The medical cost of undiagnosed sleep apnea

Development of a questionnaire to assess dentists' knowledge, opinion, education resources, physician cooperation, and clinical practice regarding obstructive sleep apnea (OSAQ-D)

This report describes the construction of a questionnaire to assess dentists' knowledge, opinion, education resources, clinical practice, and physician cooperation regarding obstructive sleep apnea (OSA) based on the PRECEDE-PROCEED model. The scale development included such steps as generating an item pool, expert review of initial item pool, pilot test, and final test. After the expert review, a total of 78 items made up the pilot test instrument including five demographic (age, year graduated from dental school, gender, years in practice dentistry, and membership of the Academy of Dental Sleep Medicine), 22 knowledge, 15 opinion, 11 education resources, 10 physician cooperation, and 15 clinical practice questions. The pilot test samples were third or fourth year dental school students and dentists from the University of Florida. Nineteen dentists and 26 students returned the survey. Based on the results of item analysis and content review, a total of 70 questions were remained for the final test. The final questionnaire was mailed to 450 dentists who were randomly selected from a list of 10,838 dentists with a Florida license and also delivered to 65 dental school students and postgraduates of the University of Florida. A total of 163 participants including 112 dentists and 51 students and postgraduates responded. The average age was 42.87 years, and most of them are males (77.8%). Only one dentist was a current member of the Academy of Dental Sleep Medicine. The item analysis was performed for five scales. 8 items with poor item difficulty, lower item discrimination, or having big effect on the item consistency were removed from the instrument, and 62 questions were kept for the further evaluation. The reliability coefficient alpha of knowledge, opinion, education resources, physician cooperation, and clinical practice scales was 0.77, 0.86, 0.67, 0.75, and 0.86, respectively. According to the standard from DeVellis (Scale development: theory and applications, Sage, Thousand Oaks, 2003), they were acceptable, or respectable, or even very good.

Initial indication of treatment in 60 patients with sleep obstructive ventilatory disturbance

Aim

The author present a retrospective descriptive study of 60 patients with sleep obstructive ventilatory disturbance who have taken medical advice at the Centro Campinas de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço during a period of three years. All the patients have been examined after standardized protocol and decisions related to the treatment have been taken after systematic multidisciplinary discussion.

Study design

clinical retrospective.

Material and method

The patients were distributed into two groups according to the proposal of surgical and non-surgical treatment. After so, they were studied according to the model of treatment proposed and the main propaedeutic findings: respiratory disturbance index (RDI), body mass index (BMI), cephalometric analysis and Müller maneuver. The main features were compared - isolated or in association - with the model of treatment proposed.

Conclusion

Amongst several conclusions obtained, the most important were: surgical and non-surgical treatment were indicated almost in the same proportion for of snoring; surgical treatments were most indicated for snoring and Apnoea-Hipopnoea Syndrome, despite of its modality; RDI, BMI and cephalometric analysis and Müller maneuver had no influence at any therapeutic modality; the therapeutic decision was taken after standardized protocol and systematic multidisciplinary discussion, where each case was discussed individually.

Troubles respiratoires pendant le sommeil et accidents du travail ou de la vie courante

Obstructive sleep apnoeas affect a significant proportion of the middle-aged population. They are due to the closure of upper airways during sleep and cause fragmented sleep, which leads to excessive daily drowsiness. Sleepiness due to apnoea is acknowledged by 10 to 30% of subjects in epidemiological surveys. It impairs vigilance, and therefore represents a risk factor for traffic, domestic and work-related accidents. In the case of domestic accidents, a study shows an increased number of accidents have been reported by subjects with apnoeas; a second study reports the reduction in the frequency of such accidents after receiving appropriate treatment. Subjects suffering from sleep apnoeas also have a higher frequency of accidents at work. Workers with persistent daily drowsiness were also found to have a higher rate of absenteeism as well.

A comparison of polysomnography and the SleepStrip in the diagnosis of OSA

OBJECTIVE

To investigate the role of a portable screening device (SleepStrip) in the diagnosis of obstructive sleep apnea (OSA).

METHODS AND MATERIALS

Prospective, nonrandomized double-blinded single cohort study at an academic health center. Patients with suspected OSA scheduled for an attended overnight Level I polysomnogram (PSG) and who consented to participate in the study wore the SleepStrip device at home the night after the PSG. The apnea-hypopnea index (AHI) determined by PSG was compared with the results of the SleepStrip recording.

RESULTS

Thirty-seven patients with a mean age of 52.1 +/- 12.2 years and mean body mass index of 35.7 +/- 5.2 participated in the study. The overall agreement between the AHI and the SleepStrip results using Cohen's Kappa value was 0.139 (P = 0.19). The sensitivity and specificity of the SleepStrip for diagnosing severe OSA when the AHI was >40 were 33.3% and 95% (P = 0.05). When the AHI was >25, the SleepStrip sensitivity and specificity were 43.8% and 81.3% (P = 0.26). The sensitivity and specificity of the SleepStrip for diagnosing OSA in patients with an AHI >15 were 54.6% and 70%, respectively (P = 0.26).

CONCLUSION

The SleepStrip has a low correlation with the AHI as measured by PSG. Further studies are needed before this device can be recommended as a screening tool for the diagnosis of OSA.

EBM RATING

B-2b.

Obstructive sleep apnea - management update

Obstructive sleep apnea (OSA) is a highly significant condition based both on the high prevalence in community and significant consequences. Obstructive sleep apnea syndrome (OSAS), OSA together with hypersomnolence, is seen in 4% of middle-aged men and 2% of middle-aged women. OSA is associated with impaired quality of life and increased risks of motor vehicle accidents, cardiovascular disease (including hypertension and coronary artery disease), and metabolic syndrome. There is some evidence for the use of conservative interventions such as weight loss and position modification. CPAP remains the mainstay of treatment in this condition with high-level evidence supporting its efficacy. Continuous positive airway pressure (CPAP) is an intrusive therapy, with long-term adherence rates of less than 70%. Dental appliances have been shown to be effective therapy in some subjects but are limited by the inability to predict treatment responders. Alternative treatments are discussed but there is little role for upper airway surgery (except in a select few experienced institutions) or pharmacological treatment. The current levels of evidence for the different treatment regimens are reviewed.

Obstructive sleep apnea–hypopnea and neurocognitive functioning in the Sleep Heart Health Study

BACKGROUND AND PURPOSE

Obstructive sleep apnea-hypopnea (OSAH) is associated with sleep fragmentation and nocturnal hypoxemia. In clinical samples, patients with OSAH frequently are found to have deficits in neuropsychological function. However, the nature and severity of these abnormalities in non-clinical populations is less well defined.

PATIENTS AND METHODS

One hundred and forty-one participants from the Tucson, AZ and New York, NY field centers of the Sleep Heart Health Study completed a battery of neuropsychological tests for 9-40 months (mean=24 months, SD=7 months) after an unattended home polysomnogram. Sixty-seven participants had OSAH (AHI>10) and 74 did not have OSAH (control (CTL), apnea-hypopnea index (AHI)<5). In addition to the individual tests, composite variables representing attention, executive function, MotorSpeed and processing speed were constructed from the neuropsychological test battery.

RESULTS

There were no significant differences in any individual neuropsychological test or composite variable between the OSAH and CTL groups. However, when time spent with O(2) saturations less than 85% was dichotomized into those participants in the top quartile of the distribution and those in the lower three quartiles, motor speed was significantly impaired in those who were more hypoxemic. In addition, poorer motor speed (model adjusted R(2)=0.242, P<0.001) and processing speed performance (model adjusted R(2)=0.122, P<0.001) were associated with more severe oxygen desaturation even after controlling for degree of daytime sleepiness, age, gender and educational level.

CONCLUSIONS

Mild to moderate OSAH has little impact on the selected measures of attention, executive function, motor speed and processing speed. However, hypoxemia adversely affects both motor and processing speed. These results suggest that in middle-aged to elderly adults the neuropsychological effects of clinically unrecognized mild to moderate OSAH are neither global nor large.

"Sleepiness" is serious in adolescence: two surveys of 3235 Canadian students

BACKGROUND

Evidence is growing that sleep problems in adolescents are significant impediments to learning and negatively affect behaviour, attainment of social competence and quality of life. The objectives of the study were to determine the level of sleepiness among students in high school, to identify factors to explain it, and to determine the association between sleepiness and performance in both academic and extracurricular activities

METHODS

A cross-sectional survey of 2201 high school students in the Hamilton Wentworth District School Board and the Near North District School Board in Ontario was conducted in 1998/9. A similar survey was done three years later involving 1034 students in the Grand Erie District School Board in the same Province. The Epworth Sleepiness Scale (ESS) was used to measure sleepiness and we also assessed the reliability of this tool for this population. Descriptive analysis of the cohort and information on various measures of performance and demographic data were included. Regression analysis, using the generalised estimating equation (GEE), was utilized to investigate factors associated with risk of sleepiness (ESS>10).

RESULTS

Seventy per cent of the students had less than 8.5 hours weeknight sleep. Bedtime habits such as a consistent bedtime routine, staying up late or drinking caffeinated beverages before bed were statistically significantly associated with ESS, as were weeknight sleep quantity and gender. As ESS increased there was an increase in the proportion of students who felt their grades had dropped because of sleepiness, were late for school, were often extremely sleepy at school, and were involved in fewer extracurricular activities. These performance measures were statistically significantly associated with ESS. Twenty-three percent of the students felt their grades had dropped because of sleepiness. Most students (58-68%) reported that they were "really sleepy" between 8 and 10 A.M.

CONCLUSION

Sleep deprivation and excessive daytime sleepiness were common in two samples of Ontario high school students and were associated with a decrease in academic achievement and extracurricular activity. There is a need to increase awareness of this problem in the education and health communities and to translate knowledge already available to strategies to address it.

Antioxidant nutrient intake and supplements as potential moderators of cognitive decline and cardiovascular disease in obstructive sleep apnea

Cognitive deficits and cardiovascular disease (CVD) are comorbid conditions frequently associated with obstructive sleep apnea (OSA). Oxygen free radical release and its differential regulation of cytokine synthesis and immune modulation resulting from OSA-related hypoxic events have been hypothesized as the underlying mechanism(s) for the cognitive deficits and CVD in OSA. A number of studies have suggested that increased levels of oxidative stress and/or antioxidant deficiencies may also be risk factors in cognitive decline and CVD. The influence of antioxidant nutrients and supplements, such as Vitamins B6, B12, C, E, folic acid, alpha-lipoic acid and Coenzyme Q(10) on cognitive decline and CVD have been investigated. The influence of antioxidant nutrients or supplements on OSA remains to be investigated. Even if dietary or supplemental antioxidants do not prove to be effective therapies for OSA, dietary assessment and prescription to increase dietary intake of neuro- and cardio-protective nutrients may make it possible to reduce some of the cognitive and cardiovascular sequelae associated with OSA.

Determinants Affecting Health-Care Utilization in Obstructive Sleep Apnea Syndrome Patients

STUDY OBJECTIVE

To investigate determinants of health-care utilization in patients with obstructive sleep apnea syndrome (OSAS).

DESIGN

Case-control prospective study with OSAS patients and a control group. We compared 218 patients with OSAS to those of age-, gender-, geographically-, and family physician-matched control subjects from the general population, matched 1:1 (chi2 = 0.999).

PARTICIPANTS

All participants were members of Clalit Health Care Services, a health maintenance organization in the southern region of Israel. All OSAS patients underwent nocturnal polysomnography studies. Indexes of health-care utilization 2 years prior to the polysomnography were analyzed.

MEASUREMENTS AND RESULTS

Health-care utilization was 1.7-fold higher (p < 0.001) in the OSAS patients due to more hospitalization days (p < 0.001), consultations (p < 0.001), and cost for drugs (p < 0.05), particularly those for the cardiovascular system. In comparison to men, women consumed significantly more health-care resources (p < 0.001). OSAS patients < or = 65 of age years consumed 2.2-fold more health-care resources than control subjects (p < 0.001). Polysomnography findings and OSAS severity and body mass index (BMI) did not predict health-care utilization, using multivariate logistic regression analysis. Age > 65 (odds ratio [OR], 2.2; p < 0.04) and female gender (OR, 2.0; p < 0.05) were the leading elements predicting the most costly OSAS patients. Arbitrarily dividing the OSAS group by cost of health-care utilization, the upper 25% (n = 55) of patients who were the "most costly" consumed sevenfold more health-care resources than the lower 75% of the patients. This was due to higher comorbidity, ie, 10 to 30% more hypertension, ischemic heart disease, diabetes mellitus, and pulmonary disease.

CONCLUSIONS

OSAS patients are heavy users of health-care resources. Age > 65 years and female gender were the leading elements predicting the most costly OSAS patients, and not necessarily patients with a high BMI and classic OSAS severity indexes.

A comparison of polysomnography and a portable home sleep study in the diagnosis of obstructive sleep apnea syndrome

OBJECTIVE

To validate the role of a portable sleep monitor device (SNAP) in the diagnosis of obstructive sleep apnea syndrome (OSAS). Inter-reader variability was also assessed for both PSG and SNAP.

STUDY DESIGN AND SETTING

Sixty consecutive adults referred for PSG at The University of Chicago Sleep Disorder Clinic were prospectively enrolled.

RESULTS

There was no significant difference between total number of apnea and hypopnea, respiratory disturbance index (RDI), and minimum oxygen obtained by PSG and SNAP, but there was a significant difference between sleep time and mean oxygen. Pearson's correlation coefficient for RDI > or = 15 was 0.92.

CONCLUSION

There was a significant correlation of RDIs between SNAP and PSG. SNAP has good sensitivity, specificity, positive and negative predictive values. Differences between SNAP and PSG could be attributed to inter-reader variability and not necessarily due to technical limitations of SNAP. SNAP is an excellent tool for the diagnosis of OSAS in the laboratory setting. Future studies should be performed to evaluate SNAP's accuracy in the home setting in the diagnosis of OSAS.

EBM RATING

B-2.

Nightly variability of sleep-disordered breathing measured over 3 nights

OBJECTIVE

To examine the nightly variability of sleep-disordered breathing (SDB) as measured by the apnea-hypopnea index (AHI).

STUDY DESIGN AND SETTING

Retrospective comparison of 3 sequential nights of testing performed in the home in 1091 patients who were referred for diagnostic testing of SDB.

RESULTS

The Pearson and Intraclass correlation coefficients ranged between 0.88 and 0.90 for each pair of nights. Based on night 1, approximately 90% of patients were classified consistently with "AHI-high" (the highest AHI measured across the 3 nights) using an AHI threshold of 5. However, 10% were misclassified on night 1 relative to the highest AHI level.

CONCLUSION AND SIGNIFICANCE

These findings suggest that (1) 1 night of diagnostic testing for SDB is not sufficient to diagnosis SDB in approximately 1 of every 10 cases, and (2) there is little, if any, significant nightly change in SDB in the home environment.

EBM RATING

D.

Knowledge, opinions, and clinical experience of general practice dentists toward obstructive sleep apnea and oral appliances

Undiagnosed obstructive sleep apnea (OSA) can contribute to hypertension, cardiovascular disease, stroke, and detract from overall quality of life. Dentists can play an important role in detecting, making recommendations for, and treating OSA with oral appliances (OAs). A survey of 18 questions of knowledge and opinion of, educational background for, and clinical experience with OSA and OAs was mailed to 500 general practice dentists in Indiana, United States. Two hundred survey returns produced 192 valid responses. Responders reported strong positive opinions toward OSA and OAs. However, 58% of dentists could not identify common signs and symptoms of OSA, and 55% of dentists did not know the mechanism for mandibular advance devices. Only 39% of dentists could identify snoring, mild OSA, and intolerance to continuous positive airway pressure as possible indications for OA treatment. Respondents reported a general lack of education about both OSA and OAs. Only 31 (16%) were taught about this issue in dental school; 77 (40%) knew little or nothing about OA treatment for OSA patients; 57 (30%) learned from postgraduate training. Cooperation and referrals between dentists and physicians were rated as "poor." Of the responders, 54% never consulted with physicians for a suspected OSA patient in their practice; 75% of dentists reported they have never been referred patients by physicians; and 80% of dentists never or less than five times prescribed OAs to OSA patients. Results suggest a need for increased education and training regarding OSA and OAs in dental school, as well as increased cooperation between dentists and physicians for better patient care.

Neuropsychological sequelae of obstructive sleep apnea-hypopnea syndrome: a critical review

Obstructive sleep apnea-hypopnea syndrome (OSAHS) is a well-recognized clinical sleep disorder that results in chronically fragmented sleep and recurrent hypoxemia. The primary daytime sequelae of the disorder include patient reports of excessive daytime sleepiness, depression, and attention and concentration problems. It has been well established that OSAHS negatively impacts certain aspects of cognitive functioning. The primary goals of this article are to (1) clarify the pattern of cognitive deficits that are specific to OSAHS; (2) identify the specific cognitive domains that improve with treatment; and (3) elucidate the possible mechanisms of cognitive dysfunction in OSAHS. At the conclusion of the paper, we propose a potential neurofunctional theory to account for the etiology of cognitive deficits in OSAHS. Thirty-seven peer-reviewed articles were selected for this review. In general, findings were equivocal for most cognitive domains. Treatment, however, was noted to improve attention/vigilance in most studies and consistently did not improve constructional abilities or psychomotor functioning. The results are discussed in the context of a neurofunctional theory for the effects of OSAHS on the brain.

Health care costs and the sleep apnea syndrome

This paper reviews some concepts on health economics from the authors personal perspective. It then examines the few papers published on health economics analysis applied to the field of sleep apnea syndrome, as well as the literature on the indirect (cost) consequences of sleep apnea syndrome. It appears that undiagnosed sleep apnea leads to a roughly two-fold increase in medical expenses in the years preceding the diagnosis and that treating the disease (once it is diagnosed) results in a decrease in these excess costs. It seems clear that sleep apnea increases the actual number of road traffic accidents, which will carry a definite, but unmeasured up to now, economic cost consequence. From the health economic point of view, the best diagnostic strategy is the one with the greater utility (i.e. polysomnography), although it could appear at first sight to be the more expensive one. From the patient's perspective, sleep apnea results in a given decrease in the possibilities to enjoy life, and its treatment is worth considering, especially if one takes into account that the actual treatment costs are not great. The global image of the health costs related to sleep apnea is still blurred, and further work is required to get the complete and clear picture of the economic consequences of this disease and of its treatment.

Sleep . 3: Clinical presentation and diagnosis of the obstructive sleep apnoea hypopnoea syndrome

Patients with OSAHS may present to a sleep clinic or to other specialists with symptoms that are not immediately attributable to the condition. The diagnostic methods available are reviewed.

The efficacy of split-night sleep studies

Positive airway pressure (PAP) therapy is the most commonly used medical modality to reverse the apneas, hypopneas and inspiratory flow-limited breaths which result in the oxyhemoglobin desaturation, altered sleep architecture, and daytime sleepiness representing the cardinal features of obstructive sleep apnea/hypopnea (OSA/H). Identifying optimal strategies to develop the initial positive airway prescription is of paramount importance to clinicians who evaluate patients with suspected OSA/H. In addition, with the growing appreciation of the clinical and physiologic importance of sleep-disordered breathing, there have been increasing demands on clinical resources to diagnose and treat these patients. The time, hardware, and personnel-intensive nature of in-laboratory polysomnography (PSG) are significant in light of the traditional paradigm that utilizes a full night PSG for a diagnostic evaluation and when indicated, another full night for PAP titration. Efforts to identify time and resource-conserving alternatives to this paradigm have focused on in-laboratory split-night studies, in which the diagnosis of OSA/H can be made, and a positive pressure prescription defined during a single overnight PSG. Case-control studies indicate that, when certain guidelines are applied, split-night PSGs result in prescription efficacy and patient adherence, which are comparable to the traditional two-night strategy. However, prospective, randomized trials designed with adequate power are required to further define the impact of a split-night strategy on clinical outcome. As more information becomes available regarding the factors that determine long-term adherence to positive pressure therapy, the potential for efficient, expeditious treatment, and cost savings with split-night sleep studies will likely receive greater attention.

Obstructive sleep apnoea syndrome: underestimated and undertreated

The obstructive sleep apnoea syndrome (OSAS) was first identified only 40 years ago and its clinical importance is increasingly recognized. Although now acknowledged as a worldwide problem, which in Western countries affects 2-4% of middle-aged men and 1-2% of middle-aged women, the majority of affected individuals remain undiagnosed. OSAS is strongly associated with obesity but is also increasingly identified in the less obese, in whom a particular craniofacial structure is an important contributory factor. The prevalence of OSAS is likely to be increasing in parallel with the epidemic of obesity currently occurring in many countries. The common presenting complaints are excessive daytime sleepiness and loud snoring. The sleepiness impairs social functioning, work performance and driving ability, and accounts for a large socio-economic burden on the community. Hypertension is an important independent association. The treatment of choice is nocturnal continuous positive airway pressure which is highly effective and is also cost effective.

Comparison of the NovaSom QSG™, a new sleep apnea home-diagnostic system, and polysomnography

BACKGROUND

Obstructive sleep apnea (OSA) is a serious, common, and underdiagnosed disorder that challenges health care resources. While polysomnography (PSG) represents the standard diagnostic test for OSA, portable devices provide an alternative diagnostic tool when issues of cost, time, geographic availability, or other constraints pose impediments to in-lab testing. This study compares the NovaSom QSG, a new sleep apnea home diagnostic system, to PSG both in the laboratory and in the home.

METHODS

Fifty-one consecutive adults referred to the sleep lab for suspicion of OSA underwent one night of in-lab, simultaneous recording of PSG and NovaSom QSG in addition to using the NovaSom QSG at home for three nights. Two separate comparisons were made using the apnea-hypopnea index (AHI): in-lab PSG to in-lab NovaSom QSG and in-lab PSG to home NovaSom QSG.

RESULTS

Using a clinical cut-off of AHI=15, the sensitivity and specificity of the in-lab NovaSom QSG vs. PSG were 95% and 91%, respectively. For home NovaSom QSG vs. in-lab PSG, the sensitivity was 91% and specificity was 83%. The intra-class correlation coefficient for the agreement between three separate nights of NovaSom QSG home data was 0.88.

CONCLUSIONS

In a patient population suspected of having OSA, the NovaSom QSG demonstrated acceptable sensitivity and specificity both in the lab and self-administered in the home, when compared to PSG.

Sleep apnoea: Finnish National guidelines for prevention and treatment 2002-2012

(1) After negotiations with the Finnish Ministry of Social Affairs and Health, a national programme to promote prevention, treatment and rehabilitation of sleep apnoea for the years 2002-2012 has been prepared by the Finnish Lung Health Association on the basis of extensive collaboration. The programme needs to be revised as necessary, because of the rapid development in medical knowledge, and in appliance therapy in particular. (2) Sleep apnoea deteriorates slowly. Its typical features are snoring, interruptions of breathing during sleep and daytime tiredness. Sleep apnoea affects roughly 3% of middle-aged men and 2% of women. In Finland, there are approx. 150,000 sleep apnea patients, of which 15,000 patients have a severe disease, 50,000 patients are moderate and 85,000 have a mild form of the disease. Children are also affected by sleep apnea. A typical sleep apnea patient is a middle-aged man or a postmenopausal woman. (3) The obstruction of upper airways is essential in the occurrence of sleep apnoea. The obstruction can be caused by structural and/or functional factors. As for structural factors, there are various methods of intervention, such as to secure children's nasal respiration, to remove redundant soft tissue, as well as to correct malocclusions. It is possible to have an effect on the functional factors by treating well diseases predisposing to sleep apnoea, by reducing smoking, the consumption of alcohol and the use of medicines impairing the central nervous system. The most important single risk factor for sleep apnoea is obesity. (4) Untreated sleep apnoea leads to an increase morbidity and mortality through heart circulatory diseases and through accidents by tiredness. Untreated or undertreated sleep apnoea deteriorates a person's quality of life and working capacity. (5) The goals of the Programme for the prevention and treatment of sleep apnoea are as follows: (1) to decrease the incidence of sleep apnoea, (2) to ensure that as many patients as possible with sleep apnoea recover, (3) to maintain capacity for work and functional capacity of patients with sleep apnoea, (4) to reduce the percentage of patients with severe sleep apnoea, (5) to decrease the number of sleep apnoea patients requiring hospitalisation and (6) to improve cost effectiveness of prevention and treatment of sleep apnoea. (6) The following means are suggested for achieving the goals: (1) to promote prevention of obesity, weight loss and weight control; (2) to promote securing of nasal respiration in child patients and removal of obstructing redundant soft tissues; (3) to promote the correction of children's malocclusions, (4) to enhance knowledge about risk factors and treatment of sleep apnoea in key groups, (5) to promote early diagnosis and active treatment, (6) to commence rehabilitation early and individually as a part of treatment and (7) to encourage scientific research. (7) On the national level, the occurrence of sleep apnoea can be prevented, for example, by encouraging weight control. The programme gives examples of such measures and appeals to various authorities and voluntary organisations to reinforce their collaboration. Preventive measures should be individualised, and based on due consideration. (8) The efficacy of diagnosing sleep apnoea should be increased. Attention should be paid to the symptoms of risk group patients at different units of the primary and occupational health care. Even mild forms of the disease should be treated appropriately. Diagnosis and treatment of the disease involve cooperation between the primary and specialised health-care sectors. Methods of treatment are (1) treatment of obesity, (2) positional therapy, (3) reduction of the use of medicines impairing the central nervous system, (4) reduction of smoking and the consumption of alcohol, (5) devices affecting the position of the tongue and lower jaw, (6) treatment with Continuous Positive Airway Pressure (CPAP-treatment), (7) surgical methods of treatment and (8) rehabilitation. (9) The hierarchy of referrals in the prevention and treatment of sleep apnoea should be revised to accord a greater role to the primary health-care sector. Good exchanges of information and cooperation between the primary health care and specialised medical-care sectors should be developed. Hospitals districts in cooperation with provincial governments and municipalities should ensure that different levels of the health-care system are capable of fulfilling the tasks assigned to them appropriately. (10) Rehabilitation of sleep apnoea should be goal-orientated and cover all forms of rehabilitation: medical, occupational and social. Rehabilitation should prevent the effects caused by the disease. Thus, it is possible to support self-care, increase the patient's resources and improve quality of life. (11) Information and training should be directed primarily towards health-care personnel, patients and their families. Organisations should produce materials for health and patient education as well as organising training events. To support the activities. financing will be needed from organisations such as Finland's Slot Machine Association. The Social Insurance Institution should disseminate information about questions of social security. Regional direction and training will mainly be the responsibilities of hospital districts, provincial governments and local health centres. The media will play an important role in the dissemination in-depth information about prevention and treatment of sleep apnoea.

Evaluation of a portable device based on peripheral arterial tone for unattended home sleep studies

BACKGROUND

Diagnosis of obstructive sleep apnea syndrome (OSAS) by ambulatory systems is a growing practice in view of the large number of patients awaiting correct diagnosis. The Watch PAT100 (WP100) [Itamar Medical; Caesarea, Israel] is a portable device based on the peripheral arterial tone (PAT) signal, and is designed for unattended home sleep studies.

OBJECTIVES

To evaluate the efficacy, reliability, and reproducibility of the WP100 device for the diagnosis of OSAS as compared to in-laboratory, standard polysomnographic-based manual scoring.

DESIGN AND METHODS

One hundred two subjects (78 men; 69 patients with OSAS and 33 normal volunteers; mean +/- SD age, 41.4 +/- 15.2 years; body mass index, 26.8 +/- 5.5) underwent in-laboratory full polysomnography simultaneously with WP100 recording. Fourteen subjects also underwent two additional unattended home sleep studies with the WP100 alone. The polysomnography recordings were blindly scored for apnea/hypopnea according to the American Academy of Sleep Medicine criteria (1999), and the polysomnography respiratory disturbance index (RDI) [PSG-RDI] was calculated. The WP100 data were analyzed automatically for the PAT RDI (PRDI) by a proprietary algorithm that was previously developed on an independent group of subjects.

RESULTS

Across a wide range of RDI levels, the PRDI was highly correlated with the PSG-RDI (r = 0.88, p < 0.0001), with an area under the receiver operating characteristic curve of 0.82 and 0.87 for thresholds of 10 events per hour and 20 events per hour, respectively. The PRDI scores were also highly reproducible, showing high correlation between home and in-laboratory sleep studies (r = 0.89, p < 0.001).

CONCLUSION

The WP100 may offer an accurate, robust, and reliable ambulatory method for the detection of OSAS, with minimal patient discomfort.

Acoustic reflection: review and clinical applications for sleep-disordered breathing

Sleep-disordered breathing (SDB) affects more than 4% of the adult population with an even higher prevalence within high-risk groups. Nasal continuous positive air pressure, although considered the current gold standard treatment for SDB, demonstrates poor patient compliance. Alternative therapies, such as palatal surgeries and airway orthotics, lack validated candidacy selection protocols, resulting in varying success rates. Although much has been published over the last several years regarding the effect of these therapies on the upper airway, no publication has presented an accounting of the use of acoustic reflection (AR) to evaluate airway characteristics pre- and post-treatment with these alternative therapies. This article will review AR and our current knowledge base of the pathological airway characteristics that can be assessed through AR. It will include the advantages, limitations, and potential clinical usefulness of this diagnostic modality in the treatment of patients with SDB.

Sleep disordered breathing

Cause and effect relationships between sleep disordered breathing (SDB) and illness, poorer quality of life, and public health have been largely overlooked and undertreated by healthcare providers. Obstructive sleep apnea (OSA), central sleep apnea, upper airway resistance syndrome, and obesity hypoventilation are the primary syndromes that fall under the rubric of SDB. Each of these syndromes is defined; however, OSA is the most common form of SDB, and is the focus of this article. Epidemiology, pathophysiology, behavioral manifestations, cardiovascular comorbidity, clinical evaluation, and treatment for OSA are the main topics covered. The article concludes with the role of the nurse in SDB.

Maxillomandibular advancement surgery for obstructive sleep apnea syndrome

BACKGROUND

Although maxillomandibular advancement, or MMA, surgery is highly successful, the indications for and staging of MMA in the treatment of obstructive sleep apnea syndrome, or OSAS, have not been settled upon.

TYPES OF STUDIES REVIEWED

The author presents a retrospective review of several published case series with inclusion criteria of 20 or more patients who underwent MMA and received documented preoperative and postoperative diagnostic polysomnography. Protocols of MMA as a primary vs. secondary operation, with and without adjunctive procedures in a site-specific approach, are compared and discussed.

RESULTS

As an extrapharyngeal operation that enlarges and stabilizes the entire veloorohypopharyngeal airway, MMA, which can be safely combined with adjunctive non-pharyngeal procedures, may circumvent the staging dilemmas associated with multiple, less successful, segmental, invasive, pharyngeal procedures. In accordance with current goals and guidelines governing OSAS surgery, MMA does not need to be limited to severe OSAS cases as a last resort after other procedures have failed but, rather, is also indicated as an initial operation for (velo-oro)hypopharyngeal narrowing.

CONCLUSIONS

MMA is a highly successful and potentially definitive primary single-staged surgery that may result in a significant reduction in OSAS-related health risks, as well as financial savings for the health care system.

CLINICAL IMPLICATIONS

The diagnosis and management of OSAS requires a multidisciplinary team approach, including a working relationship between the dentist and sleep physician. General dentists and dental specialists who participate in the management of snoring and OSAS cases should have some knowledge of basic sleep medicine.

Is there a cost-effective way to diagnose mild sleep-disordered breathing?

QUESTION OF THE STUDY

To determine the utility and the cost-effectiveness of oesophageal pressure, respiratory flow and movement, and oximetry (ORO) as a diagnostic tool for mild sleep-disordered breathing (SDB), as compared with overnight polysomnography (PSG).

PATIENTS AND METHODS

Seventy-nine patients evaluated for mild SDB by PSG and simultaneously by oesophageal pressure (Pes) measurement, oximetry, respiratory flow and respiratory movement on a single night. An oesophageal event (OE) was defined as irregular respiration with crescendo in Pes and rapid return to baseline with a minimal increase in the negative Pes at the end of the OE of at least 5 cm H2O or more than 50% of the baseline level. SDB was defined by ORO when oesophageal events were > 5/h, and by PSG when the respiratory disturbance index was > 5/h. The diagnostic accuracy and cost-effectiveness of ORO were compared with PSG.

RESULTS

Although the ability of ORO to detect SDB was poor: sensitivity 64%, specificity 78%, use of ORO for screening prior to PSG would have saved 5000 EUR per 100 patients compared to initial PSG.

CONCLUSION

Using the combination of oesophageal pressure, respiratory flow and movement and oximetry for the diagnosis of mild SDB is not cost-effective, because of its poor diagnostic accuracy. New devices having alternative means to predict arousal and respiratory effort variation should be evaluated for cost-effectiveness.

Maxillomandibular Advancement (MMA) in a Site-Specific Treatment Approach for Obstructive Sleep Apnea: A Surgical Algorithm

Maxillomandibular advancement (MMA) is the most successful acceptable surgical treatment, excluding tracheostomy, for obstructive sleep apnea syndrome (OSAS). Nevertheless, the indications for and staging of MMA, with respect to the many procedures available, are unsettled and often limited to severe OSAS, dentocraniofacial deformities, and when other surgeries have failed. An algorithm is presented that defines the indications for MMA in an expanded role, based on a site-specific approach, according to proposed principles that include general goals and guidelines for governing the surgical treatment of OSAS.

Telemedicine in the sleep laboratory: feasibility and economic advantages of polysomnograms transferred online

The costs for polysomnography (PSG) and alternative diagnostic procedures for sleep-disordered breathing are challenging public health care systems. We wanted to determine if a telemedicine protocol with online transfer of PSGs from a remote site could be cost-effective and clinically useful while improving patient access to full PSG. Fifty-nine PSGs were performed in 54 pulmonary patients with suspected sleep-disordered breathing at a remote hospital. The data were transferred by File Transfer Protocol (FTP) via the Internet to Walter Reed Army Medical Center (WRAMC) for scoring and interpretation. The results were faxed back to the remote hospital. Clinical utility was assessed by evaluating the reasons for patient referral and the resulting diagnoses. The economic benefits were calculated by comparing direct expenses of the telemedicine protocol with costs for contracting PSGs at outside sleep laboratories. A total of 93% (55) of all PSGs were transferred successfully online. Of the 54 patients, 47 had PSGs performed for diagnosis (including three split-night studies), 8 underwent treatment titration, and 1 patient had both overnight studies. Diagnoses were obstructive sleep apnea in 43 patients, central sleep apnea in 2, and upper airway resistance syndrome in 2. The disease conditions were defined as severe in 27 patients, moderate in 12 patients, and mild in 8 patients. Each PSG cost $700 (including costs for lost transmissions) compared to $1,250 for referral to a private sleep laboratory. A savings of $550 per study was realized with the telemedicine protocol. The online transfer of PSGs from a remote site to a centralized sleep laboratory is technically feasible and clinically useful. Telemedicine offers an effective alternative for cost reduction in sleep medicine while improving patient access to specialized care in remote areas.

Application of telemedicine to sleep medicine

Polysomnograms (PSGs) in specialized sleep centers with physicians and technicians trained in sleep medicine are still considered to be the most accurate form of diagnosis in patients with sleep disorders. But they are also very costly. Internet online transfer of PSGs from nonstaffed to very well-staffed sleep centers might be a solution in the future to reduce costs.