Home Sleep Testing for the Diagnosis of Obstructive Sleep Apnea—Indications and Limitations

Abstract

The increasing prevalence and recognition of obstructive sleep apnea (OSA) coupled with an awareness of its detrimental health consequences has resulted in the need for timely and cost efficient access to diagnostic sleep testing and treatment. As a result, increased emphasis is being placed on simplified ambulatory models for the diagnosis and treatment of OSA using home sleep testing (HST). An ambulatory sleep program requires the combination of clinical assessment for identifying patients at high risk for OSA, HST for the diagnosis of OSA, and home auto-titrating positive airway pressure units for treatment. Randomized control trials evaluating the efficacy of this ambulatory approach to diagnose and treat OSA in high-risk patients without significant medical comorbidities reveal the potential for equivalent patient outcomes when compared with the use of polysomnography and in-laboratory continuous positive airway pressure titration.

Keywords

obstructive sleep apnea - home sleep test - auto-titrating positive airway pressure - respiratory disturbance index

• References

• 1 Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol 2013; 177 (9) 1006-1014
• 2 Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993; 328 (17) 1230-1235
• 3 Young T, Evans L, Finn L, Palta M. Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep 1997; 20 (9) 705-706
• 4 Kapur V, Strohl KP, Redline S, Iber C, O'Connor G, Nieto J. Underdiagnosis of sleep apnea syndrome in U.S. communities. Sleep Breath 2002; 6 (2) 49-54
• 5 Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet 2005; 365 (9464) 1046-1053
• 6 Peppard PE, Young T, Palta M, Skatrud J. Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med 2000; 342 (19) 1378-1384
• 7 Engleman HM, Douglas NJ. Sleep. 4: Sleepiness, cognitive function, and quality of life in obstructive sleep apnoea/hypopnoea syndrome. Thorax 2004; 59 (7) 618-622
• 8 Redline S, Yenokyan G, Gottlieb DJ , et al. Obstructive sleep apnea-hypopnea and incident stroke: the sleep heart health study. Am J Respir Crit Care Med 2010; 182 (2) 269-277
• 9 Yeboah J, Redline S, Johnson C , et al. Association between sleep apnea, snoring, incident cardiovascular events and all-cause mortality in an adult population: MESA. Atherosclerosis 2011; 219 (2) 963-968
• 10 Young T, Finn L, Peppard PE , et al. Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin sleep cohort. Sleep 2008; 31 (8) 1071-1078
• 11 Marin JM, Agusti A, Villar I , et al. Association between treated and untreated obstructive sleep apnea and risk of hypertension. JAMA 2012; 307 (20) 2169-2176
• 12 Terán-Santos J, Jiménez-Gómez A, Cordero-Guevara J. Cooperative Group Burgos-Santander. The association between sleep apnea and the risk of traffic accidents. N Engl J Med 1999; 340 (11) 847-851
• 13 Morgenstern M, Wang J, Beatty N, Batemarco T, Sica AL, Greenberg H. Obstructive sleep apnea: an unexpected cause of insulin resistance and diabetes. Endocrinol Metab Clin North Am 2014; 43 (1) 187-204
• 14 Malone S, Liu PP, Holloway R, Rutherford R, Xie A, Bradley TD. Obstructive sleep apnoea in patients with dilated cardiomyopathy: effects of continuous positive airway pressure. Lancet 1991; 338 (8781) 1480-1484
• 15 Tregear S, Reston J, Schoelles K, Phillips B. Obstructive sleep apnea and risk of motor vehicle crash: systematic review and meta-analysis. J Clin Sleep Med 2009; 5 (6) 573-581
• 16 Bearpark H, Elliott L, Grunstein R , et al. Snoring and sleep apnea. A population study in Australian men. Am J Respir Crit Care Med 1995; 151 (5) 1459-1465
• 17 George CF. Reduction in motor vehicle collisions following treatment of sleep apnoea with nasal CPAP. Thorax 2001; 56 (7) 508-512
• 18 Haentjens P, Van Meerhaeghe A, Moscariello A , et al. The impact of continuous positive airway pressure on blood pressure in patients with obstructive sleep apnea syndrome: evidence from a meta-analysis of placebo-controlled randomized trials. Arch Intern Med 2007; 167 (8) 757-764
• 19 Campos-Rodriguez F, Martinez-Garcia MA, de la Cruz-Moron I, Almeida-Gonzalez C, Catalan-Serra P, Montserrat JM. Cardiovascular mortality in women with obstructive sleep apnea with or without continuous positive airway pressure treatment: a cohort study. Ann Intern Med 2012; 156 (2) 115-122
• 20 Antonopoulos CN, Sergentanis TN, Daskalopoulou SS, Petridou ET. Nasal continuous positive airway pressure (nCPAP) treatment for obstructive sleep apnea, road traffic accidents and driving simulator performance: a meta-analysis. Sleep Med Rev 2011; 15 (5) 301-310
• 21 Olson LG, King MT, Hensley MJ, Saunders NA. A community study of snoring and sleep-disordered breathing. Prevalence. Am J Respir Crit Care Med 1995; 152 (2) 711-716
• 22 Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med 2002; 165 (9) 1217-1239
• 23 Flemons WW, Douglas NJ, Kuna ST, Rodenstein DO, Wheatley J. Access to diagnosis and treatment of patients with suspected sleep apnea. Am J Respir Crit Care Med 2004; 169 (6) 668-672
• 24 Ferber R, Millman R, Coppola M , et al. Portable recording in the assessment of obstructive sleep apnea. ASDA standards of practice. Sleep 1994; 17 (4) 378-392
• 25 Chesson Jr AL, Berry RB, Pack A. American Academy of Sleep Medicine, American Thoracic Society, American College of Chest Physicians. Practice parameters for the use of portable monitoring devices in the investigation of suspected obstructive sleep apnea in adults. Sleep 2003; 26 (7) 907-913
• 26 Collop NA, Anderson WM, Boehlecke B , et al; Portable Monitoring Task Force of the American Academy of Sleep Medicine. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. J Clin Sleep Med 2007; 3 (7) 737-747
• 27 National Coverage Determination (NCD) for Continuous Positive Airway Pressure (CPAP) Therapy For Obstructive Sleep Apnea (OSA) (240.4). Retrieved August 27, 2014 from, http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=226&ncdver=3&NCAId=204&NcaName=Continuous+Positive+Airway+Pressure+(CPAP)+Therapy+for+Obstructive+Sleep+Apnea+(OSA)&IsPopup=y&bc=AAAAAAAAIAAA&
• 28 Decision Memo for SLEEP TESTING for Obstructive SLEEP Apnea (OSA) (CAG-00405N). Retrieved August 27, 2014 from, http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=227&ver=11&NcaName=Sleep=Testing+for+Obstructive+Sleep+Apnea+(OSA)&CoverageSelection=National&KeyWord=sleep=testing&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAEAAA&
• 29 Mulgrew AT, Fox N, Ayas NT, Ryan CF. Diagnosis and initial management of obstructive sleep apnea without polysomnography: a randomized validation study. Ann Intern Med 2007; 146 (3) 157-166
• 30 Work plan: fiscal year 2011 Available at: oig.hhs.gov/publications/workplan/2011/FY11_WorkPlan-All.pdf (Accessed July 1, 2012)
• 31 Ungar L. In-home tests gain traction in sleep disorder diagnoses. The Louisville, KY Courier Journal, 2013. Retrieved August 27, 2014 from, http://www.usatoday.com/story/news/nation/2013/02/15/home-sleep-apnea-tests-momentum/1922335/
• 32 Conaboy C. Insurers push clinic sleep testing into homes. The Boston Globe, 2013 Retrieved August 27, 2014 from, http://www.bostonglobe.com/lifestyle/health-wellness/2013/02/02/insurers-push-sleep-testing-from-clinics-homes-saving-money/E7OomPKTbEeNu5QPYChZfO/story.html
• 33 Collop NA, Tracy SL, Kapur V , et al. Obstructive sleep apnea devices for out-of-center (OOC) testing: technology evaluation. J Clin Sleep Med 2011; 7 (5) 531-548
• 34 Smith LA, Chong DW, Vennelle M, Denvir MA, Newby DE, Douglas NJ. Diagnosis of sleep-disordered breathing in patients with chronic heart failure: evaluation of a portable limited sleep study system. J Sleep Res 2007; 16 (4) 428-435
• 35 Santos-Silva R, Sartori DE, Truksinas V , et al. Validation of a portable monitoring system for the diagnosis of obstructive sleep apnea syndrome. Sleep 2009; 32 (5) 629-636
• 36 Dingli K, Coleman EL, Vennelle M , et al. Evaluation of a portable device for diagnosing the sleep apnoea/hypopnoea syndrome. Eur Respir J 2003; 21 (2) 253-259
• 37 Levendowski D, Steward D, Woodson BT, Olmstead R, Popovic D, Westbrook P. The impact of obstructive sleep apnea variability measured in-lab versus in-home on sample size calculations. Int Arch Med 2009; 2 (1) 2
• 38 Calleja JM, Esnaola S, Rubio R, Durán J. Comparison of a cardiorespiratory device versus polysomnography for diagnosis of sleep apnoea. Eur Respir J 2002; 20 (6) 1505-1510
• 39 Flemons WW, Littner MR, Rowley JA , et al. Home diagnosis of sleep apnea: a systematic review of the literature. An evidence review cosponsored by the American Academy of Sleep Medicine, the American College of Chest Physicians, and the American Thoracic Society. Chest 2003; 124 (4) 1543-1579
• 40 Quan SF, Howard BV, Iber C , et al. The Sleep Heart Health Study: design, rationale, and methods. Sleep 1997; 20 (12) 1077-1085
• 41 Redline S, Sanders MH, Lind BK , et al; Sleep Heart Health Research Group. Methods for obtaining and analyzing unattended polysomnography data for a multicenter study. Sleep 1998; 21 (7) 759-767
• 42 Whitney CW, Gottlieb DJ, Redline S , et al. Reliability of scoring respiratory disturbance indices and sleep staging. Sleep 1998; 21 (7) 749-757
• 43 Kapur VK, Rapoport DM, Sanders MH , et al. Rates of sensor loss in unattended home polysomnography: the influence of age, gender, obesity, and sleep-disordered breathing. Sleep 2000; 23 (5) 682-688
• 44 Nieto FJ, Young TB, Lind BK , et al. Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study. JAMA 2000; 283 (14) 1829-1836
• 45 Berry RB, Hill G, Thompson L, McLaurin V. Portable monitoring and autotitration versus polysomnography for the diagnosis and treatment of sleep apnea. Sleep 2008; 31 (10) 1423-1431
• 46 Antic NA, Buchan C, Esterman A , et al. A randomized controlled trial of nurse-led care for symptomatic moderate-severe obstructive sleep apnea. Am J Respir Crit Care Med 2009; 179 (6) 501-508
• 47 Kuna ST, Gurubhagavatula I, Maislin G , et al. Noninferiority of functional outcome in ambulatory management of obstructive sleep apnea. Am J Respir Crit Care Med 2011; 183 (9) 1238-1244
• 48 Hoy CJ, Vennelle M, Kingshott RN, Engleman HM, Douglas NJ. Can intensive support improve continuous positive airway pressure use in patients with the sleep apnea/hypopnea syndrome?. Am J Respir Crit Care Med 1999; 159 (4, Pt 1) 1096-1100
• 49 Jean Wiese H, Boethel C, Phillips B, Wilson JF, Peters J, Viggiano T. CPAP compliance: video education may help!. Sleep Med 2005; 6 (2) 171-174
• 50 Skomro RP, Gjevre J, Reid J , et al. Outcomes of home-based diagnosis and treatment of obstructive sleep apnea. Chest 2010; 138 (2) 257-263
• 51 Rosen CL, Auckley D, Benca R , et al. A multisite randomized trial of portable sleep studies and positive airway pressure autotitration versus laboratory-based polysomnography for the diagnosis and treatment of obstructive sleep apnea: the HomePAP study. Sleep 2012; 35 (6) 757-767
• 52 Littner M. Ed. Sleep Medicine Clinics. Philadelphia, PA: Elsevier Inc; 2011
• 53 Hesselbacher S, Mattewal A, Hirshkowitz M, Sharafkhaneh A, Classification, technical specifications, and types of home sleep testing devices for sleep-disordered breathing. In: Littner M. , ed. Sleep Medicine Clinics. Philadelphia, PA: Elsevier; 2011: 261-82
• 54 Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep 1991; 14 (6) 540-545
• 55 Vasu TS, Doghramji K, Cavallazzi R , et al. Obstructive sleep apnea syndrome and postoperative complications: clinical use of the STOP-BANG questionnaire. Arch Otolaryngol Head Neck Surg 2010; 136 (10) 1020-1024
• 56 Netzer NC, Stoohs RA, Netzer CM, Clark K, Strohl KP. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Ann Intern Med 1999; 131 (7) 485-491
• 57 Flemons WW, Whitelaw WA, Brant R, Remmers JE. Likelihood ratios for a sleep apnea clinical prediction rule. Am J Respir Crit Care Med 1994; 150 (5, Pt 1) 1279-1285
• 58 Maislin G, Pack AI, Kribbs NB , et al. A survey screen for prediction of apnea. Sleep 1995; 18 (3) 158-166
• 59 Rowley JA, Aboussouan LS, Badr MS. The use of clinical prediction formulas in the evaluation of obstructive sleep apnea. Sleep 2000; 23 (7) 929-938
• 60 Crocker BD, Olson LG, Saunders NA , et al. Estimation of the probability of disturbed breathing during sleep before a sleep study. Am Rev Respir Dis 1990; 142 (1) 14-18
• 61 Viner S, Szalai JP, Hoffstein V. Are history and physical examination a good screening test for sleep apnea?. Ann Intern Med 1991; 115 (5) 356-359
• 62 Kushida CA, Efron B, Guilleminault C. A predictive morphometric model for the obstructive sleep apnea syndrome. Ann Intern Med 1997; 127 (8, Pt 1) 581-587
• 63 Chai-Coetzer CL, Antic NA, Rowland LS , et al. A simplified model of screening questionnaire and home monitoring for obstructive sleep apnoea in primary care. Thorax 2011; 66 (3) 213-219
• 64 Abraham WT, Trupp RJ, Phillilps B , et al. Validation and clinical utility of a simple in-home testing tool for sleep-disordered breathing and arrhythmias in heart failure: results of the Sleep Events, Arrhythmias, and Respiratory Analysis in Congestive Heart Failure (SEARCH) study. Congest Heart Fail 2006; 12 (5) 241-247 , quiz 248–249
• 65 Oliveira MG, Nery LE, Santos-Silva R , et al. Is portable monitoring accurate in the diagnosis of obstructive sleep apnea syndrome in chronic pulmonary obstructive disease?. Sleep Med 2012; 13 (8) 1033-1038
• 66 Morales CR, Hurley S, Wick LC , et al. In-home, self-assembled sleep studies are useful in diagnosing sleep apnea in the elderly. Sleep 2012; 35 (11) 1491-1501
• 67 Santiago VZM, Wallace J, Cacho V, Kole A, Fogelfeld K, Santiago S. Comparing the results of a normal or technically inadequate home sleep test to the polysomnogram. Sleep 2013; 36: A131
• 68 Lloberes P, Ballester E, Montserrat JM , et al. Comparison of manual and automatic CPAP titration in patients with sleep apnea/hypopnea syndrome. Am J Respir Crit Care Med 1996; 154 (6, Pt 1) 1755-1758
• 69 Stradling JR, Barbour C, Pitson DJ, Davies RJ. Automatic nasal continuous positive airway pressure titration in the laboratory: patient outcomes. Thorax 1997; 52 (1) 72-75
• 70 Teschler H, Berthon-Jones M, Thompson AB, Henkel A, Henry J, Konietzko N. Automated continuous positive airway pressure titration for obstructive sleep apnea syndrome. Am J Respir Crit Care Med 1996; 154 (3, Pt 1) 734-740
• 71 Teschler H, Farhat AA, Exner V, Konietzko N, Berthon-Jones M. AutoSet nasal CPAP titration: constancy of pressure, compliance and effectiveness at 8.  month follow-up. Eur Respir J 1997; 10 (9) 2073-2078
• 72 Berkani M, Lofaso F, Chouaid C , et al. CPAP titration by an auto-CPAP device based on snoring detection: a clinical trial and economic considerations. Eur Respir J 1998; 12 (4) 759-763
• 73 Gagnadoux F, Rakotonanahary D, Martins de Araujo MT, Barros-Vieira S, Fleury B. Long-term efficacy of fixed CPAP recommended by Autoset for OSAS. Sleep 1999; 22 (8) 1095-1099
• 74 Sériès F. Accuracy of an unattended home CPAP titration in the treatment of obstructive sleep apnea. Am J Respir Crit Care Med 2000; 162 (1) 94-97
• 75 Masa JF, Jiménez A, Durán J , et al. Alternative methods of titrating continuous positive airway pressure: a large multicenter study. Am J Respir Crit Care Med 2004; 170 (11) 1218-1224
• 76 West SD, Jones DR, Stradling JR. Comparison of three ways to determine and deliver pressure during nasal CPAP therapy for obstructive sleep apnoea. Thorax 2006; 61 (3) 226-231