal, ophthalmologic and neurological complications.

Influence of gender and anthropometric measures on severity of obstructive sleep apnea

PURPOSE

Gender differences influence upper airway anatomy and physiology. The purpose of our study was to evaluate the influence of gender as well as anthropometric measures on severity of obstructive sleep apnea (OSA).

METHODS

A retrospective review of patients referred to our sleep laboratory for evaluation of OSA was done. Patients with a diagnosis of OSA (Respiratory Disturbance Index (RDI) > 5) were included in the study. Anthropometric measurements were available for all the patients included in the study. Measurements of subjects' height, weight, neck size, and waist and hip sizes were used in the study; waist-hip ratio and neck-to-height ratio were calculated.

RESULTS

Three hundred eighty-six females and 661 males were included. Women were older than men and had a higher body mass index (BMI) and waist-to-hip ratio; men had a thicker neck circumference and a higher neck-to-height ratio. The severity of OSA was significantly higher in males (RDI 41.2 ± 27.9 in men vs. 30.0 ± 26.7 in women, p < 0.0001) despite a lower BMI and age in the men. Severity of OSA, as measured by RDI, varied significantly with changes in anthropometric measures such as neck circumference, and waist and hip sizes in both genders. Waist-to-hip ratio was associated with severity of OSA in men but not in women (p = 0.19 and 0.0001 in women and men, respectively). However, no single anthropometric value was found to be strongly predictive of OSA severity.

CONCLUSION

Despite having a higher mean BMI and age, women have lower RDI compared with men. Waist-to-hip ratio is more predictive of severity of OSA in men than in women. However, the correlation of anthropometric measures with severity of OSA was weak in our subjects.