PORTABLE MONITORING FOR THE
DIAGNOSIS OF OBSTRUCTIVE
SLEEP APNEA
ADNAN ABBASI, MBBS, MPH
• Conflict of interest
• None
• Disclosure
• None
OBJECTIVES
• Understand the need of Portable Monitoring (PM) and Home Sleep Testing
(HST) in evaluation of obstructive sleep apnea (OSA) in current practice model
• Review technology for PM for diagnosis of OSA
• Review algorithmic approach to diagnosis and management of OSA using PM
and auto-PAP
• Identify patients in whom HST can be effective
EPIDEMIOLOGY OF SLEEP-DISORDERED BREATHING
• Prevalence of OSA (defined as an apnea-hypopnea index >5 events per
hour) 33.9% in men and 17.4% in women
• OSA syndrome (OSA + excessive daytime sleepiness) is 14.3% in men and
5% in women
• Increasing rates of obesity
Peppard PE. Am J Epidemiol. 2013 May 1;177(9):1006-14
Young T. N Engl J Med. 1993 Apr 29;328(17):1230-5
Al Lawati NM. Prog Cardiovasc Dis. 2009 Jan-Feb;51(4):285-93
CONSEQUENCES OF UNTREATED SLEEP APNEA
• Excessive daytime sleepiness
• Decreased workplace productivity
• Car crashes
• Systemic hypertension
• Cardiovascular disease
• Increased mortality
Mulgrew AT. Sleep Med. 2007 Dec;9(1):42-53
Marin JM. Lancet 2007; 365:1046-1053
Peppard PE. NEJM 2000; 342:1378-1384
Barbe F. Am Jr Respir Crit Care Med. 1998;158:18-22
DIAGNOSIS OF SLEEP APNEA
• Historically, in-laboratory attended
polysomnography (PSG) has been
considered as the preferred method
• High cost
• Long wait times
HOME TESTING MODEL
• In the last 15 years, there is growing
interest in algorithmic approach that
bypass in-laboratory sleep studies
TERMINOLOGY FOR TECHNOLOGY USED TO
DIAGNOSE SLEEP APNEA
•
Level 1: In-laboratory attended – EEG, chin EMG, ECG, measure of airflow,
respiratory effort, oxygen saturation
•
•
Level 2: Same as level 1, but performed outside the sleep laboratory
•
Level 4: one or two channels – nocturnal oximetry or nasal airflow alone
Level 3: minimum of 4 parameters including oxygen saturation, measurement of
heart rate or ECG, and at least two channels assessing respiration (e.g., respiratory
movement and airflow)
Ferber R. Sleep. 1994;17(4):378-392
REVISED CLASSIFICATION SYSTEM FOR PM- SCOPER
• S: Sleep
• C: Cardiac measure
• O: Oximetry
• P: Position
• E: Effort
• R: Respiration
Collop NA. J Clin Sleep Med 2011;7(5):531-548
IN-LABORATORY PSG VS. HST
•
•
Most PM devices lack ability to differentiate awake from sleep state
•
•
PM underestimates severity of OSA
Total recording time is used as denominator for calculating AHI (Respiratory Event
Index)
Several PM are able to estimate total sleep time
•
•
•
Limited EEG 1 or 2 leads
Lack of head movement
Actigraphy
J Clin Sleep Med 2007;3(7):737-747
J Clin Sleep Med 2007;3(7):737-747
INDICATIONS FOR PORTABLE MONITORING
• PM for diagnosis of OSA should be performed only in conjunction
with a comprehensive sleep evaluation.
• Clinical sleep evaluations using PM must be supervised by a Board
Certified (or Board eligible) Sleep Specialist.
• In the absence of a comprehensive sleep evaluation, there is no
indication for the use of PM.
J Clin Sleep Med 2007;3(7):737-747
INDICATIONS FOR PORTABLE MONITORING
• PM may be used as an alternative to PSG for diagnosis of OSA in
patients with a high pre-test probability of moderate to severe
OSA.
J Clin Sleep Med 2007;3(7):737-747
PM IS NOT APPROPRIATE FOR THE DIAGNOSIS OF OSA
• Patients with significant comorbid medical such as moderate to
severe pulmonary disease, neuromuscular disease, or congestive
heart failure.
• Patients suspected of having other sleep disorders, including
central sleep apnea, periodic limb movement disorder (PLMD),
insomnia, parasomnias, circadian rhythm disorders, or narcolepsy.
• For general screening of asymptomatic populations.
J Clin Sleep Med 2007;3(7):737-747
PM MAY BE INDICATED
• PM may be indicated for the diagnosis of OSA in patients for
whom in-laboratory PSG is not possible by virtue of immobility,
safety, or critical illness.
• PM may be indicated to monitor the response of non-CPAP
treatments for OSA, including oral appliances, upper airway
surgery, and weight loss.
J Clin Sleep Med 2007;3(7):737-747
TECHNOLOGY OF PORTABLE MONITOR
• At a minimum, the PMs must record airflow, respiratory effort, and
blood oxygenation.
• The type of biosensors that are used to monitor these parameters
for in-laboratory PSG are recommended for use in PMs.
• The sensor to detect apnea is an oronasal thermal sensor and to
detect hypopnea is a nasal pressure transducer. Ideally, PMs
should use both sensor types.
J Clin Sleep Med 2007;3(7):737-747
TECHNOLOGY OF PORTABLE MONITOR
• Ideally the sensor for identification of respiratory effort is either
calibrated or uncalibrated inductance plethesmography.
• The sensor for detection of blood oxygen is pulse oximetry with
appropriate signal averaging time and accommodation for motion
artifact.
J Clin Sleep Med 2007;3(7):737-747
METHODOLOGY FOR PORTABLE MONITORING
• Under the auspices of an AASM accredited comprehensive Sleep
Medicine Program with policies and procedures for sensor
application, scoring, and interpretation of PM.
• An experienced sleep technician, sleep technologist, or
appropriately trained healthcare practitioner must perform the
application of PM or directly educate the patient in the correct
application of sensors.
J Clin Sleep Med 2007;3(7):737-747
METHODOLOGY FOR PORTABLE MONITORING
• PM devices must allow for the display of raw data for manual
scoring or editing of automated scoring by a trained and qualified
sleep technician/technologist.
• Evaluation of PM data must include review of the raw data by a
Board Certified (or Board eligible) Sleep Specialist.
• Scoring criteria should be consistent with the current published
AASM standards for scoring of apneas and hypopneas.
J Clin Sleep Med 2007;3(7):737-747
METHODOLOGY FOR PORTABLE MONITORING
• Due to the known rate of false negative PM tests, in-laboratory
PSG should be performed in cases where PM is technically
inadequate or fails to establish the diagnosis of OSA in patients
with a high pre-test probability.
• A follow-up visit with a physician or other appropriately trained
and supervised health provider should be performed on all
patients undergoing PM to discuss the results of the test.
J Clin Sleep Med 2007;3(7):737-747
J Clin Sleep Med 2007;3(7):737-747
CMS DECISION MEMO FOR SLEEP TESTING FOR OSA
• In 2009 CMS approved coverage for PAP for patients diagnosed with sleep
disordered breathing using PM
• Devices covered for diagnosis of OSA:
• Type I sleep testing device -if performed attended in a sleep lab facility
• Type II or a Type III sleep testing device if performed unattended in or out of a sleep lab
facility or attended in a sleep lab facility
https://www.cms.gov/medicare-coverage-database/overview-and-quicksearch.aspx?FriendlyError=InvalidNCAID Document ID: CAG-00405N
CMS DECISION MEMO FOR SLEEP TESTING FOR OSA
• A Type IV sleep testing device measuring three or more channels, one of
which is airflow if performed unattended in or out of a sleep lab facility or
attended in a sleep lab facility.
• A sleep testing device measuring three or more channels that include
actigraphy, oximetry, and peripheral arterial tone is covered if performed
unattended in or out of a sleep lab facility or attended in a sleep lab facility.
https://www.cms.gov/medicare-coverage-database/overview-and-quicksearch.aspx?FriendlyError=InvalidNCAID Document ID: CAG-00405N
PRE-TEST CLINICAL ASSESSMENT OF OSA
• History and physical examination
• Assessment of excessive daytime sleepiness- Epworth Sleepiness Scale
• Review of overnight oximetry
• Sleep Questionnaires
• STOP-BANG Questionnaire
• Berlin Questionnaire
• Wisconsin Questionnaire
STOP-BANG QUESTIONNAIRE
•
•
•
•
•
•
•
•
S: Snoring
T: Tired
O: Observed
P: Pressure (Hypertension)
B: Body Mass Index > 35 Kg/M2
Low Risk : Yes to 0 - 2 questions
Intermediate Risk : Yes to 3 - 4 questions
High Risk : Yes to 5 - 8 questions
or Yes to 2 or more of 4 STOP questions + male gender
or Yes to 2 or more of 4 STOP questions + BMI > 35kg/m2
or Yes to 2 or more of 4 STOP questions + neck circumference
> 17 inches in M or 16 inches in F
A: Age > 50 years
N: Neck circumference >17” in M >16” in F
G: Gender= Male
http://www.stopbang.ca/osa/screening.php
Doshi V. Springerplus. 2015 Dec 22;4:795
Ghegan MD. Laryngoscope. 2006 Jun;116(6):859-64
Ghegan MD. Laryngoscope. 2006 Jun;116(6):859-64
J Clin Sleep Med 2014;10(12):1269-1275
J Clin Sleep Med 2014;10(12):1269-1275
J Clin Sleep Med 2014;10(12):1269-1275
J Clin Sleep Med 2014;10(12):1269-1275
Am J Respir Crit Care Med. 2011, 183(9):1238-44
Am J Respir Crit Care Med. 2011, 183(9):1238-44
Am J Respir Crit Care Med. 2011, 183(9):1238-44
Am J Respir Crit Care Med. 2011, 183(9):1238-44
Am J Respir Crit Care Med. 2011, 183(9):1238-44
Sleep. 2012 Jun 1;35(6):757-67
Sleep. 2012 Jun 1;35(6):757-67
Sleep. 2012 Jun 1;35(6):757-67
Take home messages…
•
PM has become an important tool in the armamentarium used to manage sleep
disordered breathing.
•
In out-patient setting, PM/HST algorithms are non-inferior to laboratory-based diagnosis
of OSA and titration of PAP therapy.
•
For appropriately selected patients- with moderate to high clinical suspicion of
obstructive sleep apnea and without significant co-morbid conditions, HST can be used
effectively to diagnose and auto-PAP to treat OSA.
•
Patients with normal AHI on HST but high pre-test clinical suspicion for OSA should
undergo in-laboratory PSG.
Cooksey JA. Chest 2016; 149(4):1074-1081